ChanBeDu/relevant_section_length · Datasets at Hugging Face

6,914

116,969

51747

Discharge summary

report

Admission Date: [**2147-11-24**] Discharge Date: [**2148-1-20**] Date of Birth: [**2071-9-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: Bilateral parotid gland swelling; dehydration. Major Surgical or Invasive Procedure: Endotracheal intubation Placement of plasmapheresis catheter Tracheostomy History of Present Illness: 76 yo male with below med hx presents with bilateral parotitis suspectedly due to dehydration who are consulting for help with management of fluid balance and question of when to restart [**First Name3 (LF) 17339**]. Pt reports increasing parotid pain and swelling for 4 days associated with worsening dry mouth. He denies fever, chills, cough or sick contacts but does produced very thick oral secretions that he has to spit out and are white in color. Pain on left face radiates up to his ear but no changes in hearing. He reports not being able to tolerate PO's since his radiation but has be taking 2 cans of G-tube feeds tid along with 2x 16oz boluses of water [**Hospital1 **] consistently. He denies current diziness but does report diziness with standing in the past around his time of chemotherapy which is why he was taken off his lasix and lopressor. His blood pressure had been in the low 100's systolic and so they have not been reinitiated. He is very sedentary and does report intermittent LE swelling worse on the left leg where his SVG CABG graft was harvested from. He denies any CP, CT, SOB, PND or orthopnea. He stopped his [**Hospital1 17339**] 2 months ago since he had to start Diflucan to treat XRT associated thrush and has not initiated it since. He lost >20 lb's over the past 3 months and felt that his cholesterol can't be bad at this point. Past Medical History: 1. Laryngeal SCC T4 dx [**5-15**] s/p chemo unknown type(still has port in place followed by Dr. [**Last Name (STitle) 17315**] at [**Hospital1 4601**] ) and XRT for 7 weeks 5 days/week ending [**2147-8-17**] Esophageal stricture s/p dilation for stricture [**2147-11-16**] s/p G tube placement CHF preserved EF(records at [**Hospital1 756**]) CAD s/p 3v CABG [**10-14**] HTN-off meds for unclear reason hypercholesterolemia BCC on nose and back Social History: Quit smoking 20 yrs ago after 1ppd x 30yrs Pt admits to 3 shots of vodka a day Family History: Mother died at the age 65 from an MI/CAD Physical Exam: PE-T 98.7 HR 84 BP 100/50 RR 18 O2sats 96% [**Female First Name (un) **] Gen-NAD HEENT-PERRL, mild left mouth droop, severe parotid swelling bilat, no ant or post cerv LAD, erythema and warmth over parotids bilat, neck supple, JVD to 7cm Hrt-RRR nS1S2 [**2-13**] SM at RUSB Lungs-poor air movement, no crackles or wheeze Abd-soft, NT, mod distended, PEG in place with min surrounding erythema and no drainage Extrem-2+ pitting edema to mid shin on left and to ankle on rt Neuro-CNII-XII intact except mouth droop as above, [**4-13**] UE and LE strenth, distal sensation intact Skin-multiple telangiectasias around neck and erythema Pertinent Results: Admission Labs: 134 97 19 ------------<135 4.6 29 0.8 estGFR: >75 (click for details) Ca: 8.7 Mg: 2.2 P: 3.0 D Alb: 3.7 Cholesterol:145 . Iron: 20 calTIBC: 222 Ferritn: 483 TRF: 171 Triglyc: 57 HDL: 52 CHOL/HD: 2.8 LDLcalc: 82 . 10.5 2.7>---<120 29.0 N:87.0 L:8.2 M:3.3 E:1.4 Bas:0.1 Macrocy: 3+ . . OTHER: . . [**2147-12-3**] GBM AB: <3 U/ML [**2147-12-3**] C-ANCA positive Summary of results of proteinase 3 [**Doctor First Name **]: Date Direct [**Doctor First Name **] [**Location (un) **] [**Doctor First Name **] (anti-proteinase 3 titer in units) ---- ------------ -------------- [**2147-12-3**] 301 >65,536 [**2147-12-14**] 147 3,225 [**2147-12-15**] 83 2.304 . [**2147-12-16**] HEPARIN DEPENDENT ANTIBODIES: NEGATIVE . MICROBIOLOGY: [**2147-11-28**] BRONCHOALVEOLAR LAVAGE: GRAM STAIN (Final [**2147-11-28**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2147-11-30**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2147-11-29**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2147-11-29**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending) [**2147-11-28**] Rapid Respiratory Viral Screen & Culture: No Virus isolated so far. STOOL [**2147-11-25**]: negative for c.diff. [**2147-11-28**]: negative for c.diff, shigella, campylobacter [**2147-11-29**]: negative for c.diff . . IMAGING AND PATHOLOGY: . . EKG: sinus rhythm, no change from prior Bronchoscopy report [**11-27**]: Hemoptysis with likely source the anterior segment of the left upper lobe blood cultures: [**2147-11-26**] NGTDx2, [**2147-11-27**] NGTDx2, [**2147-11-29**] NGTDx2 urine cx [**2147-11-25**] <10,000 organisms, [**2147-11-26**] NG, [**2147-11-30**] pending . [**11-26**] CXR: Patchy opacities throughout the left lung are concerning for pneumonia. Small bilateral pleural effusions. . [**11-27**] CXR: Compared with [**2147-11-27**], the moderately extensive left lung infiltrate shows marked interval consolidation, consistent with progressive pneumonia and/or intra-alveolar blood or infarction. Right lung remains grossly clear. No CHF. . [**11-27**] Echo The left atrium is mildly dilated. 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. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate pulmonary hypertension. . CTA CHEST W&W/O C &RECONS [**2147-12-3**] 3:51 PM 1. Interval marked worsening of alveolar consolidations including the entire lungs The findings appear consistent with infection ehich might overlay aspiration, especially in the setting of gradual worsening. 2. No evidence of pulmonary emboli. 3. Small associated bilateral pleural effusions. 4. Mild-to-moderate emphysema, unchanged. 5. Heterogeneous spleen enhancement with rounded hypodense lesions might represent splenic infection. . [**12-2**] Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS. Scant cellularity with bronchial epithelial cells, pulmonary macrophages and blood. . CT NECK W/CONTRAST (EG:PAROTIDS) [**2147-12-4**] 10:17 AM Limited study, without definite fluid collection. Fluid in nasopharynx and upper trachea, with fluid density posterior to left nasopharynx, probably a continuation of nasopharyngeal cavity. No definite abscess. Mild diffuse increase of the subcutaneous fat, especially at the level of the tongue base, which can be due to edema, however, inflammation in this area cannot be totally excluded given the clinical setting. Please correlate with physical examination. . [**2147-12-18**] CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Limited study due to bony artifact from patient's arms in the scanner. Bilateral pleural effusions, intra-abdominal fluid, and anasarca are suggestive of fluid overload. No evidence of retroperitoneal bleed or fluid collections within the abdomen. . Tracheal Wall Bx: Fibrous connective tissue, cartilage and focal ossification. No malignancy identified. . Skin Bx [**2147-12-12**] Skin, left cheek, biopsy (A): Leukocytoclastic vasculitis with adjacent granulomas, some containing fragmented elastic fibers (see note). . . BILAT LOWER EXT VEINS PORT [**2147-12-28**] 4:57 PM No evidence of deep vein thrombosis in the bilateral lower extremities. . CHEST (PORTABLE AP) [**2147-12-28**] 11:31 AM 1. Interval improvement in right mid lung and left upper lung air space opacities, consistent with either resolving pneumonia or resolving pulmonary hemorrhage given history of Wegener's granulomatosis. 2. Increase in right perihilar opacity likely represents worsening mild asymmetric pulmonary edema. Brief Hospital Course: Mr. [**Known lastname 27273**] is a 76 yo gentleman with newly diagnosed laryngeal ca ([**5-15**]) c/b esophageal stricture s/p dilation, who presented with bilateral parotiditis, transferred to the medical ICU with hypoxia and diffuse alveolar hemorrhage. Found to have Wegeners by C-ANCA and skin biopsy. His hospital course is summarized below and by problem subsequently. . Patient was admitted to the ENT service and started on clinda and ceftriaxone. He was later transferred to the medicine service for fevers x 2 d ([**11-25**]). On medicine team, patient was complaining of worsening shortness of breath, and cough with hemoptysis. CXR revealed patchy opacities and CTA revealed multifocal PNA L>R. Patient was treated vanco (started [**11-27**])/levo (started [**11-26**])/clinda (started [**11-23**]). . Patient also had loose stools x 2 d (c diff neg x 2). In addition his Hct dropped from 28--> 24. Aspirin was held. Patient was then transferred to the ICU after bronch and IR procedure for concern of hemoptysis and hypoxia. He continued to have hemoptysis, dried dark blood, small amounts. He continued to be dyspneic but was improving with 40% humidified face mask. He has been noted to be tachycardic in the ICU (sinus) and was given 500cc IVF [**11-29**] with no improvement. He was also restarted on metoprolol at 12.5 tid [**2147-11-28**] which was increased to 25mg tid [**2147-11-29**]. Patient was transferred to the floor [**11-29**] as his respiratory status improved and this RUL bleeding seemed to be stable. . On the floor, patient remained on 40% fm until a.m. of [**11-30**] when he was found to be tachypneic to the 20's. His hematocrit was found to be 22 so he was given 1u prbc. During the transfusion he became increasingly tachypneic, tachychardic and had a fever of 101. He was given 40 IV lasix. ABG was done 7.5/32/67 on 60%. He was then changed to 100% FM and tranferred back to the MICU. . MICU COURSE BY PROBLEM: . # WEGENER'S: Diagnosed [**12-7**] by positive C-ANCA, Anti-GBM negative. Derm biopsy of neck rash demonstrated vasculitis. Patient was transferred to the MICU and reintubated due to increasing hemoptysis and bloody output from ETT. No focal bleeding sites were found on Bronchoscopy [**12-2**]. Patient was started on treatment with Cytoxan 150 mg [**Hospital1 **] for 10 days however this was held on [**2147-12-22**] in the setting of dropping WBC and pancytopenia. He was also treated with Dexamethasone. He also received plasmapheresis starting [**12-7**] for four sessions. He was treated with Vit K and FFP to maintain an INR <1.5. He remained difficult to wean from the ventilator despite no further bleeding. A tracheostopy was placed on [**2146-12-22**] by ENT. Rheumatology was consulted and recommended Prednisone 60 mg daily. Patient was placed on Neutropenic precautions when his WBC reached a nadir of 1.1, although the ANC remained >1000. He was started on Ceftriaxone for a fever on [**12-24**]. He was also treated with GCSF. Cytoxan was restarted once his WBC recovered on [**12-28**], GCSF discontinued. Mr. [**Known lastname 27273**] was eventually able to use the trach collar duing the day with minimal rusty sputum production. Patient spiked a low grade fever to 100.7 on [**12-29**] and was started on Ceftrixone. Repeat sputum cultures have been negative. Prednisone and Cytoxan were continued with close monitoring of his counts. Eventually Rituxan was also added at the request of the rheumatology service. Eventually, the family decided to make the patient CMO due to failing clinical status. At this time, his immunosuppressants (prednisone, cytoxan, and rituxan) were all discontinued. . # RESPIROTORY FAILURE: Patient was intubated in the MICU for diffuse alveolar hemorrhage subsequently diagnosed with Wegener's. The patient was difficult to wean from the vent and ultimately required trach placement by ENT on [**2147-12-22**]. Eventually, he required less support and was maintained on the trach collar during the day with pressure support overnight. He continued to have minimal rusty sputum production with cultures showing sparse oropharyngeal flora. He was very weak secondary to a prolonged hospitalization and possibly steroid myopathy. At one point during his hospitalization, he successfully used a Passy Muir valve; however, his speech was not fully recovered. ENT changed his trach to a 7.0 on [**2147-12-30**]. Laryngoscopy at that time showed laryngeal edema. In addition, Mr. [**Known lastname 27273**] had been fluid overloaded due to IVF he received throughout his admission. He was transiently on a lasix drip and subsequently diruesed with prn lasix IV boluses. Eventually, he began to have increase in bloody secretions. After discussion with the family, he was made CMO and eventually expired secondary to respiratory failure due to diffuse alveolar hemorrhage related to his underlying Wegener's. He was made comfortable at the time of his death with morphine, ativan, and scopolamine to minimize secretions. . # PANCYTOPENIA: Thought to be multifactorial in etiology with largest contributant from cytoxan therapy and possibly Bactrim. Plts nadir at 41 on [**2147-12-19**], Hct nadir 20.7 [**2147-12-18**], WBC nadir 1.1 ANC 1010 on [**2147-12-24**]. Anemia exacerbated by ongoing slow ongoing bleeding, phlebotomy, thrombocytopenia exacerbated by recent plasmapheresis. As described above, patient was transiently on Neutropenic precautions, never frankly neutropenic. He was started on GCSF transiently. Cefepime was used transiently for fever and neutropenia. Patient's lines (left port) and PIV's were monitored closely for infection, blood cx remained negative, sputum with sparse oropharyngeal flora. Patient had loose stool however was negative for C.diff. . #) LARYNGEAL CANCER: Status post chemo and radiation. Recently had esophageal stricture dilated [**11-15**]. Patient was maintained NPO during his admission and given tube feeds. . #) ABDOMINAL PAIN: The patient complained of intermittent abdominal pain, with decreased bs/increased residuals, likely secondary to ileus. This resolved with reglan. . #) PAROTIDIS: This was thought to be secondary to radiation scarring vs. infection. Resolved throughout his admission. . #) CAD s/p CABG: No evidence of active ischemia. He was continued on high dose metoprolol; however, [**Month/Day (4) **] was held due to alveolar hemorrhage. He was also continued on [**Month/Day (4) 17339**] and captopril. . #) NSVT: Patient had recurrent NSVT. Bilateral LENIs ruled out clot. EKG was unchanged. The patient's beta blocker was uptitrated with good effect. . #) HTN: Continued metoprolol, captopril. . #) CODE STATUS: Patient was initially DNR, not DNI; patient was later made CMO by family after clinical status continued to decline and patient had further bloody secretions. . #) DISPO: Patient expired on [**2148-1-20**] secondary to respiratory failure due to diffuse alveolar hemorrhage related to his underlying Wegener's. He was made comfortable at the time of his death with morphine, ativan, and scopolamine. Family was present at the time of expiration and declined autopsy. . Medications on Admission: Roxicet [**12-12**] tsp q4h prn Lopressor 50mg [**Hospital1 **] Lasix 40mg qd [**Hospital1 **] 10mg qd Discharge Disposition: Expired Discharge Diagnosis: 1) Wegener's 2) Diffuse Alveolar Hemorrhage 3) Respiratory Failure 4) Pancytopenia 5) Laryngeal Cancer 6) Acute Renal Failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

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icd9pcs

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45338

Discharge summary

report

Admission Date: [**2196-11-21**] Discharge Date: [**2196-11-29**] Date of Birth: [**2131-2-9**] Sex: F Service: MEDICINE Allergies: Codeine / Percocet / Erythromycin Base / Aspirin Attending:[**First Name3 (LF) 898**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: NIPPV (BiPAP) PICC placement and removal History of Present Illness: Ms. [**Name13 (STitle) 42306**] is a 65 year old female with COPD on 3LNC and steroids at baseline admitted with shortness of breath. Patient was discharged on [**11-7**] for COPD flare on steroid taper by 10 mg/ week, currently at 30 mg daily. She begain feeling SOB yesterday evening and took several nebs. She had difficulty sleeping due to SOB. In the AM, she had gradual worsening of SOB and so took 4 back to back nebs at home without relief. SHe denies fevers, chills, abdominal pain, nausea, vomiting, diaphoresis, diarrhea or constipation. She reports chronic cough and difficulty producing sputum. Has left sided rib pain due to vigorous cough. . In the ED, her vitals were HR 138, BP 133/71, RR 22, 98% on NRB. She appeared to be in respiratory distress and was noted to be wheezing diffusely. She was given azithromycin, 125 mg IV of solumedrol and was started on bipap. She then got ceftriaxone and levaquin for unclear reasons (?pneumonia). She got albuterol nebs x 2 and atrovent neb x 1. She was given 2mg IV of morphine for back pain. Past Medical History: - COPD: PFTs [**7-31**]- FEV1 0.6 (35%), FEV1/FVC 29 (41%); on Advair, Combivent, Spiriva. On 2-3L home O2. - H/o Takasubo cardiomyopathy, EF recovered to >55% as of [**4-/2196**] - Microscopic hematuria, no pathology on CT or on cystoscopy - Back pain; known vertebral compression fractures at T8 (wedge) and T5 and T12 (loss of height) - 5mm nodule at left lung base, stable from [**2193-9-7**] to [**7-31**] - S/p basal cell carcinoma s/p resection [**2184-10-26**] - Esophagitis: dx'd on EGD [**2185**], on PPI - S/p appendectomy at age 20 - S/p CCY at age 25 - S/p TAH at age 32 Social History: Social History: Lives in a [**Location (un) 470**] apartment with her two children. She has one son and one daughter. Pt has been widowed since [**2178**]. Patient worked as a cafeteria worker for 15 years, retiring at age 60. Tobacco: 1-1.5 packs per day x 47 years (Quit in [**12-31**]). EtOH: 4 beers once/month. Drugs: Denies. Family History: Father died of heart attack. Mother died of cervical cancer at age 72. 3 brothers and 2 sisters: 1 brother and 1 sister with emphysema, both smokers. HTN, nephrolithiasis. Sister with with hysterectomy for "cancer". Paternal aunt with breast cancer. No family history of diabetes, liver disease, lung cancer, or colon cancer. Physical Exam: Tmax: 35.9 ??????C (96.7 ??????F), Tcurrent: 35.9 ??????C (96.7 ??????F), HR: 114 (112 - 123) bpm BP: 127/81(92) {91/60(68) - 139/81(92)} mmHg, RR: 15 (14 - 23) insp/min, SpO2: 93% Admission Physical Exam: Gen: ill appearing woman in respiratory distress HEENT: NC, AT, EOMI, PERRLA CV: tachycardic, normal S1,S2, no murmurs Pulm: Wheezes BL, no crackles or rhonchi Abd: soft, NT, ND, +BS Ext: no cyanosis, clubbing or edema Neuro: a+Ox3, cn2-12 intact, sensory and motor intact Pertinent Results: Admission labs: [**2196-11-21**] 10:50AM BLOOD WBC-16.7*# RBC-4.58 Hgb-13.6 Hct-39.6 MCV-87 MCH-29.7 MCHC-34.3 RDW-13.7 Plt Ct-435 [**2196-11-21**] 10:50AM BLOOD Neuts-92.6* Lymphs-5.0* Monos-1.3* Eos-0.8 Baso-0.3 [**2196-11-21**] 10:50AM BLOOD PT-12.3 PTT-27.0 INR(PT)-1.0 [**2196-11-21**] 10:50AM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-140 K-4.0 Cl-100 HCO3-25 AnGap-19 [**2196-11-22**] 02:12AM BLOOD ALT-19 AST-21 LD(LDH)-222 AlkPhos-127* TotBili-0.4 [**2196-11-21**] 10:58AM BLOOD Lactate-2.0 . CXR [**11-21**]: IMPRESSION: Severe emphysematous changes with superimposed pneumonia vs atelectasis within the left lower lung. Recommend PA and Lateral for further evaluation. . ECG [**11-21**]: sinus tachycardia, rate 136, no significant change from prior . CXR [**11-23**]: Left lower lobe is still collapsed. New consolidation at the base of the right lung medially could be contralateral atelectasis or pneumonia. The pattern suggests difficulty clearing secretions or recurrent aspiration. Upper lungs are hyperlucent suggesting emphysema. Heart size is normal. Pleural effusion, if any, is small. . Discharge labs: [**2196-11-29**] 04:46AM BLOOD WBC-14.4* RBC-3.81* Hgb-11.5* Hct-33.5* MCV-88 MCH-30.2 MCHC-34.4 RDW-14.7 Plt Ct-396 [**2196-11-29**] 04:46AM BLOOD Glucose-92 UreaN-17 Creat-0.8 Na-138 K-3.5 Cl-101 HCO3-30 AnGap-11 [**2196-11-28**] 04:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.6 Brief Hospital Course: 65 yo female with severe COPD on chronic steroids admitted with SOB secondary to COPD exacerbation. . #. Shortness of breath: Most likely COPD exacerbation in setting of steroid taper (now at 30 mg/day of prednisone) with concominant LLL pneumonia on CXR. As the patient had been admitted recently, this pneumonia was suspected to be a hospital acquired pneumonia. She also had been treated with levaquin multiple times in the past for COPD flares. Based on those two reasons, the patient was started on azithromycin in addition to vancomycin and zosyn for HAP. She briefly required BIPAP on admission, however did not require other non-invasive or invasive airway during her ICU course. She was quickly transitioned to 4-5L NC and sats remained stable at 88-94%. She is on 4L at baseline. She was initially maintained on nebulizer treatments of albuterol and atrovent, however then switched to Xopinex given her significant tachycardia. She was also started on a short course of high dose steroids of solumedrol 125 IV q 8 hours for 4 days. She was then switched to a long prednisone taper which is currently at 30mg daily. She was started on bactrim prophylaxis for chronic steroid use and frequent exacerbations requiring high doses of steroids. She was evaluated by PT and found to be very deconditioned in the setting of significant lung disease and it was felt that she would benefit from acute pulmonary rehab. She completed 8 days of vancomycin and Zosyn for HAP and her WBC count trended down and she remained afebrile once transitioned to the floor. Her PICC was removed prior to d/c given no further need for IV meds. She should continue bactrim ppx. She will require a slow steroid taper, currently at 30mg daily. Her inhalers were continued on discharge. . #. Leukocytosis: Most likely secondary to hospital acquired pneumonia worsened by high dose steroid use. Trended WBC and it normalized. Monitored fever curve. Continued azithromycin, vancomycin, and zosyn. Azithromycin was discontinued on transfer to the floor. Blood, urine, sputum cultures were negative at the time of discharge. WBC was 14 on the day of discharge and the patient remained afebrile. Her slight leukocytosis was attributed to steroids given she looked clinically well. . # Anxiety: Patient was continued on ativan prn. . #. Osteoporosis: History of vertebral fractures. Continued calcium and vit D. . #. Tachycardia: Patient has longstanding tachycardia. Was euthyroid on last admission, had negative CTA on [**2196-11-1**]. Most likely worsened by increased albuterol use. No evidence of dehydration. Monitored on telemetry and HR improved with antibiotics and improvement in her pulmonary status. . #. Left rib pain: Concern for rib fracture given osteoporosis, however x-ray's negative. Oxycodone was used as needed for pain. . # Ppx: HSQ, bowel regimen, calcium/vitamin D, bactrim . # FULL CODE Medications on Admission: Albuterol nebs Lisinopril 10 mg daily Fluticasone-Salmeterol 250-50 [**Hospital1 **] Omeprazole 20 mg daily Licoderm patch daily Oxycodone 5 mg prn pain Tiotropium Bromide 18 mcg daily Dextromethorphan-Guaifenesin 10-100 mg/5mL [**4-2**] ml prn cough Vitamin D 800 mg daily B12 500 mcg [**Hospital1 **] Ativan 0.5 mg [**Hospital1 **] Prednisone 30 mg daily (10 daily at baseline) Calcium [**Last Name (un) **] 500 TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Cyanocobalamin 250 mcg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed. 10. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 15. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation every four (4) hours as needed for PRN wheezing. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 18. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 19. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED): sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: COPD exacerbation Hospital acquired pneumonia Secondary: Anemia Osteoporosis Discharge Condition: Stable. Sats >92% on 4L NC (baseline O2 requirement) Discharge Instructions: You were admitted to the hospital for respiratory distress. This was thought to be due to COPD exacerbation and pneumonia. You were treated with antibiotics and steroids and your breathing improved. You should continue your medications as previously prescribed. Please keep your follow up appointments as below. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2197-1-5**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2197-1-24**] 9:45

[ "300.00", "733.00", "486", "491.21", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "93.90" ]

icd9pcs

[ [ [] ] ]

9983, 10054

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330, 372

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3273, 3273

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2430, 2757

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2978, 3254

270, 292

400, 1454

3289, 4381

1476, 2065

2097, 2414

83,261

142,523

44639

Discharge summary

report

Admission Date: [**2199-3-4**] Discharge Date: [**2199-3-15**] Date of Birth: [**2128-6-30**] Sex: M Service: MEDICINE Allergies: Phenelzine Attending:[**First Name3 (LF) 2145**] Chief Complaint: fever, acute renal failure. Major Surgical or Invasive Procedure: chest tube insertion History of Present Illness: Mr [**Known lastname **] is a 70M with history of advanced MS, anxiety, CAD status post CABG presenting from nursing home with acute renal failure, fever to 101. . Patient reports feeling unwell for the last few days with diarrhea and dysuria. He was having low grade temperatures with a positive urine culture with proteus bacteria with multiple resistances. For this he was started on Tobramycin 350mg X two doses 12 hours apart starting [**3-3**] in the evening. By morning, patient was febrile to 101, WBC count 2.6, creatinine 4.1 up from 1.1 on [**2-19**]. . Of note patient was recently hospitalized at [**Last Name (un) 4199**] and [**Hospital1 2025**] ([**2-3**] - [**2-12**]) for R sided PNA and COPD exacerbation. He has also had worsening anema from baseline Hct of 39 to 32, with iron deficieny and was started on iron supplmentation last week. Stools have been guaic negative. . In the ED, initial vital signs were T99.3 HR 64 BP 87/48 RR 16 O2 sat 99%. Triggered for hypotension in mid 80s. Foley catheter was placed for urine sample with output of small amount of blood and dark urine. Received 300 cc NS with improvement of his BP to BP100/52 HR71 BP30 O2 sat 98% on 2L. He received vancomycin and levofloxacin. Past Medical History: CAD s/p CABG Multiple Sclerosis COPD Depression Hypertension GERD Osteoarthritis Social History: Previously worked for Delta, long time smoker, currently quit. Resides in a nursing home Family History: No family history of pulmonary disease obtained. Physical Exam: Admission exam Gen: chronically ill appearing gentleman, lying in bed, anxious with tremor HEENT: PERRL, no jaundice. MMM, OP clear CV: RRR, soft systolic murmur at LUSB Lungs: few rales in the R middle lobe, otherwise clear Abd: soft, ND, NT, ABS Ext: thin, warm and well perfused, palp DP pulses Neuro: patient responds to questions, 4/5 strength in all extremities, able to sit up without assistance. Skin: erythema of the buttocks, no skin breakdown. Discharge exam Tm 98.0 BP 141/76 HR 53 RR 18 O2 100% 2L Gen: elderly male, ND, breathing comfortably, very flat affect w/ delayed response HEENT: MMM, PERRL, EOMI, oropharnyx clear CV: RRR, [**1-7**] ejection murmur best at RUSB Pulm: crackles in bilateral bases, w/ decreased BS at R base. CT in place, w/o leakage, no erythema. Abd: BS+, soft, non-tender, non-distended, no HSM Ext: warm, well perfused, no edema, 2+ pulses globally Neuro: A+Ox3, baseline tremor present, CN2-12 intact, weakness in right foot at baseline Pertinent Results: Admission labs [**2199-3-4**] 06:05PM BLOOD WBC-7.7 RBC-3.66* Hgb-10.2* Hct-32.5* MCV-89 MCH-27.9 MCHC-31.4 RDW-14.0 Plt Ct-381# [**2199-3-4**] 06:05PM BLOOD Neuts-66 Bands-4 Lymphs-16* Monos-13* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2199-3-4**] 06:05PM BLOOD Glucose-105* UreaN-26* Creat-5.2*# Na-136 K-4.4 Cl-97 HCO3-27 AnGap-16 [**2199-3-5**] 03:52AM BLOOD Calcium-7.7* Phos-4.2 Mg-1.8 [**2199-3-4**] 06:12PM BLOOD Lactate-1.5 Other labs [**2199-3-5**] 03:52AM BLOOD ALT-12 AST-14 AlkPhos-51 TotBili-0.1 [**2199-3-10**] 05:56AM BLOOD calTIBC-157* Ferritn-280 TRF-121* [**2199-3-6**] 07:07AM BLOOD LDLmeas-<50 [**2199-3-5**] 03:52AM BLOOD TSH-1.0 [**2199-3-6**] 07:07AM BLOOD CRP-142.4* Discharge labs [**2199-3-14**] 06:18AM BLOOD WBC-5.4 RBC-3.17* Hgb-8.5* Hct-27.2* MCV-86 MCH-26.9* MCHC-31.3 RDW-14.6 Plt Ct-311 [**2199-3-13**] 05:09AM BLOOD PT-12.4 PTT-31.4 INR(PT)-1.1 [**2199-3-14**] 06:18AM BLOOD Glucose-92 UreaN-11 Creat-0.8 Na-140 K-3.8 Cl-103 HCO3-33* AnGap-8 [**2199-3-14**] 06:18AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1 CXR [**3-4**]: Right lower lobe consolidation compatible with infection in the proper clinical setting. Recommend repeat after treatment to document resolution of this finding and of nodular opacity in the right mid lung. . Renal U/S [**3-5**]: The right kidney measures 10.5 cm and the left kidney measures 11.7 cm. There is no hydronephrosis seen bilaterally. No cyst or stone or solid mass is seen in either kidney. The bladder is collapsed on a Foley catheter. IMPRESSION: Unremarkable renal ultrasound. No hydronephrosis identified . CT chest [**2199-3-6**] 1. Loculated moderate right pleural effusion. Adjacent consolidation most likely reflecting rounded atelectasis. 2. Nodular opacity seen on the radiograph most likely represents summation of shadows or atelectasis adjacent to the major fissure, 4:108. 3. A loculated pleural effusion and rounded atelectasis are of uncertain chronicity. 4. Right upper lobe 3.5-mm nodule that in the presence of severe emphysema should be reevaluated in one year for documentation of stability. Given the presence of multiple mediastinal lymph nodes, a short-term followup is recommended such as three to six months. 5. Calcified gallstones with no evidence of cholecystitis. 6. Lunate shape of the trachea that might reflect tracheomalacia, if clinically indicated, correlation with dedicated assessment of the trachea is recommended. . TTE [**2199-3-8**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No left ventricular thrombus seen. Mild symmetric LVH with normal global and regional biventricular systolic function. Mild calcific aortic stenosis. Mild mitral regurgitation . Chest CT [**3-8**]: 1. Interval placement of a right pleural catheter with decrease in size of the right pleural effusion and persistent but decreased adjacent atelectasis. 2. Hypodensity of the contents of the left ventricle with possible discrete area of thrombus, although this most likely represents artifact. Although suspicion is low, further evaluation is recommended with echocardiogram . Chest CT [**3-10**]: 1. No significant change in the right hydropneumothorax with drainage catheter in situ. 2. Stable parenchymal changes in the subpleural right lower lobe which could reflect pneumonic consolidation, rounded atelectasis, or a combination of the two. . [**2199-3-7**] 11:06 am PLEURAL FLUID GRAM STAIN (Final [**2199-3-7**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2199-3-7**] @ 1440. FLUID CULTURE (Final [**2199-3-11**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH. Urine culture was done at an OSH, had multi-drug resistant proteus Brief Hospital Course: Mr. [**Known lastname **] is a 70yoM with h/o multiple sclerosis, recent PNA, recurrent UTI, who presents with fever, urinary tract infection and acute renal failure, later found to have strep milleri empyema. . # Urinary tract infection, w/ urosepsis: initially presented febrile and hypotensive to 80's. He was initially in the MICU, but responded very well to IVF, so was called out after 24 hours. He grew resistant proteus, and was started on meropenem. He was initially to complete a 2 week course, but then empyema was found so course of meropenem extended to 28 days minimum. A PICC line was inserted on [**3-8**]. While on meropenem, should check weekly CBC with dif, BUN, Creatinine, and LFTs . # Empyema: Likely related to PNA [**1-4**] prior to admission at [**Hospital1 2025**]. A thoracentesis was done, with chest tube left in place. Fluid was grossly purulent, consistent with empyema. The empyema eventually grew strep milleri. After 48 hours after admission. he was afebrile and breathing well for rest of admission. CT scan on [**3-10**] suggested trapped lung. Thoracic surgery consulted and felt that decortication was not warranted, recommended that the chest tube stay in place for at least 3 weeks, w/ thoracic surgery follow-up at that time. TPA/DNase x2 was used to get out residual empyema. Will continue extended course of meropenem as well. At rehab, chest tube should be flushed w/ 20cc normal saline 2-3 times daily. It should be to bulb suction or water seal. He should have a repeat chest CT scan w/ IV contrast in 3 weeks . # Acute kidney injury: Admission creatinine was 5.1, from a normal baseline. Likely was ATN from diarrhea/dehydration, and pt also has ibuprofen 800mg TID listed on home meds. Was given IVF, diarrhea resolved, and NSAIDs were held. His creatinine returned to baseline of 0.9 upon discharge. NSAIDS should continue to be held. . # Diarrhea: Now resolved. c dif negative, likely viral illness. No abd pain or N/V. . # Multiple sclerosis: per NH records, has been getting tylenol. Written for opiate but not regularly receiving. Continued that therapy in house, and also oxybutynin. . # Depression/Anxiety: Continued mirtazepine, trazadone, and klonopin. Pt declined seeing SW or psychiatry. His affect is very flat. . # Hyperlipidemia - simvastatin was decreased to 40 mg due to black box warning on simvastatin 80 mg. LDL is <50 this admission, so will permanently change simva to 40mg daily. . # CAD s/p CABG [**2184**]: continued aspirin and statin (at lower dose) . # COPD on 2L O2 baseline: continued advair and spiriva with prn albuterol. . # OSA: on bipap at home, but refused in house. . # GERD: continued PPI and H2 blocker. Decrease PPI as no symptoms, and did not want to overdose w/ PPI's . # H/o prostate ca s/p XRT: continued flomax. . # Mild aortic stenosis: will need to be followed long term . # Access on discharge: PICC # Communication: Patient, wife [**Name (NI) **] [**Telephone/Fax (1) 95541**], [**Telephone/Fax (1) 95542**] # Code: Full ============================== TRANSITIONAL ISSUES # Chest CT scan w/ contrast in 3 weeks (to be ordered by outpatient provider) # Should follow up with thoracic surgery in 3 weeks to assess empyema and see if chest tube can be removed # While on meropenem, check weekly CBC with dif, BUN, Creatinine, and LFTs # should have f/u CT chest in [**2-5**] months for left lung nodule # Should see outpatient Neurologist soon to assess for Parkinson's disease, and further depression management w/ psychiatrist. Medications on Admission: spiriva 18mcg daily miralax qday flomax 0.4mg qhs pravastatin 80mg daily imdur 60 mg daily lisinopril 5 mg daily mvi daily omperazole 40mg [**Hospital1 **] oxybutynin 5mg tid advair 500-50 [**Hospital1 **] ferrous sulfate 325mg daily compazine 5mg daily prn senna 2 tabs [**Hospital1 **] prn tobramycin 350mg IV daily first dose 4/1 evening aspirin 325 mg daily hydrocodone-acetaminophen 5-500 q4h prn ibuprofen 800mg tid prn acetaminophen 1000mg q6h prn mirtazapine 45mg qhs trazadone 100mg qhs clonazepam 1mg [**Hospital1 **] prn ranitidine 300mg qhs albuterol neb q6h prn bisacodyl 10mg qhs prn tums 2 tabs qid prn indigestion duoneb q4h prn famotidine 20mg qhs prn fleet enema qday prn fluticasone nasal spray [**Hospital1 **] prn guaifenesin 15mL q4h prn hydrocortisone 25mg suppository qday prn milk of mag prn albuterol 2 puffs q4 hr prn Discharge Medications: 1. diaper,brief, adult,disposable Misc Sig: One (1) diaper Miscellaneous as needed. Disp:*60 diapers* Refills:*6* 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 4. Flomax 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 12. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. hydrocodone-acetaminophen 5-500 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for pain. 16. mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 19. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob/wheeze. 21. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 22. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 23. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 24. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 19 days. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living Discharge Diagnosis: Urosepsis Acute kidney injury Empyema with streptococcus milleri Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for a urinary tract infection, renal failure, and a lung infection. For this, you were treated with antibiotics and IV fluids. Your kidneys recovered very well. You also had a chest tube put in. You improved with these treatments, but will require more antibiotics when you leave, and the chest tube will need to stay in for 3 weeks to completely drain the infected fluid. The following changes have been made to your medications ** START meropenem [antibiotic] ** because you are on meropenem, you will need to have blood work done once weekly at your nursing home. This should be done for you. ** DECREASE omeprazole to 40mg once daily (instead of twice daily) ** STOP ibuprofen ** STOP compazine ** DECREASE simvastatin to 40mg daily (from 80mg daily) Followup Instructions: Department: WEST PROCEDURAL CENTER When: MONDAY [**2199-4-8**] at 12:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2199-4-8**] at 12:30 PM [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2199-4-8**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: ADULT SPECIALTIES When: WEDNESDAY [**2199-4-10**] at 10:20 AM With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1142**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Parking on Site You should follow up with your Neurologist as soon as possible about further care for multiple sclerosis You should follow up with your Psychiatrist as soon as possible about further care for your depression [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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Discharge summary

report

Admission Date: [**2192-1-31**] Discharge Date: [**2192-2-17**] Date of Birth: [**2137-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Fevers, seizure Major Surgical or Invasive Procedure: Central line placement. Lumbar puncture. History of Present Illness: The patient is a 54 year old male with DMII, CAD, and HTN who presented to an OSH after a witnessed seizure. The morning of admission, the patient was found by his wife to have a generalized tonic-clonic seizure with urinary incontinence. The patient received Valium by EMS and was transported to an outside hopsital. There, a head CT was negative and the patient then complained of [**6-5**] SSCP with ?lateral ST changes and received SLNTG x3 and a heparin bolus. As a result, the physicians at the outside hospital contact[**Name (NI) **] [**Hospital1 18**] for ?emergent cath and the patient was sent directly to the cath lab. In the cath lab, the patient was noted to be febrile to 103.8 and had a witnessed GTC seizure, then became obtunded and was emergently intubated with SBPs in 250s. Sedative meds caused a drop in MAPs to 40s, on and off levophed. Neurology was consulted, dilantin loaded, and the patient was given ceftriaxone and transferred to the MICU. According to his wife, the patient had no sick contacts and felt well on the day prior to admission with no mental status changes, myalgias/arthralgias. In the MICU, he was presumed to have pneumococcal meningitis (HSV negative) with ?temporal lobe involvement. The patient completed a 2 week course of ceftriaxone on [**2192-2-13**]. In addition, the patient was found to have a MRSA aspiration pneumonia and was treated with linezolid for a total of a 3 week course. When in the MICU, the patient developed a perioral HSV rash and was treated with acyclovir (last dose on [**2-13**]) and post-extubation, had new delirium and elevated LFTS that were new since admission. He was then transferred to the floor on [**2192-2-13**]. Past Medical History: CAD, DM, HTN, lipids Social History: Lives with wife with 40 pack year smoking history. Family History: Noncontributory. Physical Exam: Tc=99.5 Tm=99.7 P=81 BP=155/84 RR=24 97% on 4 L NC Gen - Obtunded, obese alert, able to follow simple commands, knows name, place, not year, mild jaundice HEENT - PERLA, anicteric, MMM, no oral/perioral lesions Heart - RRR, no M/R/G Lungs - Bilateral rhonchi (transmitted bronchial breath sounds) Abd - Soft, NT, ND, + BS Ext - RUE with convalescent, erythematous papular rash near R hand (unclear if new), SCD bilateral LE, no edema/cyanosis. Neuro - PERLA, wiggles bilateral toes, moves left leg spontaneously but not the right lower extremity however does withdraw to painful stimuli. Downgoing toes on the left with minimal response to Babinski on right. Moves bilateral upper extremities spontaneously and wiggles bilateral fingers. Pertinent Results: CHEST (PORTABLE AP) [**2192-2-12**] 6:13 AM The lungs are clear. LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2192-2-12**] 7:46 PM IMPRESSION: 1. Normal appearance of the gallbladder with no evidence of gallstones or biliary ductal dilatation. 2. Diffusely increased hepatic echogenicity, a finding consistent with fatty infiltration. Other forms of liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded. 3. Simple cyst along the upper pole of the right kidney. CT HEAD W/ & W/O CONTRAST [**2192-2-11**] 9:38 AM IMPRESSION: Pan sinusitis. No evidence of cerebral abscess or change from [**2192-2-5**]. [**2192-1-31**] 10:33PM TYPE-ART PO2-130* PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 [**2192-1-31**] 10:33PM K+-3.2* [**2192-1-31**] 10:33PM freeCa-1.18 [**2192-1-31**] 10:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2192-1-31**] 10:22PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2192-1-31**] 08:54PM GLUCOSE-373* UREA N-22* CREAT-1.2 SODIUM-138 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20 [**2192-1-31**] 08:54PM ALT(SGPT)-31 AST(SGOT)-46* LD(LDH)-373* CK(CPK)-846* ALK PHOS-68 TOT BILI-0.5 [**2192-1-31**] 08:54PM CK-MB-28* MB INDX-3.3 cTropnT-0.73* [**2192-1-31**] 08:54PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-1.9* MAGNESIUM-1.6 [**2192-1-31**] 08:54PM WBC-18.0* RBC-4.27*# HGB-12.8*# HCT-36.7* MCV-86 MCH-29.9 MCHC-34.8 RDW-12.8 [**2192-1-31**] 08:54PM PLT COUNT-200 [**2192-1-31**] 08:54PM PT-14.2* PTT-27.3 INR(PT)-1.3 [**2192-1-31**] 08:44PM CEREBROSPINAL FLUID (CSF) PROTEIN-1419* GLUCOSE-225 [**2192-1-31**] 08:44PM CEREBROSPINAL FLUID (CSF) WBC-26 RBC-[**Numeric Identifier 5519**]* POLYS-91 LYMPHS-4 MONOS-5 [**2192-1-31**] 07:05PM TYPE-ART TEMP-38.3 PO2-135* PCO2-40 PH-7.38 TOTAL CO2-25 BASE XS-0 [**2192-1-31**] 07:05PM K+-3.4* [**2192-1-31**] 07:05PM freeCa-1.21 [**2192-1-31**] 05:27PM TYPE-ART TEMP-38.4 PO2-222* PCO2-46* PH-7.32* TOTAL CO2-25 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2192-1-31**] 05:27PM O2 SAT-99 [**2192-1-31**] 01:40PM GLUCOSE-271* UREA N-16 CREAT-0.6 SODIUM-147* POTASSIUM-2.4* CHLORIDE-117* TOTAL CO2-13* ANION GAP-19 [**2192-1-31**] 01:40PM CK(CPK)-260* [**2192-1-31**] 01:40PM CK-MB-6 cTropnT-0.20* [**2192-1-31**] 01:40PM ALBUMIN-2.7* CALCIUM-5.4* PHOSPHATE-3.4 MAGNESIUM-1.0* [**2192-1-31**] 01:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2192-1-31**] 01:40PM WBC-19.1*# RBC-3.36* HGB-10.1* HCT-30.1* MCV-90 MCH-30.2 MCHC-33.7 RDW-12.8 [**2192-1-31**] 01:40PM NEUTS-71.5* BANDS-0 LYMPHS-22.3 MONOS-5.5 EOS-0.3 BASOS-0.4 [**2192-1-31**] 01:40PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-2+ ACANTHOCY-1+ [**2192-1-31**] 01:40PM PLT SMR-NORMAL PLT COUNT-264 [**2192-1-31**] 01:40PM PLT SMR-NORMAL PLT COUNT-264 [**2192-1-31**] 01:40PM PT-16.8* PTT-38.7* INR(PT)-1.8 Brief Hospital Course: The patient is a 54 year old male with presumed pneumococcal meningitis s/p seizures now with delirium status post extubation and transaminitis of unclear etiology. 1. Pneumococcal meningitis - The patient completed a 14 day course of CTX on [**2192-2-13**]. He was presumed to have pneumococcal meningitis although no organism grew on CSF culture secondary to a high grade pneumococcal bacteremia noticed at an outside hospital. - The etiology of his pneumococcal meningitis is unclear. The CT of his head had shown pansinusitis and further imaging showed no temporal bone involvement. After his transfer to the floor, ENT was consulted to comment on his pansinusitis and whether this may have been the nidus for infection. However, they stated that by the time he was transferred out of the MICU, he did not appear to have clinical sinusitis on physical exam with clear tympanic membranes and nares and there was nothing to drain or to do differently in management. They were unable to comment on whether his pansinusitis may have contributed to his presenting symptoms as they only saw the patient after he had been treated for his pneumococcal meningitis and his symptoms had resolved. 2. MRSA pneumonia - The patient was maintained on Linezolid for a total of a 3 week course which he was to continue as an outpatient for 17 more days since discharge. - His O2 sats were in the high 90s upon discharge on room air. 3. Delirium - Neurology was consulted to see the patient. On exam, the patient at first appeared to be weaker in his right lower extremity in the MICU, however, a CT of the head showed no intracranial abnormality except for pansinusitis. The patient was intended to receive an MRI of the head, however, his symptoms greatly improved before the study could be performed. - It was felt that the patient's delirium was more consistent with a toxic metabolic picture in the setting of pneumococcal meningitis. His ammonia level was normal. He was initially monitored with a 1:1 sitter but this was discontinued as he did not exhibit any unusual, erratic behavior after being transferred out of the MICU. - On the day of discharge, the patient was able to get out of bed, interact appropriately with his nurses and doctors. He was alert and oriented x 3 ( at times, he would say that he was at the [**Hospital **] hospital). He would have intermittent moments of mumbling or strange affect but otherwise, his delirium was slowly resolving. - Neurology had recommended a slow taper of kaletra for his febrile seizures. He remained seizure free after he was transferred from the MICU on kaletra which was then discontinued as it was felt that his seizures were secondary to his meningitis and not from an intrinsic seizure disorder. 4. Transaminitis - The origin of his transaminitis is unclear. However, it is most likely drug-induced as it was new during his admission. The most likely etiology of a drug-induced hepatitis in this patient would be the dilantin load he originally received secondary to his seizures. As a result of his elevated LFTs, his statin was discontinued. His LFTs should be followed as an outpatient and his statin restarted. - An abdominal U/S showed fatty infiltration of liver with diffuse changes and no other abnormalities.. - His ammonia level was within normal limits. 5. CAD - The patient was continued on an aspirin, B-blocker, and ACE. He was discontinued from his statin in the setting of elevated LFTs. The patient was also continued on Plavix. - Of note, the patient never underwent a cardiac catheterization during this admission although he was transferred to [**Hospital1 18**] for emergent catheterization as he had witnessed febrile seizures in the cath lab. 6. HTN - The patient was hypertensive on his maxed out regimen of an ACE and B-blocker. As a result, norvasc 5 mg was added to his antihypertensive regimen. 7. DMII- The patient was continued on a sliding scale, with frequent fingersticks, and NPH was started on [**2192-2-13**] and increased to 6 in am, 6 units in pm. He was discharged on metformin 500 [**Hospital1 **] as well. 8. It was felt by the patient's wife and attending that the patient would benefit most from being at home with his family in his normal environment and receive home visits from a nurse. Thus he was discharged with VNA. 9. After the patient's discharge, a preliminary result from one blood culture showed coagulase negative staphylococcus. As a result, his visiting nurse was called that day and asked to draw 3 sets of blood cultures on her upcoming visit and make sure that the patient had been afebrile. The patient's blood culture appears to have been contaminated with skin flora and did not grow out any organisms in any other blood cultures taken simultaneously. The results of the outpatient cultures were to be sent to Dr. [**Last Name (STitle) **], who would see the patient the following week. Medications on Admission: Seroquel 25 mg [**Name6 (MD) **] [**Name8 (MD) **] NP 4 qam, qpm albuterol q4 prn ipratropium prn olanzapine 5 mg TID prn Captopril 50 mg TID Lopressor 75 mg TID PPI Isordil 10 mg TID Glipizide 10 mg [**Hospital1 **] Linezolid 600 mg IV Q12 Levetiracetam 1 gm Bisacodyl 10 mg PR [**Hospital1 **]:PRN [**2-4**] @ 1216 View Lactulose 30 ml PO Q8H:PRN constipation [**2-4**] @ 1216 View Docusate Sodium (Liquid) 100 mg PO BID [**2-4**] @ 1216 View Artificial Tear Ointment 1 Appl OU PRN Ipratropium Bromide MDI 2 PUFF IH QID Albuterol [**1-29**] PUFF IH Q4H Aspirin 325 mg PO DAILY Heparin 5000 UNIT SC TID Clopidogrel Bisulfate 75 mg PO DAILY Acetaminophen (Liquid) 650 mg PO Q6H:PRN Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 17 days. Disp:*34 Tablet(s)* Refills:*0* 10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. insulin Please take 6 units of NPH insulin in the am and 6 units NPH before bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Pneumococcal meningitis. Delirium. Transaminitis - likely drug-induced. Coronary artery disease. Urinary tract infection. Discharge Condition: Stable. Discharge Instructions: Please call your primary care physician or return to the ER if you experience increased confusion, fevers, or seizures. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **], your cardiologist in 1 week, by calling ([**Telephone/Fax (1) 5455**]. Please follow up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.

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Discharge summary

report

Admission Date: [**2192-10-14**] Discharge Date: [**2193-1-14**] Date of Birth: [**2137-2-23**] Sex: M Service: MEDICINE Allergies: Ceftriaxone / Oxycodone Attending:[**First Name3 (LF) 2145**] Chief Complaint: Free intraperitoneal air and abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, right hemicolectomy, end ileostomy and Hartmann's pouch. History of Present Illness: Per initial surgical HPI: 55M recently discharged after work up for bilateral thalamic stroke, PNA, line infection, NJ feeding tube placement, and UTI, was intubated briefly at that time. Now presenting as transfer from OSH with reports of free air, was presumably seen there from rehab. Unable to answer questions coherently. Medicine Team HPI on [**2192-12-11**] upon transfer to floor which partly summarizes hospital course prior to transfer Briefly, patient is a 55M with hx of morbid obesity, type II DM, OSA on BiPAP, with a very complicated 2 month hospital course s/p Cardiac Arrest on [**11-21**] transferred to the unit for MRSA HAP. In the unit, patient had JP drain placed in an abdominal abscess. He also had a Hct drop with no clear source and had a negative abdominal CT. His Hct has been stable at 25. He also developed a UTI and was started on diflucan. Pt initially presented on [**9-13**] with acute change in MS [**First Name (Titles) **] [**Last Name (Titles) **] weakness, and was found to have bilateral thalamic, and L cerebral peduncle infarcts, transferred to the floor and discharged to rehab (see prior DC summary for details related to initial hospital course). Pt re-admitted on [**10-14**] and found to have intra-peritoneal air and abdominal pain, was taken to the OR and found to have perforated Cecum thought to be secondary to [**Last Name (un) **] syndrome. He had right hemicolectomy and end ileostomy with Hartmann's patch. . His post-op course was complicated by abdominal abscess. The pt developed purulence at his op site and wound was opened and cultured. He was started on Vancomycin on [**10-23**]. Cultures grew MRSA and VRE. CT abd showed large fluid collection. He was intubated on [**10-28**] for inability to manage airway secretions and was started on zosyn. CT abd on [**10-30**] again showed an organizing fluid collection R hepatic flex to pelvis and on [**10-31**] the collection was drained. Fluid grew VRE. He was continued on antibiotics. He also had sputum cultures on [**10-27**] and [**10-28**] with MRSA. In addition CT scan [**2192-11-6**] to evaluate his fluid collections showed an SMV clot. Hematology was consulted and hypercoag labs were sent and he was anticoagulated with heparin bridged to COumadin. . On [**11-20**] pt had CT abd w/ PO contrast via Dobhoff tube for re-eval of abdominal abscess/leak that was drained by a pigtail. Overnight pt triggered for tachypnea and subsequently transferred from East to [**Hospital Ward Name 517**] to the TICU. On arrival to the TICU the pt was in respiratory distress. He was emergently intubated. Following intubation he suffered a cardiac arrest with pulseless VT responding to epi X3. Down time estimated at 5 minutes. He underwent a bronchoscopy on [**11-21**] with cultures growing coag + staph. He was started on Vancomycin and Levaquin. Pt now transferred to the MICU for further medical management. Pt was admitted to MICU [**Location (un) **], following transfer from TICU during which he suffered a cardiac arrest. The pt was intubated and sedated on arrival for Acute Hypoxemic Respiratory Failure thought to be secondary to mucous plugging. The patient was weaned off the vent over the course of his first day and was subsequently extubated without complications. The pt was placed on scoop mask and subsequently transferred to the floor with a 2-3L O2 requirment. The patient was transferred to the floor on [**11-26**] during which time his mental status began to clear. He had been intermittently oriented to [**2192-11-14**] and could discuss the [**Company **]. He received multiple debridements of a sacral ulcer that had been present since his original surgery. A wound culture from [**11-27**] grew e.coli and enterococcus and Zosyn was added to his regimen on [**11-30**]. Of note, his percutaneous drainage tube was removed on [**12-1**] after multiple days of <5cc drainage. On [**12-2**], the patient developed fevers to 100-101. Standard infectious work up was negative with unchanged CXR, negative blood cultures, and U/A with only yeast. ID was consulted and Zosyn was changed to Meropenem out of concern for drug fever on [**12-3**]. However, the patient continued to have fevers. The evening of [**12-5**], the patient had an episode of tachypnea to the 30s without new hypoxia or acidosis on ABG, which resolved by morning. Later he was sent for a repeat CT Torso to evaluate for potential worsening of his abscess. This showed a large and worsened phlegmon at the site of the previous pigtail with a new fluid collection. Upon returning from CT, he was tachycardic to the 130s-140s (sinus) and tachypnic with worsened abdominal pain. Surgery was called but felt his abdomen did not require surgical intervention. He received 1L NS and 10mg PO vit K for a potential IR drainage procedure in the am. He denied chest pain, worsened SOB, N/V. He was not hypotensive and an ABG confirmed the lack of acidosis. . In the MICU, the patient had JP drain placed in an abdominal abscess. He also had a Hct drop with no clear source and had a negative abdominal CT. His Hct has been stable at 25 for two days at time of transfer. He also developed a UTI and was started on diflucan. Past Medical History: -Bilateral Thalamic and Left Peducle Cerebrovascular Accident -Hospital Acquired PNA -Urinary Tract Infection -Central Line Infection -Type II DM -OSA not on CPAP Social History: Works in real estate, and owns several small businesses, including liquor store. Remote smoking history, quit ~10 years ago. No alcohol or drug use Family History: No sudden cardiac death, mother with "a cardiomyopathy" and CHF Physical Exam: Initial Physical exam: Vitals- T 98, HR 130, BP 113/82, RR 37, O2sat 97% NRB Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no rhonchi, no crackles Abd- soft, ? distended, diffuse abdominal tenderness c peritonitis Rectal- guiac neg, no masses (per ER) Ext- warm, well-perfused, no edema Discharge Physical Exam [**2193-1-8**] T97.5 BP 108/79 HR 95 RR 18 O2 96% RA General: Morbidly obese, Mildly ill appearing man in NAD HEENT: nc/at PERRL. EOMI with mild impairment of upward gaze. Dobhoff tube in place. OP clear. No exudate. Patient intermittently squints closing alternate eyes ([**3-17**] double vision) Neck: No JVD appreciated CV: Distant. RRR. No m/r/g Resp: CTA anteriorly Abd: Obese. SOft. Ostomy with brown stool. Ventral incision wound with pink granulation tissue Back: Circular approx 5 by 7 cm sacral decubitus ulcer extending to bone with some surrounding pink granulationt issue, with associated skin breakdown at 2 to 6 oc lock Ext: LUE PICC. R 3rd digit, black nodule, stable, nontender. No c/c/e Neuro: AAO x 3. CN grossly intact. Wiggles toes B/L, can lift LLE off bed, unable to lift [**Month/Day (2) **]. 3/5 strength RUE. 5/5 strength LUE Pertinent Results: ADMISSION LABS [**2192-10-14**] 10:30AM BLOOD WBC-7.3 RBC-5.04 Hgb-12.4* Hct-39.0* MCV-77* MCH-24.6* MCHC-31.8 RDW-13.3 Plt Ct-450* [**2192-10-14**] 10:30AM BLOOD Glucose-212* UreaN-38* Creat-1.0 Na-140 K-4.4 Cl-106 HCO3-20* AnGap-18 Other Selected Laboratory Data [**2192-11-12**] TSH-3.1 [**2192-11-12**] T4-6.6 T3-78* Free T4-1.1 [**2192-11-23**] CRP-182.0* [**2193-1-1**] CRP-28.5* [**2192-11-21**] WBC-15.5* RBC-3.86* Hgb-9.3* Hct-31.6* MCV-82 MCH-24.1* MCHC-29.4* RDW-14.5 Plt Ct-597* [**2192-12-10**] Lactate-1.8 [**2192-12-19**] calTIBC-263 Hapto-346* Ferritn-1217* TRF-202 [**2192-10-14**] 10:30AM BLOOD WBC-7.3 RBC-5.04 Hgb-12.4* Hct-39.0* MCV-77* MCH-24.6* MCHC-31.8 RDW-13.3 Plt Ct-450** [**2192-11-21**] 08:41AM BLOOD CK-MB-NotDone cTropnT-0.16* [**2192-11-24**] 11:16PM BLOOD CK-MB-2 cTropnT-0.04* Negative Factor V Leiden mutation Prothrombin Mutation: No Mutation Detected. Method is PCR amplification and restriction fragment length polymorphism analysis for detection of the [**Numeric Identifier 23885**] G/A mutation in the 3' untranslated region of the prothrombin gene. Discharge Laboratory Data [**2193-1-5**] PT-24.2* PTT-83.7* INR(PT)-2.4* 11/23/08PT-23.9* PTT-31.6 INR(PT)-2.3* [**2193-1-7**] PT-22.3* PTT-31.3 INR(PT)-2.1* [**2193-1-9**] WBC-6.0 RBC-3.62* Hgb-9.4* Hct-28.5* MCV-79* MCH-26.1* MCHC-33.1 RDW-16.9* Plt Ct-392 [**2193-1-9**] PT-25.3* PTT-31.8 INR(PT)-2.5* [**2193-1-9**] Glucose-110* UreaN-32* Creat-0.6 Na-139 K-4.2 Cl-102 HCO3-29 AnGap-12 [**2193-1-9**] ALT-21 AST-23 LD(LDH)-149 AlkPhos-85 TotBili-0.2 [**2193-1-9**] Calcium-9.6 Phos-4.2 Mg-1.9 MICROBIOLOGY DATA [**2192-11-27**] 10:39 am TISSUE Source: Coccyx. **FINAL REPORT [**2192-12-3**]** GRAM STAIN (Final [**2192-11-27**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS & IN SHORT CHAINS. TISSUE (Final [**2192-12-3**]): ESCHERICHIA COLI. MODERATE GROWTH. ENTEROCOCCUS SP.. MODERATE GROWTH. GRAM NEGATIVE ROD #2. SPARSE GROWTH. RESEMBLING ALCALIGENES SPECIES. LEVOFLOXACIN <=2 MCG/ML. CEFEPIME <=2 MCG/ML. MEROPENEM <=1 MCG/ML. sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | GRAM NEGATIVE ROD #2 | | | AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S S CEFTAZIDIME----------- <=1 S <=2 S CEFTRIAXONE----------- <=1 S <=4 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S =>2 R GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S S PENICILLIN G---------- 4 S PIPERACILLIN---------- <=4 S <=8 S PIPERACILLIN/TAZO----- <=4 S <=8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2192-12-1**]): NO ANAEROBES ISOLATED. R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2192-11-9**]): ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | VANCOMYCIN------------ >256 R FLUID CULTURE (Final [**2192-11-4**]) from RLQ: ENTEROCOCCUS SP.. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R 0/08/08 4:15 pm SPUTUM Source: Induced. **FINAL REPORT [**2192-11-23**]** GRAM STAIN (Final [**2192-11-21**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. [**2192-11-21**] 12:16 pm URINE Source: Catheter. **FINAL REPORT [**2192-11-23**]** URINE CULTURE (Final [**2192-11-23**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. YEAST. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LINEZOLID------------- 2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R RESPIRATORY CULTURE (Final [**2192-11-23**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S [**2192-10-23**] 8:56 am SWAB Source: abdominal wound. **FINAL REPORT [**2192-10-27**]** GRAM STAIN (Final [**2192-10-23**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. WOUND CULTURE (Final [**2192-10-26**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**8-/2490**]) immediately if sensitivity to clindamycin is required on this patient's isolate. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ENTEROCOCCUS SP. | | AMPICILLIN------------ =>32 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R =>64 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S =>32 R ANAEROBIC CULTURE (Final [**2192-10-27**]): NO ANAEROBES ISOLATED. [**2192-12-7**] 3:45 pm ABSCESS RIGHT LOWER QUADRANT. **FINAL REPORT [**2192-12-25**]** GRAM STAIN (Final [**2192-12-7**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2192-12-10**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2192-12-13**]): NO GROWTH. FUNGAL CULTURE (Final [**2192-12-25**]): NO FUNGUS ISOLATED. C diff negative x 3 Blood cultures (including mycolytic) from [**1-5**] x 2, [**1-6**] x 2 NGTD All other blood cultures have been negative STUDIES Echo [**2192-12-22**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2192-11-23**], the findings are similar. [**2192-12-23**] CXR FINDINGS: Two AP views. Lung volumes are low. Comparison is made with the previous study done [**2192-12-19**]. There is some motion artifact. Streaky density is again demonstrated at the lung bases consistent with subsegmental atelectasis. Mediastinal structures are unchanged. A feeding tube is again demonstrated and is coiled in the upper abdomen as before, terminating in the region of the gastric body or antrum. Non contrast Head CT [**2192-11-12**] FINDINGS: There are [**Hospital1 **]-thalamic hypodensities, and left mid brain hypodensity, consistent with the site of the patient's previous infarcts, as demonstrated on the previous examination of [**9-14**], [**2192**]. There is no evidence of acute infarct. The remainder of [**Doctor Last Name 352**]-white differentiation is maintained. There is no intra- or extra-axial hemorrhage, mass, mass effect, or midline shift. Ventricles and cisterns are patent. Paranasal sinuses, mastoids and middle ear cavities are clear. Globes, orbits, skull, and extracranial soft tissues are unremarkable. IMPRESSION: No acute intracranial process. Previous infarcts as described above. CT Abdomen Pelvis [**2192-10-24**] IMPRESSION: 1. Large fluid collection extending from the right hepatic flexure into the pelvis. Discussed with Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) 4401**] on [**2192-10-25**]. 2. Bilateral sacroiliitis. CT Torso [**2192-12-6**] IMPRESSION: 1. Right lower quadrant phlegmonous collection at the site of the prior pigtail catheter measuring approximately 6 cm x 8 cm x 7 cm. There is central hypattenuation within this phlegmon, suggestive of fluid. 2. Bibasilar atelectasis and a trace right pleural effusion. 3. 1.3-cm exophytic lesion in the interpolar region of the left kidney, not fully characterized on this study. 4. Sacral decubitus ulcer which extends to the level of the underlying bone, raising concern for osteomyelitis. CT ABdomen/Pelvis [**2192-12-14**] IMPRESSION: 1. Minimal decrease in size of a right lower quadrant collection. 2. No significant change in a collection within the pelvis. 3. No new collections identified. 4. Large sacral decubitus ulcer, directly abutting the sacrum. Although no direct signs of osteomyelitis is seen on this study, the sacrum is at high risk for developing osteomyelitis. 5. Bibasilar consolidation within the visualized lungs, may reflect atelectasis. TTE [**2193-1-7**] The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets 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 fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular pathology or pathologic flow identified. Brief Hospital Course: Mr. [**Known lastname 19484**] has had prolonged hospital course and has been cared for by multiple services. Different parts of hospital course are summarized below by each primary team who cared for the patient at the time. I have also summarized hospital course prior to [**2192-12-11**] (when I assumed care for patient) in my initial HPI. I have subsequently summarized his medical floor course in the last section below which details events from [**Date range (1) 79602**]. -[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2689**]) . Initial Admission/Surgical Course Patient was admitted to Dr.[**Name (NI) 6218**] surgical service on [**2192-10-14**]. In short, the patient is a 55-year-old gentleman who was discharged 3 days ago prior after a month long hospitalization for bilateral acute thalamic strokes. He has had 3 days of abdominal pain and poor p.o. intake. He now presents after evaluation at an outside hospital that showed a significant amount of free air on an upright chest x-ray. Upon house staff examination, decision was made to take patient to the operating room for exploratory laparotomy for probable perforated viscus. During operation, upon entering the abdomen, it was noted that the patient had a distended perforated cecum. It was thinned out and ischemic area on the antimesenteric wall of the cecum with his perforation in the ischemic area. The cecum itself was large and patulous and the perforation was partially walled off with omentum against the right lateral sidewall. There were feculent contents in the peritoneal fluid throughout the abdomen, indicating prior free perforation which had walled off. There was no evidence of gastric or duodenal injury. The sigmoid colon was normal as was the transverse colon and the small bowel. The liver on palpation was also normal. The decision was then made to continue with a right hemicolectomy, end ileostomy and Hartmann's pouch. Blood loss was 150 ml and patient resuscitated with almost 4 liters of crystalloids. Patient tolerated the procedure and there were no complications to the operation. He was immediately transferred to trauma surgical intensive care unit for postoperative monitoring and recovery. Patient remained intubated at this time. . Major Events [**10-14**]: hypotensive responded to fluids; levophed [**10-15**]: weaned off levophed [**10-19**]: started tube feeds via dobbhoff [**10-20**]: cont lasix, cont pressure support [**10-21**]: extubated, doing well overnight [**10-22**]: abx dc'd...desat overnight--low 90's..encouraged to cough. spiked temp--101.5 (axillary) pan cx. possible UTI--urine--cloudy. [**10-23**]: wound grossly purulent, minimally opened by primary team and cultured, VANC started for gpc clusters, CVL changed over wire. [**10-24**]: CT abd: no collections, PO lasix with IV boluses, desated, likely plug ? bronch [**10-27**]: sputum Cx with GPC in pt with hx of Hosp Acquired PNA - Vanc started, [**10-28**]: reintubated secondary to large amount of secretions which patient was unable to clear, on vancomycin, zosyn for hosptial aquired pneumonia [**10-31**]: intrabdominal fluid collection tapped by ultrasound, diuresis to continue; spontaneous breathing trial tolerated for an hour and a half [**11-1**]: successfully extubated [**11-2**]:[**Month (only) **] TF 80/hr, NaCl nebs [**11-4**]: continue aggressive diuresis, no bronch [**11-9**]: failed swallow eval, switched back to PO lasix, coumadin 10mg started for SMV thrombus [**11-12**]: therapeutic on coumadin, dose decreased to 5mg [**Date range (1) 57528**]: Tube feeds continued. Status stable. Continues with 5mg of Coumadin. INR goal= [**3-18**]. [**11-15**]: Transferred to Stone 5. ICU care not required due to stable status. INR 4.4, Coumadin dose decreased to 1mg. Status remains stable until transfer as below. TICU COURSE: On [**11-20**], patient was transferred from East to [**Hospital Ward Name **]. He had respiratory arrest most likely secondary to MRSA Pneumonia and mucus plug. He developed tachypnea, O2 sats 70s on bipap, 80s on facemask, 90s NRB and HR 120s on arrival to unit. Sats on arrival to unit were 86-89 on NRB. He desatted to low 80s in ICU and was intubated with etomidate and succinylcholine. Two to 3 minutes later, pt went into v-tach arrest. He was successfully resuscitated. On [**11-21**] weaned off pressors. Continued on antibiotics. MICU COURSE: [**11-23**] - [**11-26**] Pt was admitted to MICU [**Location (un) **], following transfer from TICU during which he suffered a cardiac arrest. The pt was intubated and sedated on arrival for Acute Hypoxemic Respiratory Failure thought to be secondary to mucous plugging. The patient was weaned off the vent over the course of his first day and was subsequently extubated without complications. The pt was placed on scoop mask and subsequently transferred to the floor with a 2-3L O2 requirment. . In addition the patient was also initially treated for a likely MRSA PNA given fevers and increased sputum. CXR was without supporting evidence. Sputum Cultures grew MRSA however it was felt that this was likely a tracheo-bronchitis rather than a true PNA. . The patient had a known intrabdominal abcess for which surgery had placed a drain. Cultures had previously confirmed VRE however the pt had never been treated with antibiotics. I.D. was consulted and in conjunction with surgery a plan was made to continue treating with IV Linezolid for a duration of 14 days post the plugging of the surgical drain (once it is deemed to no longer be draining adequate ammounts). . The pt was also noted to have an enterococcal UTI in the setting of Vancomycin use. This was treated concurrently with Linezolid. . The pt has a stage III-IV sacral decub. This likely required further imaging and a Plastic Consult. Further imaging was not able to be obtained while the patient was intubated in the unit, however this information was conveyed to the floor team at the time of transfer. . The pt has a hx of SMV thrombosis. The patient presented to the MICU with a supratherapeutic INR in the setting of Coumadin and Levaquin use. The patients Coumadin was initially held, but restarted the date of transfer from the unit. . The patient has a hx of extremely labile sugars. During the patients stay in the MICU, the pts tube feeds were at sub-goal levels. The patient had one episode of FS 30 with hypotension to the 70s, and received 4 Amps of d50. The patients fixed lantus and sliding scales were adjused prior to his transfer from the unit. Recommendations were made to the transfer team for [**Last Name (un) **] to consult on the pt. .. [**Doctor Last Name **] Medicine Course: [**11-27**] - [**12-6**] . The patient was transferred to the floor on [**11-26**] during which time his mental status began to clear. He had been intermittently oriented to [**2192-11-14**] and could discuss the [**Company **]. Plastics was consulted for the patient's stage III sacral decub, who noted that the decub is extending to the sacral fascia but not to the bone, and recommended wound debridement, packing, and continuing Linezolid. He received multiple debridements of a sacral ulcer that had been present since his original surgery. A wound culture from [**11-27**] grew e.coli and enterococcus and Zosyn was added to his regimen on [**11-30**]. Pt triggered [**11-29**] for RR 30's-40s, 94%on 2L. Pt was afebrile at the time, and hemodynamically stable, and abg normal with 7.42/38/85/25/0. It was thought it was likely [**3-17**] mucous plugging. CXR did show possible retrocardiac infiltrate but without cough and white count aspiration PNA or HAP is unlikely. Pt's respiratory rate came down after nebs, and humidifying face mask on fio2 50% Pt does have sleep apnea with bipap at home and maybe a possiblity. We held off on bipap/cpap since pt still at high risk for aspiration. Subsequent CXRs in the following days were negative, and pt remained stable on RA (and no futher episodes of triggers until day of transfer to MICU on [**12-7**]) Concerning the pt's anemia, iron studies c/w ACD (ferritin 801, iron 15). Pt had prior transfusion with Hct 20s, Pt's Hct dropped to 23.2 on [**12-4**], and received 1u PRBC on the [**12-4**]. Pt remained Guaic neg per ostomy. Pt also of italian descent - G6PD consideration, which was negative. Prior to coming to the floor pt's factor V lieden, and prothrombin mutation were also negative. Pt was continued on Coumadin for his SMV thrombosis, and it was not clear to Neuro what caused the SMV thrombosis and the thalamic strokes in the first place (on his prior admisison). Pt's coumadin did become subthereapeutic at one point, and pt was started on Heparin to be continued until he became therapeutic again. Concerning the patient's mental status his delirium initially when he came to the floor improved. Once there was some improvement and pt was able to communicate Neuro was consulted, who did not believe the pt has anoxic brain injury [**3-17**] cardiac arrest. Instead pt's delerium [**3-17**] infections and hospital setting likely bring out the cognitive defects associated with his thalamic stroke causing his decrescendo speech. They also recommended to place his eye glasses and alternating eye patch for his diploplia [**3-17**] stroke to help with delirium. Also pt's DM was well controlled, with [**Last Name (un) **] following, and at no point did the pt become hypoglycemic, and his lantus was up-titrated. His ventral hernia continued to slowly heal. Concerning his percutaneous drain, general surgery's recommendation was to remove the drain after 48h of scant drainage. To ensure that this was the case the pigtail was flushed with 5cc [**Hospital1 **], flushed well, and continued to not have drainage. Surgery then was called, who agreed, and then pulled the drain. tube was removed on [**12-1**] after 48-72h of <5cc drainage. Pt was developing low-grade fevers of 99 axillary, so pt's standing order of tylenol 1g q8 was d/c. On [**12-2**], the patient developed fevers to 100-101. Standard infectious work up was negative with unchanged CXR, negative blood cultures, and U/A with only yeast. The foley was changed but continued to grow only yeast. ID was consulted and Zosyn was changed to Meropenem out of concern for drug fever on [**12-3**] (with urine eos). However, the patient continued to have fevers. Furthermore meropenem was kept on to treat the sacral decub infection presumptively for sacral osteomyelitis. The linezolid was continuing to treat possible MRSA and VRE. The evening of [**12-5**], the patient had an episode of tachypnea to the 30s without new hypoxia or acidosis on ABG, which resolved by morning. On [**12-7**] since the patient continued to have intermittent fevers the only remaining source was that the pt may have reaccumulated his intraabdominal abscess or developed a new abscess. He was sent for a repeat CT torso. This showed a large and worsened phlegmon at the site of the previous pigtail with a new fluid collection. Upon returning from CT, he was tachycardic to the 130s-140s (sinus) and tachypnic with worsened abdominal pain. Surgery was called but felt his abdomen did not require surgical intervention. He received 1L NS and 10mg PO vitamin K for a potential IR drainage procedure in the am. He denied chest pain, worsened SOB, N/V. He was not hypotensive and an ABG confirmed the lack of acidosis. Pt was then transferred to the MICU for closer monitering, and had replacement of intrabdominal drain by IR the next day. MICU course [**Date range (1) 79603**]: Upon arrival to MICU, he was tachycardic, hypotensive with drop in HCT. He was transfused PRBC. CT abdomen did not reveal any new bleeding and showed fluid collection. JP placed by IR for drainage phlegmon. He remained hemodynamically stable and he was transferred back to floor. .. [**Doctor Last Name **] Medicine course organized by problem [**Date range (2) 79604**]: . Sacral decubitus ulcer/Osteomyelitis: While on the floor, patient was continued on Meropenem and Linezolid for presumed osteomyelitis for a sacral decubitus ulcer that extends to bone. He will complete a 6 week course of these antibiotics on [**2193-1-14**]. He had bleeding from this ulcer which resulted in a hematocrit drop and he was transfused. Plastic surgery also saw him at this time and sutured part of the wound that was bleeding. They did not perform any more debridements due to risk of bleeding while on anticoagulation but recommended [**Hospital1 **] to TID wet to dry dressing changes. They did not feel he was a candidate for VAC dressing. His heparin drip was held for [**2-15**] days while we ensured his hematocrit remained stable and he no longer required transfusions. Two weeks prior to discharge, it was noted that he had some surrounding area of skin breakdown with eshar formation. Plastics was reconsulted on [**2193-1-7**] and saw the wound but did not have any further recommendations other than continuing dressing changes. They saw patient and examined wound on day of discharge and recommended wet-to-dry dressing changes with [**Last Name (un) 79605**] x approx. 1 week then follow up with plastic surgery in clinic. Plastic surgery follow-up was arranged at earliest possible appointment. . SMV thrombosis/ CVA: Heparin was initially held x 1-2 days when patient had bleed from sacral decubitus ulcer. Once hematocrit was stable and he did not have any further episodes of bleeding, heparin drip was restarted since benefits of anticoagulation outweighed risks. He was bridged to Coumadin. He did not have any further episodes of bleeding while on anticoagulation. He will likely need lifelong anticoagulation given venous and arterial clots and should have INR followed closely on Coumadin with goal INR [**3-18**]. Regarding his double vision from CVA, neurology recommended alternating eye patches which the patient did not like wearing. They felt his visual problems should improve with time. . Intra-abdominal abscess: For his intra-abdominal abscess (E. coli, VRE) repeat CT was obtained which did not show any new collections. His RLQ JP drain was removed in early [**Month (only) **] and he did not subsequently spike a fever, show any signs of recurrent infection, or have any abdominal pain. . DM 2: For his Type 2 diabetes, he was continued on Lantus which was uptitrated for improved glycemic control and he was continued on humalog sliding scale with good glycemic control. . Anemia: Patient had a chronic anemia which was consistent with anemia of chronic inflammation with elevated ferritin. He did not have any further episodes of bleeding x 2 weeks prior to discharge and hematocrit remained stable. . Hematuria/Candiduria: He had some hematuria in early [**Month (only) **] which was felt to be secondary to foley trauma and resolved after foley was removed. At time of discharge, he was using urinal. Hematocrit remained stable. Patient completed 7 day course of Diflucan for fever and candiduria (from [**12-11**] to [**12-17**]). . Peripheral lesions: On [**1-5**], patient developed black lesion on tongue and right 3rd digit which was initially tender. It was most likely secondary to trauma from fingersticks and possible tongue biting but there was concern for septic emboli. He did not have any signs or symptoms of infection with no fever, no elevated WBC, and no new murmurs. TTE was obtained which did not show any vegetations. Lesion on tongue resolved and lesion on finger was no longer tender at time of discharge. ID was consulted and did not believe lesion was consistent with septic emboli. Blood and mycolytic cultures were obtained on [**1-6**] and showed no growth at time of discharge. Also, despite patient's multiple infections, he never had bacteremia or positive blood cultures. . FEN: Multiple multidisciplinary family meetings were held to discuss various issues including nutrition. The patient's mental status had improved, he was oriented x 3 and was judged to be competent to make his own decisions. PEG tube placement was recommended for nutrition given risks of sinusitis and infection with NGT but pt declined and preferred to keep Dobhoff NGT. He was discharged on tube feeds via Dobhoff. He was regularly seen by speech and swallow therapy who helped him with swallowing exercises and therapy. They recommended performing daily supervised trials of PO puree intake with the speech and swallow therapist. . Code Status: Full Medications on Admission: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 40 Subcutaneous twice a day. Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO every 6-8 hours as needed for pain. 4. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred Four (504) mg PO DAILY (Daily). 5. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours) for 1 doses. Disp:*1 qs* Refills:*0* 6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL Cartridge Sig: Forty Two (42) units Subcutaneous twice a day: Please give qam and qhs. 9. Humalog 100 unit/mL Solution Sig: 8-16 units Subcutaneous four times a day: Humalog insulin sliding scale as directed. See attached. . 10. Outpatient Lab Work Please have CBC and LFTs checked twice per week while you are on antibiotics. 11. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Intravenous four times a day for 2 doses. Disp:*2 qs* Refills:*0* 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Outpatient Lab Work INR should be checked daily until stabilized in therapeutic range of 2.0-3.0. Current warfarin dose of 6 mg once daily may need to be readjusted. 14. Outpatient Occupational Therapy Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Perforated cecum Abdominal abscess and wound infection (MRSA, VRE) s/p JP drain Superior Mesenteric Vein thrombus Hospital Acquired PNA (MRSA) Cardiac arrest in setting of respiratory failure, PNA Urinary Tract Infection (VRE) Stage 4 Sacral pressure ulcer and infection (E. coli, VRE) Probable sacral osteomyelitis Secondary Diagnosis: Bilateral thalamic & left peduncle strokes Type 2 Diabetes Mellitus OSA Discharge Condition: Hemodynamically stable, afebrile, tolerating dobhoff tube feedings, pain free Discharge Instructions: You were admitted to the hospital with perforation of your colon. You had surgery for this and had a hemicolectomy with ostomy placement. You developed multiple infections which were treated with antibiotics. You should continue on two antibiotics, Linezolid and Ertapenem, through [**2193-1-14**]. This is to treat an infection in the bone where you have a sacral ulcer. We are also treating you with a blood thinning medication called Coumadin which you need to take every day. This is to treat a clot you had in your blood vessels. Your dose of this medication may need to be adjusted based on blood levels which need to be followed very closely. You should continue to take long and short acting insulin for you diabetes. We made the following changes to your medications. 1. We added Linezolid and Ertapenem, two antibiotics, which you should take until [**2193-1-14**] 2. We added Coumadin, a blood thinning medication 3. We added Vitamin C, Vitamin D, and zinc 4. We adjusted your insulin doses for your diabetes 5. You are also on a baby aspirin and a statin medication for high cholesterol Below are directions regarding management of your ostomy. Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. -[**Name8 (MD) **] MD with increased ostomy output. Please call your doctor or return to the ER if you develop chest pain, shortness of breath, cough, fever >100.4, chills, abdominal pain, blood in the stool or dark stool, nausea, vomiting, or any other concerning symptoms. Also please call your doctor if you have increased pain, swelling, redness, or drainage from the incision site in your abdomen. Followup Instructions: 1. Please follow-up in infectious disease clinic on [**2193-1-24**]. URGENT CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-1-24**] 1:30. The address is [**Last Name (NamePattern1) 79606**]. 2. Please follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] at [**Hospital 191**] MEDICAL UNIT Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-1-29**] 11:20. 3. Follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 15665**] in 2 weeks. Please call for an appointment. 4. Follow up with plastic surgery: PLASTIC SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2193-1-25**] 2:00 5. Please follow up with Infectious disease: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 79607**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-2-25**] 10:00. This was the soonest appointment we could arrange for you but you may be called with an earlier appointment if there is a cancellation. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2193-1-14**]

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icd9cm

[ [ [] ] ]

[ "86.28", "54.91", "96.71", "99.04", "54.4", "33.24", "96.72", "00.14", "45.62", "96.04", "46.20", "45.73", "96.6" ]

icd9pcs

[ [ [] ] ]

39203, 39275

20275, 36837

330, 413

39748, 39828

7355, 20252

41740, 42822

6036, 6101

37771, 39180

39296, 39296

36863, 37748

39852, 41717

6139, 7336

246, 292

441, 5666

39653, 39727

39315, 39632

5688, 5852

5868, 6020

16,902

167,044

29649

Discharge summary

report

Admission Date: [**2179-2-8**] Discharge Date: [**2179-2-11**] Date of Birth: [**2140-1-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: ORIF of mandibular fractures [**2179-2-9**] History of Present Illness: 30 yo male s/p fall from [**Location (un) **] balcony. +EtOH (301). GCS 7 at scene. He was intubated in the emergency department because of decreaseed mental status. Family History: Noncontributory Pertinent Results: [**2179-2-8**] 04:34AM GLUCOSE-102 UREA N-8 CREAT-0.9 SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15 [**2179-2-8**] 04:34AM CALCIUM-7.7* PHOSPHATE-2.8 MAGNESIUM-2.1 [**2179-2-8**] 04:34AM ETHANOL-273* [**2179-2-8**] 04:34AM WBC-11.9* RBC-5.08 HGB-15.1 HCT-42.9 MCV-85 MCH-29.8 MCHC-35.3* RDW-12.3 [**2179-2-8**] 04:34AM PLT COUNT-221 CT SINUS/MANDIBLE/MAXILLOFACIA Reason: eval for facial fractures [**Hospital 93**] MEDICAL CONDITION: 30 year old man s/p fall. REASON FOR THIS EXAMINATION: eval for facial fractures CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Fall. COMPARISONS: None. TECHNIQUE: MDCT axial images of the sinuses and facial bones were obtained without IV contrast. FINDINGS: There is a linear nondisplaced fracture through the ramus of the right mandible. There is a comminuted fracture through the neck of the left mandible. There is moderate mucosal thickening of the frontal, ethmoid, maxillary and sphenoid sinuses. IMPRESSION: 1. Comminuted left mandibular neck fracture. 2. Nondisplaced linear right mandibular ramus fracture. CHEST (PORTABLE AP) Reason: ?PTX ,,FX INDICATION: Trauma. No prior studies for comparison. AP CHEST RADIOGRAPH: Evaluation is limited by overlying trauma board. Two views were obtained and demonstrate placement of an endotracheal tube which is appropriately positioned. Accounting for technique, the cardiomediastinal silhouette is likely within normal limits and there is no left apical cap. There is no pneumothorax and the osseous structures are unremarkable. IMPRESSION: 1. Endotracheal tube in appropriate position. 2. No acute abnormality. MANDIBLE SERIES INCLUD PANOREX Reason: assess post arch bar placements [**Hospital 93**] MEDICAL CONDITION: 30 year old man with mandib fxs bilat REASON FOR THIS EXAMINATION: assess post arch bar placements HISTORY: Mandibular fracture. Assess stabilization bars. These two examinations consist of a single Panorex view of the mandible and for additional view radiographs of the mandible and face. This patient has previous CT but no comparison radiographs or Panorex views. There is a slightly comminuted fracture of the neck of the left mandibular condyle. There is a dental fixation of both the maxilla and mandible. Unerupted left third mandibular molar tooth. Brief Hospital Course: He was admitted to the Trauma Service. OMFS was consulted because of his injuries; he was ultimately taken to the operating for repair of his bilateral mandible fractures. His jaws are wired shut. Follow up with Dr. [**First Name (STitle) **] is scheduled for Friday [**2179-2-12**] at 1 p.m. His pain is being controlled with Roxicet elixir; instructions for use of wire cutters were provided in the event of an emergency. Psychiatry and Social work were consulted because of his alcohol related issues. He was provided with information on resources for counseling and self help groups. Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). Disp:*1350 ML(s)* Refills:*0* 2. Roxicet 5-325 mg/5 mL Solution Sig: [**6-17**] ML's PO every [**5-14**] hours as needed for pain. Disp:*350 ML's* Refills:*0* 3. Colace 50 mg/5 mL Liquid Sig: Ten (10) ML's PO twice a day as needed for constipation. 4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: s/p Fall Bilateral Mandible fractures Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, increased facial/jaw pain; nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Take your medications as prescribed. You have been given wire cutters for your jaw wires in the event of an emergency such as increased shortness of breath, nausea with vomiting; the wires will need to be cut if any of these symptoms occur. Please notify the Trauma resident on call if this happens by dialing [**Telephone/Fax (1) 13471**] and having the Trauma resident on call paged. Followup Instructions: Follow up with Dr. [**First Name (STitle) **] in [**Hospital 40530**] Clinic located on the [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Hospital Ward Name 516**] on Friday [**2-12**] at 1 p.m. The appointment has already been scheduled for you, if you need to make any changes please call [**Telephone/Fax (1) 274**]. Completed by:[**2179-2-11**]

[ "305.00", "296.7", "E884.9", "802.22", "873.44" ]

icd9cm

[ [ [] ] ]

[ "96.71", "23.19", "96.04", "76.75", "86.59" ]

icd9pcs

[ [ [] ] ]

4055, 4061

2958, 3548

322, 368

4143, 4152

615, 1044

4760, 5124

579, 596

3571, 4032

2375, 2413

4082, 4122

4176, 4737

274, 284

2442, 2935

396, 563

21,900

149,698

50045+50046+59225

Discharge summary

report+report+addendum

Admission Date: [**2198-2-5**] Discharge Date: [**2198-2-14**] Date of Birth: [**2142-12-26**] Sex: F Service: [**Last Name (un) **] CHIEF COMPLAINT: Elevated creatinine. HISTORY OF PRESENT ILLNESS: 55 year old female status post cadaver kidney transplant [**2198-1-18**], complicated by delayed graft function, seen in the office by Dr. [**Last Name (STitle) **] [**2198-1-29**]. Noted erythema at the superolateral aspect of the incision, treated with Keflex x seven days. The patient continued to have outpatient lab work. On [**2-1**], creatinine was noted to have risen from 2.6 to 3.3, with Prograf level of 22. Prograf level was 3 mg b.i.d. That dose was lowered to 2 mg twice a day, and at that time labs were remarkable for a creatinine of 5.1 and a Prograf level of 16.4 on [**2-5**]. The patient was admitted to the transplant unit for further workup. Upon review of systems, the patient denied fevers, chills. No shortness of breath, chest pain, palpitations, cough or cold. No change in bowel habits. Oral intake was poor. No nausea or vomiting. No dysuria. The patient did report persistent hematuria. Reported moderate pain from the incision, with persistence of erythema at the incision site, and the patient's family reported yellow drainage from the wound. PAST MEDICAL HISTORY: Significant for end stage renal disease on hemodialysis secondary to ANCA GN, scleroderma, hypertension, coronary artery disease status post myocardial infarction x 2, status post LAD stent, congestive heart failure with ejection fraction of 30 percent, peripheral vascular disease, and right upper lobe mass which is chronic. History of mycobacterium avium, gastric erosions and anemia. PAST SURGICAL HISTORY: Significant for cadaver renal transplant [**2198-1-18**]. She also had a cadaver renal transplant in [**2189**] that failed. History of total abdominal hysterectomy and bilateral salpingo-oophorectomy, cholecystectomy, and repair of a left femoral aneurysm. History of a peritoneal dialysis catheter needing repositioning x 2. Also a right A- V fistula. SOCIAL HISTORY: Lives at home with family. Continues to smoke. MEDICATIONS AT HOME: Prograf 2 mg p.o. b.i.d. CellCept [**Pager number **] mg twice a day. Bactrim single strength one tab every day. Nystatin swish and swallow 5 mL orally four times a day. Valcide 450 every other day. Protonix 40 mg p.o. daily. Coreg 3.125 mg p.o. twice a day. Albuterol p.r.n. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to the transplant unit alert and oriented in no acute distress, well appearing. Vital signs were stable at 97.6 for temperature, heart rate 78, blood pressure 130/68, respiratory rate 20; 98 percent on room air. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm, no murmurs. Abdomen was soft, nondistended, positive bowel sounds. Incision was clean, dry and intact. A little bit of erythema with approximately 2 cm to the edge of approximately a 6 cm length of superior edge, tender around incision, not specifically tender over kidney. No expressible drainage from the incision. Extremities - No cyanosis, clubbing or edema. The patient was admitted for Prograf adjustment based on levels, and intravenous hydration. An ultrasound was ordered and done on [**2-6**]. This ultrasound revealed mild hydronephrosis with resistive indices of 0.8 to 0.1. Ultrasound also revealed mild hydronephrosis, which was new compared to the exam on [**2198-1-23**]. Again, the resistive indices at the lower and interpolar regions of the transplanted kidney approached 1, with waveforms demonstrating good systolic upstroke with virtually no diastolic flow. This was an acute change compared to the prior exam. The resistive index at the upper pole of the transplanted kidney was approximately 0.8. The patient was evaluated by the renal attending, Dr. [**Last Name (STitle) **], and a transplant biopsy was discussed with the patient and performed on [**2198-2-6**]. At this time, Prograf was held for the elevated Prograf level of 18.8. Prograf was resumed on the second postoperative day at 1 mg p.o. b.i.d. On [**2-7**], the Prograf level came down to 6.6, and Prograf level was adjusted to 2 mg p.o. b.i.d. The transplant kidney biopsy returned with results significant for endothelialitis, significantly more prominent that the tubulitis and significant donor disease, and also acute cellular rejection was noted. ATG was initiated on [**2-7**] at 100 mg for the acute cellular rejection, and a followup tissue typing and crossmatch was sent post-transplant on [**2-7**], prior to initiating ATG, anti-thymocyte globulin. The anti-thymocyte globulin second dose was lowered to 50 mg for white counts of 2.5. She resumed ATG 100 mg on the eighteenth, as her white blood cell count improved slightly to 2.6. At this time, hematocrit was noted to be 25.4, and a transfusion of one unit of packed red blood cells was ordered. Subsequently, the patient developed shortness of breath and acute pulmonary edema after the first unit of blood was transfused. The patient was sitting up in bed using accessory muscles on a scoop mask, looking very uncomfortable. Heart rate was 84, blood pressure 176/84, respiratory rate 28, oxygen saturation 92 percent on three liters. She had bilateral diffuse crackles anteriorly and posteriorly on lung exam, from apex to the base. Heart rate was regular. No murmurs were noted. No pedal edema was noted. The patient was given intravenous Lasix 40 mg x one, and a stat chest x-ray was obtained, as well as an EKG. Chest x-ray revealed pulmonary edema. ABG's were obtained. ABG results were as noted - 7.09/100/58/19/-12. X-ray revealed pulmonary edema. The patient was transferred to the SICU and received a respiratory treatment x 1 and the thymoglobulin infusion was stopped. The patient's urine output remained low after intravenous Lasix. Cardiac enzymes were sent off, and the patient was intubated and further Lasix was given. Of note, during transport to the SICU, the patient became unresponsive and the patient was cyanotic. Anesthesia intubated the patient. Apparently the patient had vomited a little bit prior to becoming unresponsive. Copious sputum was suctioned from the endotracheal tube. During this time, the patient did not lose her blood pressure or pulse. Cardiac enzymes returned with a CK-MB of 17, a troponin of 0.31, and a CK-MB of 10.8. At that time, creatinine was 6, potassium 3.4, sodium 141, chloride 108, CO2 20, BUN 49, calcium 9.5, phosphorus 4.3, magnesium 1.2, hematocrit 24.6. The patient resumed consciousness, remained intubated for a second intensive care unit day. Cardiology was consulted for evaluation of increased enzymes. The patient was monitored by Telemetry. Blood pressure was controlled with intravenous metoprolol and nitroglycerin drip, and volume was removed with further intravenous diuresis. The patient put out 3530 cc of urine, with an intravenous intake of 903 and 370 cc p.o. Breath sounds were improved, but diminished at the bases. Cardiology had also recommended obtaining an echocardiogram. On [**2-12**], a cardiac echo was obtained. The left atrium appeared normal in size. The right atrium appeared normal in size. The left ventricle revealed mild, symmetric left ventricular hypertrophy with normal cavity size. There was some severe regional left ventricular systolic dysfunction noted. No resting left ventricular outflow tract gradient. No left ventricular mass or thrombus was noted. Regional left ventricular wall motion abnormalities include mid anteroseptal hypo, mid inferoseptal hypo. The anterior apex was akinetic. Septal apex akinetic. Inferior apex akinetic, as well as the apex. The right ventricle appeared normal in size and had free wall motion. There was no aortic stenosis, no aortic regurgitation. One plus mitral regurgitation was noted. There was normal tricuspid valve reflux with trivial tricuspid regurgitation. The ejection fraction was 25-30 percent. The patient had excellent diuresis following intravenous Lasix. Renal function was stable, with a creatinine of 3. The new B cell cross match was positive, but there was no clear evidence of antibody mediated rejection on biopsy. The patient was transferred after three days in the SICU to the transplant unit on [**2-12**], where she continued to receive her ATG, for a total of seven doses, as well as Solu-Medrol on a tapering dose. She continued on CellCept one gram b.i.d., and her creatinine continued to trend down to a low of 1.5 on [**2-13**]. Urine output was good, at one liter, 460 cc for 24 hours, with an oral intake of 880 cc. She had stable vital signs, with a high of 169/67 for blood pressure and a low of 113/37, with a heart rate in the fifties to sixties. The patient was beta blocked, and per Cardiology recommendations, she was switched from carvedilol to Lopressor. Of note, the patient's respiratory status was improved. She had been successfully weaned from the ventilator when she was in the intensive care unit, with the patient able to tolerate room air off the ventilator. The patient was comfortable. Denied shortness of breath or chest pain. Of note, the patient was also started on hydralazine 10 mg p.o. q 6 hours per Cardiology recommendations, to get her systolic blood pressure approximately in the range of 120. The patient was discharged home on [**2-14**] after a ten day stay. Vital signs were stable. Urine output was approximately averaging a liter and a half. LABS ON DISCHARGE: The patient's white blood cell count was 3.9, hematocrit 31.6, platelets 132, sodium 138, potassium 4.5, chloride 103, CO2 28. BUN 32, creatinine 1.5, with a glucose of 175. During this hospital stay, the patient's glucoses were elevated, with a low of 120 to a high of 215. She did receive insulin drip in the intensive care unit and on the floor, sliding scale insulin. Given her prednisone dose, 20 mg tapered down to 10 mg on [**2-14**], she was discharged on 10 mg of prednisone, and her glucoses will be monitored on an outpatient basis. She may need an oral [**Doctor Last Name 360**] if glucoses do not improve with steroid taper. Of note, her SK level on discharge was 12.9. Her discharge Prograf level dose was 3 mg orally twice a day. She will follow up in the outpatient clinic. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Doctor Last Name 31787**] MEDQUIST36 D: [**2198-2-14**] 20:45:57 T: [**2198-2-15**] 00:44:31 Job#: [**Job Number 104506**] Admission Date: [**2198-2-5**] Discharge Date: [**2198-2-14**] Date of Birth: [**2142-12-26**] Sex: F Service: [**Last Name (un) **] CHIEF COMPLAINT: Elevated creatinine. HISTORY OF PRESENT ILLNESS: 58 year old female status post cadaver renal transplant on [**2198-1-18**], seen in the office by Dr. [**Last Name (STitle) **] [**1-29**]. Noted a little incision infection, transplant incision infection treated with Keflex x seven days. The patient was followed on an outpatient basis and noted to have an elevated creatinine on [**2198-2-1**] - the creatinine was 3.3 and the Prograf level was 22. The Prograf level dose was reduced from 3 mg twice a day to 2 mg twice a day. On [**2-5**], the patient's creatinine was noted to be 5.1, with a Prograf level of 16.4. The patient was admitted to the transplant unit for further evaluation of elevated creatinine. Review of systems included the patient denying fevers, chills, shortness of breath, chest pain, palpitations, cough, cold. No change in bowel habits. No melena, no bright red blood per rectum, though poor p.o. intake. Patient without explanation why. No nausea or vomiting. No dysuria, though the patient reported persistent hematuria. The patient reports moderate pain from incision, with persistent of erythema. Family reports yellow drainage from wound. PAST MEDICAL HISTORY: Significant for end stage renal disease on hemodialysis, secondary to ANCA glomerulonephritis, scleroderma, hypertension, coronary artery disease status post myocardial infarction x two, status post LAD stent, congestive heart failure with ejection fraction of 30 percent, peripheral vascular disease, right upper lung mass, chronic, history of MAC. History of gastric erosions and anemia. PAST SURGICAL HISTORY: Significant for chronic cadaver renal transplant on [**2198-1-18**]. Also cadaver renal transplant in [**2189**] which failed. History of total abdominal hysterectomy and bilateral salpingo-oophorectomy, history of cholecystectomy and a repair of a left femoral aneurysm, and peritoneal dialysis catheter with repositioning x 2 and a right A-V fistula. Socially, the patient lives at home with family, continues to smoke. MEDICATIONS AT HOME: Prograf 2 mg p.o. b.i.d. CellCept [**Pager number **] mg p.o. b.i.d. Bactrim single strength one daily. Nystatin q.i.d. Valcide 450 mg q.o.d. Protonix 40 mg once a day. Coreg 3.125 mg twice a day. Albuterol inhaler p.r.n. The patient was admitted, received initial intravenous fluid hydration, and ultrasound was obtained on [**2-5**]. Ultrasound of the right kidney transplant revealed mild hydronephrosis, which was new compared to [**2198-1-23**]. Resistive indices at the lower and interpolar regions of the transplant kidney approached 1, with waveforms demonstrating good systolic upstroke with virtually no diastolic flow. This was an acute change compared to the prior exam. It was noted that at the upper pole of the transplanted kidney, the resistive index was 0.8. Nephrology was consulted. The patient was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], and it was decided that a kidney biopsy would be obtained. This was done on [**2-6**], and the patient was not given any Prograf on hospital day one, and the Prograf was held on hospital day two in the morning. This was re-started on hospital day two for a level of 18.1. Prograf was resumed at one mg p.o. b.i.d. Biopsy results returned significant for acute cellular rejection. The patient was initiated on ATG. The patient was also initiated on 500 mg of Solu-Medrol. She received three doses of ATG on separate days. Her white count did trend down to 3.5. It was noted on hospital day five that the patient's crit was low at 25.4. She was ordered for one unit of packed red blood cells. Just after this infusion, the patient was noted to be acutely short of breath. She was sitting up in bed using accessory muscles on a scoop mask, looking uncomfortable. Vital signs were as follows: Temperature 96.2, heart rate 84, blood pressure 176/84, respiratory rate 28, oxygen saturation on three liters 92 percent. She had bilateral diffuse crackles anteriorly and posteriorly. Cardiovascularly, the heart rate was regular, with a normal S1 and S2 without any murmurs. There was no pedal edema. Lasix IV 40 mg x 1 was given. A chest x-ray was ordered stat, and an EKG was done as well. The patient was transferred to the intensive care unit for respiratory distress. Her chest x-ray result revealed pulmonary edema Her EKG was normal. Initial ABG's were 7.09, 100, 58, 19 and negative 12. Upon transfer to the SICU, the patient was briefly unresponsive until arrival in the SICU, where she was cyanotic. She was bagged and her oxygen saturation was 72 and came up to 100 percent with the bag breathing. Anesthesia was called stat to intubate the patient. The patient had vomited a small amount after becoming unresponsive. Once the patient was intubated successfully, the patient was suctioned for a copious amount of sputum, and the sputum was frothy. The patient was ventilated, and further intravenous Lasix was given. The ATG infusion was stopped. Hematocrit was stable. Vital signs were stable, and labs were as follows: Sodium 141, potassium 3.9, chloride 106, CO2 20, BUN 47, creatinine 3. The patient did receive cardiac enzymes that were as follows: Troponin 0.31, CK-MB 17, MBI 10.8. Cardiology recommended that the patient receive a transesophageal echocardiogram to evaluate heart function. She was placed on a nitroglycerin drip as well, given the elevated enzymes, and serial enzymes were drawn. She was further diuresed, and gradually her urine output picked up. The ATG was resumed. She was given a further transfusion of packed red blood cells for a crit of 27. This was followed by some intravenous Lasix. Urine output continued to improve. The patient was weaned from the ventilator with stable vital signs and respiratory function. She remained in the intensive care unit for three days, and was transferred back to the medical-surgical floor on hospital day eight. She continued to get ATG, for a total of seven days. She received a tapering dose of Solu-Medrol, and was initiated on prednisone on the day of discharge to 10 mg. That will be further tapered. Urine output improved to a liter and a half per day. Creatinine trended down to 1.5 on day of discharge on [**2-14**]. LABS ON DISCHARGE ([**2-14**]): Creatinine 1.5, BUN 32, sodium 138, potassium 4.5, chloride 103, CO2 28, glucose 175. Of note, her glucose ranged from a low of 117 to a high of 215. During intensive care unit, she received insulin drip. This was converted to a sliding scale when she was back on the medical-surgical unit, and this was given intermittently based on her lowered prednisone dose. She was discharged without insulin, and she will be followed in the outpatient clinic to monitor the hyperglycemia induced by steroids. She may benefit by an oral [**Doctor Last Name 360**]. Also of note, white blood cell count was improved upon discharge, with a white blood cell count of 3.9. It had trended down to a low of 1.7. Her hematocrit was 31.6 on day of discharge. Vital signs were stable. She was tolerating diet. No respiratory distress, with clear lung sounds. She was switched from carvedilol per Cardiology recommendations, and placed on Lopressor to beta block her, and also received a nitroglycerin patch. This was converted on day of discharge to Imdur 30 mg. Her echocardiogram revealed ejection fraction of 25-30 percent. The left atrium was normal in size. There was mild symmetric left ventricular hypertrophy with normal cavity size. There was severe regional left ventricular systolic dysfunction, with near akinesis of the distal half of the anterior septum and the anterior walls and distal inferior walls. The apex is mildly dyskinetic. No masses or thrombi were seen in the left ventricle. The right ventricular chamber size and free wall motion were normal. The aortic valve leaflets, three of them, appeared structurally normal, with good leaflet excursion and no aortic regurgiation. Mitral valve leaflets were structurally normal. Mild one plus mitral regurgitation was seen. The pulmonary artery systolic pressure could not be determined. There was very small, circumferential pericardial effusion. She was also started on hydralazine. She will follow up in the outpatient medical clinic for further management of her hypertension and coronary artery disease. The patient was discharged on [**2-14**] with creatinine of 1.5. She will stay on 10 mg p.o. daily, Prograf 3 mg p.o. b.i.d., CellCept one gram p.o. b.i.d. Further medications on discharge are Colace 100 mg p.o. b.i.d., metoprolol 75 mg p.o. t.i.d., prednisone 10 mg p.o. daily, hydralazine 25 mg p.o. q 6 hours, Protonix 40 mg one tablet p.o. daily, Imdur 30 mg p.o. daily, Bactrim single strength one tab p.o. daily, Valcide 450 mg p.o. q.o.d., Nystatin swish and swallow 5 mL p.o. q.i.d. after meals and at bedtime. She will follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the transplant center on [**2198-2-19**] at 1 p.m., as well as with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2198-2-26**]. She was in stable condition, with good urine output, and tolerating a regular diet. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Doctor Last Name 31787**] MEDQUIST36 D: [**2198-2-14**] 21:12:51 T: [**2198-2-15**] 01:18:39 Job#: [**Job Number 104507**] Name: [**Known lastname 16976**], [**Known firstname 16977**] Unit No: [**Numeric Identifier 16978**] Admission Date: [**2198-2-5**] Discharge Date: [**2198-2-14**] Date of Birth: [**2142-12-26**] Sex: F Service: [**Last Name (un) **] DISCHARGE DIAGNOSES: 1. Acute cellular rejection status post cadaver kidney transplant. 2. Pulmonary edema. 3. Hypertension. 4. Coronary artery disease. 5. Scleroderma. 6. Peripheral vascular disease. 7. Hypercholesterolemia. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 16979**] Dictated By:[**Doctor Last Name 7504**] MEDQUIST36 D: [**2198-2-14**] 21:18:31 T: [**2198-2-15**] 01:37:52 Job#: [**Job Number 16980**]

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Discharge summary

report

Admission Date: [**2163-4-18**] Discharge Date: [**2163-4-29**] Date of Birth: [**2107-2-1**] Sex: M Service: SURGERY Allergies: Minoxidil Attending:[**First Name3 (LF) 668**] Chief Complaint: Pheochromocytoma Major Surgical or Invasive Procedure: [**2163-4-21**] R adrenalectomy History of Present Illness: 56M history of type 1 diabetes status post deceased donor kidney transplantation on [**2157-3-26**] and pancreas-after-kidney on [**2157-9-18**], the latter which eventually failed. During his past admission from [**Date range (1) 103063**] for nephrolithiasis in the transplanted kidney, an incidental right adrenal mass measuring 4.4cm was seen on CT. Outpatient workup of this lesion included an MRI on [**3-22**] which showed a 4.9 x 4.4 x 4.1 cm mass is located in the right adrenal gland. Elevated urine and plasma metanephrines were consistent with pheochromocytoma. Pt has been on alpha blockade with Terazosyn since [**2163-4-11**], increased on [**4-18**]. He is postural on BP testing with a drop from 160/60 to 140/60 admitted tonight for IV fluids to improve his intravascular stores in preparation for his surgery tomorrow [**2163-4-19**]. Also needs repair of umbilical hernia. Bowels are normal, no abdominal pain. Denies sick contacts, chest pain, shortness of breath . Past Medical History: 1. Diabetes Mellitus, Type I - since age 21 2. ESRD s/p CRT [**3-/2157**] - post-op course complicated by delayed graft function and hydronephrosis s/p ureteral stent and percutaneous nephrostomy in [**3-8**]. Now with [**Date Range **] insufficiency with baseline creatinine 2.0. 3. Pancreas [**Date Range **] [**9-/2157**], rejected [**2158**] 4. h/o Partial SBO - treated conservatively 5. Hypertension 6. Coronary Artery Disease s/p stent of Ramus Intermedius in [**2156**] 7. Paroxysmal Atrial Fibrillation 8. s/p ventral hernia repair with mesh in [**2153**] 9. Orthostatic hypotension 10.Medial malleolar fracture [**8-/2161**] - treated with Keflex and Vicodin. Ortho evaluation [**9-22**] - no infection, no ulcer. . Social History: golf instructor, lives with wife [**Name (NI) **], 3 children, no tob, occ etoh (1 beer daily) Family History: non-contributory Physical Exam: VS: 97.3, 62, 175/78, 18, 100%RA 85.2 kg General: Appears well, engages easily, non-icteric, alert/oriented HEENT: Non-icteric sclera, has had laser surgery, right ear with bandaid s/p mohs procedure, moist mucous membranes, cracked tooth left upper, no LAD Card: III/VI systolic murmur, regular rate and rhythm, no rub or gallop Lungs: CTA bilaterally Abdomen: soft, protruding/reducible umbilical hernia at site of old pancreas incision, + BS Extr: Left leg with bandage on shin, also s/p mohs procedure. 1+ edema bilateral lower extremities, Skin: warm and dry Neuro: EOMI, PERRL, no focal deficits Pertinent Results: [**2163-4-29**] 06:15AM [**Month/Day/Year 3143**] WBC-8.1 RBC-3.28* Hgb-9.2* Hct-28.4* MCV-87 MCH-27.9 MCHC-32.3 RDW-14.3 Plt Ct-439 [**2163-4-25**] 04:40AM [**Month/Day/Year 3143**] PT-14.1* PTT-28.2 INR(PT)-1.2* [**2163-4-29**] 06:15AM [**Month/Day/Year 3143**] Glucose-86 UreaN-51* Creat-2.5* Na-141 K-4.3 Cl-111* HCO3-20* AnGap-14 [**2163-4-27**] 05:32AM [**Month/Day/Year 3143**] ALT-29 AST-15 AlkPhos-58 TotBili-0.4 [**2163-4-29**] 06:15AM [**Month/Day/Year 3143**] Calcium-8.0* Phos-4.9* Mg-1.9 Brief Hospital Course: He was admitted to the [**Month/Day/Year **] service for pre-op management in anticipation of adrenalectomy the next day, but surgery was postponed 2 days in order to continue IV hydration and up titration of alpha blockade per endocrinology to prevent intraop hypertension and postop hypotension. On [**2163-4-21**], he underwent right adrenalectomy and ventral hernia repair with mesh for Pheochromocytoma and ventral hernia. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note. A 19 [**Doctor Last Name 406**] drain was placed beneath the flaps. He had BPs ~ 200 on Nitroprusside with sudden drop to 90s with use of phenylephrine. BP stabilized and pressure support was weaned off. PACU course was notable for extubation and BP stabilized. One unit of PRBC was given. He deveoped hypoglycemia. Several amps of dextrose were given and a 20% Dextrose continuous infusion was given. Endocrinology felt this was due to abrupt catecholamine withdrawal. He was given Hydrocortisone 100mg then prednisone 5mg qd was started. He was transferred to the SICU for management. Dextrose was weaned off and an IV drip was started to prevent ketoacidosis. He was kept npo and given TPN. Abdomen was firmly distended and NG remained in place. Hydralazine was given intermittently for SBP ranging between 170-180s. On [**4-24**], creatinine trended up 3.6 from baseline of 2.5. Possibilities for ARF included hypotension intraop and neoral toxicity. Urine lytes were consistent with ATN. Home dose of Neoral continued at 100mg [**Hospital1 **]. A [**Hospital1 **] U/S was done showing no hydronephrosis or perinephric fluid collection of the left lower quadrant transplanted kidney. Resistive indices ranged from 0.81 to 0.87 which were stable, with a stable slightly echogenic appearance of the transplanted kidney. On [**4-23**], he had a temp of 101.7. UA was positive with 29 wbc, few bacteria and no epi's. He also had a RLL atelectasis and effusion noted on CXR. Cipro was started. Urine culture was negative. Fever abated. He was transferred out of SICU on [**4-24**]. [**Month/Year (2) 2793**] function improved with IV hydration. Diet was slowly advanced and TPN stopped. Insulin drip was stopped and Lantus with sliding scale was added. [**Month/Year (2) **] sugar control improved. IV hydration was discontinued due to some sob. O2 was 96% RA. CXR on [**4-24**] revealed mild pulmonary congestion. CXR on [**4-26**] showed a right lower lobe opacity unchanged, a small right pleural effusion and a tiny left pleural effusion. Pulmonary edema was slightly improved. Mild cardiomegaly was stable His incision developed erythema on [**4-26**] and Vancomycin was started. JP was removed on [**4-27**]. He received 3 days of vanco from [**4-25**] thru [**4-27**] with improvement. Vancomycin was switched to Levaquin for 10 days. Creatinine improved to 2.5. Pathology findings were consistent with pheochromocytoma. PT evaluated and declared him safe for discharge to home. At time of discharge he was amulating independently, vitals were stable and he was tolerating a regular diet. Medications on Admission: Alendronate 70mg PO QWeek, Norvasc 10mg PO QDay, Cinacalcet 30mg PO Qday, Clonidine 0.2mg TD Patch Qweek (sat), Neoral 100mg PO BID, Lasix 20mg PO PRN (last [**4-17**]), Lantus SC 15 AM, 10 PM, Lispro SS, Lisinopril 20mg PO BID, Lopressor 25mg PO BID, Cellecpt 1000mg PO BID, Protonix 40mg PO QDay, Pravastatin 80mg PO QDay, Prednisone 5mg PO Qday, Terazosyn 2 mg PO QHS, Bactrim SS [**Last Name (LF) **], [**First Name3 (LF) **] 81mg PO QDay Last 6 [**Last Name (un) 32460**] ago, Calcium+D QDay Discharge Medications: 1. Levaquin 250 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 13. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 17. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 18. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: pheochrocytoma DM s/p [**Last Name (un) **] [**Last Name (un) **] cellulitis ARF, resolving pheochromocytoma Discharge Condition: good Discharge Instructions: Please call the [**Last Name (un) 1326**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, dizziness, inability to take any of your medication, incision redness/drainage No heavy lifting [**Month (only) 116**] shower Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2163-5-4**] 10:40 Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Date/Time:[**2163-8-12**] 8:30 Completed by:[**2163-5-4**]

[ "733.00", "362.01", "250.51", "357.2", "511.9", "583.81", "996.86", "427.31", "E878.0", "518.0", "458.0", "E849.8", "V45.82", "584.9", "996.81", "553.29", "250.61", "414.01", "227.0", "V10.83", "250.41" ]

icd9cm

[ [ [] ] ]

[ "99.15", "53.59", "07.22" ]

icd9pcs

[ [ [] ] ]

8734, 8740

3398, 6546

285, 319

8893, 8900

2872, 3375

9189, 9453

2216, 2234

7094, 8711

8761, 8872

6572, 7071

8924, 9166

2249, 2853

228, 247

347, 1336

1358, 2087

2103, 2200

43,917

159,529

54712

Discharge summary

report

Admission Date: [**2156-5-19**] Discharge Date: [**2156-5-30**] Date of Birth: [**2125-5-9**] Sex: F Service: MEDICINE Allergies: Penicillins / Shrimp / Mayonnaise Attending:[**First Name3 (LF) 348**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient in a 31yo woman with a h/o recurrent pancreatitis with last episode in [**2152**] presenting as an OSH transfer for pancreatitis with a lipase of 982. Through an interpretter, the patient states that burning epigastric pain awoke her from sleep at 2 a.m. and progrssively began to spread around her flanks to her back and into her L shoulder. The pain was similar in quality to her prior episodes of pancreatitis, but was much more intense. Symptoms were accompanied by nausea and more than 12 episodes of emesis with a green tinge. About half of time, the emesis was tinged with red blood. She also reports HA, blurry vision, and dizziness assoicated with the emesis and limited inspiration due to pain. She denies any alcohol use, changes to her medications including those for HLD, OTC or herbal remedies, no changes in bowel habits, and a normal brown BM yesterday. Labs at the OSH ([**Last Name (un) 11560**]) were notable for lab samples that could not initially be processed to due grossly lipemic collections and lipase of 982. She was given pain medications and anti-emetics and was transfered to [**Hospital1 18**] for possibly plasmapheresis. In the [**Hospital1 18**] ED, she was AVSS w/ ongiong [**8-25**] pain. Labs were notable for WBC of 12.9, ALT 48, AST 24, lipase 514, lactate 1.8, Cr 0.2, Ca 7.6, Mg 1.7, and Phos of 2.0. RUQUS showed an edematous pancrease without a definitive organized fluid collection, no focal lesion in the liver with patent portal veins and a 4 mm CBD, and a surgically absent gall bladder. The patient received 2 mg of IV hydromoprhone and 4 mg of IV ondansetron with minimal symptom relief. VS prior to admission were T 98.9 BP 105/52 HR 88 RR 16 96%on RA. Of note, she reports that this is her fourth episode of intense pain due to pancreatitis. She also reports that in [**2144**] in [**Male First Name (un) 1056**], she underwent a pancreatic biopsy that found "cancer cells," and she underwent a course of radiation therapy but not chemotherapy. Past Medical History: CCY-[**2151**] Recurrent pancreatitis (3x) Hypercholesterolemia Anxiety Gastritis Migraines Hypoglycemia-- patient follows a nutritionist and says she eats 3x a day. Denies hyperglycemia or metabolic syndrome, and says she gets "low blood sugar". No LOC or seizures from this. Tubal Ligation Social History: Patient lives in a shelter with 12 other families in [**Hospital1 487**] MA. Curently smokes, reporting history of 1 pack every 3 days. Infrequent EtOh use, and no history of IVDU. Family History: No history of pancreatitis, gallstones, liver disease or pancreatic disease. No history of cystic fibrosis Physical Exam: ADMISSION EXAM: VITALS: 98.7| BP 98/50| HR 95| RR16 | satting 94% on RA GENERAL: uncomfortable, tearful, moaning in pain. HEENT: PERRL, EOMI. Sclera anicteric. Injected conjunctiva. No oral lesions or ulcers with moist mucous membranes. NECK: no carotid bruits, JVD about 1 cm above clavicle at 90 degrees. Thyroid is full without any nodules appreciated or masses. LUNGS: CTAB. HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft. NBS. Intense TTP in epigastric/RUQ region. No change in symptoms with rebound manuver. Could not appreciate organomegaly. Extremities: No c/c/e. No rashes. NEUROLOGIC: A+OX3. CNII-XII focally in tact. Moving all extremities. DISCHARGE EXAM: VITALS: T 98.4 HR 66 RR 18 BP 95/61 SaO2 98% on RA GENERAL: Obese woman, speaking spanish HEENT: Mucous membranes moist LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Obese, moderately distended, mildly TTP in epigastrum and left side, improved. EXTREMITIES: WWP, no edema NEUROLOGIC: A&Ox3, CNS intact. Moving all four. Follows commands. Pertinent Results: ADMISSION LABS: [**2156-5-19**] 07:10PM BLOOD WBC-12.9* RBC-4.41 Hgb-12.5 Hct-38.5 MCV-83 MCH-28.1 MCHC-34.2 RDW-13.8 Plt Ct-168 [**2156-5-19**] 07:10PM BLOOD Neuts-85.9* Lymphs-10.5* Monos-2.9 Eos-0.5 Baso-0.2 [**2156-5-19**] 07:10PM BLOOD Glucose-105* UreaN-8 Creat-0.2* Na-137 K-3.7 Cl-108 HCO3-19* AnGap-14 [**2156-5-19**] 07:10PM BLOOD ALT-48* AST-24 AlkPhos-61 TotBili-0.3 [**2156-5-19**] 07:10PM TRIGLYCER-2765* [**2156-5-19**] 08:35PM URINE UCG-NEGATIVE [**2156-5-19**] 08:35PM URINE HOURS-RANDOM [**2156-5-19**] 08:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2156-5-19**] 07:24PM LACTATE-1.8 [**2156-5-19**] 07:10PM LIPASE-514* [**2156-5-19**] 07:10PM ALBUMIN-4.1 CALCIUM-7.8* PHOSPHATE-2.0* MAGNESIUM-1.7 [**2156-5-19**] 07:10PM WBC-12.9* RBC-4.41 HGB-12.5 HCT-38.5 MCV-83 MCH-28.1 MCHC-34.2 RDW-13.8 [**2156-5-19**] 07:10PM NEUTS-85.9* LYMPHS-10.5* MONOS-2.9 EOS-0.5 BASOS-0.2 [**2156-5-19**] 07:10PM PLT COUNT-168 Sinus rhythm. Normal ECG. No previous tracing available for comparison. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 95 110 86 378/439 18 51 24 US FINDINGS: Pancreas has no definitive organized fluid collections. The liver is unremarkable with no focal lesions. Main portal vein is patent with appropriate directional flow. Limited views of the kidneys are unremarkable. The common bile duct is not dilated measuring 4 mm. The patient is status post cholecystectomy. No stones are seen within the common bile duct. The spleen is unremarkable measuring 12 cm. Limited views of bilateral kidneys show no evidence of hydronephrosis, stones or masses. IMPRESSION: 1. Patient is status post cholecystectomy. 2. No evidence of CBD dilation or stones. CXR: FINDINGS: The lung volumes are low. Normal appearance of the lung parenchyma. No pulmonary edema. No pneumonia. No pleural effusions. Normal size and shape of the cardiac silhouette. Normal hilar and mediastinal contours. KUB: FINDINGS: There is a non-obstructive bowel gas pattern with air seen in the colon. There is a paucity of bowel gas within small bowel loops. Clips are seen in the right upper quadrant. There is no evidence of free air. Osseous structures are unremarkable. DISCHARGE LABS [**2156-5-30**] 06:10AM BLOOD WBC-5.5 RBC-3.57* Hgb-9.9* Hct-30.5* MCV-86 MCH-27.6 MCHC-32.3 RDW-13.8 Plt Ct-397 [**2156-5-30**] 06:10AM BLOOD Plt Ct-397 [**2156-5-30**] 06:10AM BLOOD Glucose-107* UreaN-8 Creat-0.5 Na-140 K-4.2 Cl-101 HCO3-26 AnGap-17 [**2156-5-23**] 05:25PM BLOOD ALT-19 AST-27 LD(LDH)-303* AlkPhos-55 TotBili-0.5 DirBili-0.3 IndBili-0.2 [**2156-5-28**] 06:00AM BLOOD Triglyc-426* Brief Hospital Course: 31F female with history of recurrent pancreatitis presenting with intense epigastric pain and elevated lipase c/w pancreatitis. #Pancreatitis: This is the 4th time the patient has been hospitalized with pancreatitis, and she reports intermittent epigastric pain at baseline. She reports only minimal alcohol use and most recently about a month ago. Given her hypertriglyceridemia and grossly lipemic blood samples, it seems most likely that her recurrent bouts of pancreatitis are caused by elevated triglycerides. She was adopted, so no family history of hypertriglyceridemia or pancreatitis could be obtained. She also has an unclear history of pancreatic radiation therapy in [**Male First Name (un) 1056**] in [**2144**] after a biopsy showed "cancer cells," but her first episodes of pancreatitis predate that procedure. She was made NPO and given IVF boluses and a basal rate of 250cc/hr, but had only minimal urine output and began to have progressively more abdominal distension suggesting extravascular fluid accumulation. Her O2 sats remained in the 90s on room air, and her lung exam was clear. For pain, she was started on a morphine PCA, but despite escalating doses, her pain was very difficult to control. She required Dilaudid PCA followed by Dilaudid IV. She was then transitioned to Dilaudid PO with good results. She eventually tolerated PO without significant pain. #Hypertriglyceridemia: patient with TG close to 3000 on admission. Responded well to fluids. Once tolerating PO, gemfibrozil was started. TG on discharge were ~600. Appointment was made for lipid clinic, however unable to be seen until [**Month (only) **]. #Hypotension: In the afternoon on the day of admission, she developed SBPs in the 70s-80s and appeared progressively more drowsy, although her RR remained in the high teens, and she continued to moan in pain. Distributional shock due to the pancreatitis with accumulation of extravascular fluid despite aggressive resuscitation was considered to be likely. Given her ongoing need for aggressive fluid resuscitation and concern for acute pulmonary edema, she was transferred to the ICU for hemodynamic instability and a possible imminent need for pressors and airway protection. Upon arrival to floor,patient was normotensive and did not require any management of hypotension. #Anxiety/Agitation: patient had numerous episodes of anxiety/agitation. She stated she was unhappy with the care here, and that she wanted to report the hospital news agencies. She also complained of anxiety and responded well to 0.5mg Ativan. She eventually had less complaints as her panreatitis improved. #Depression: patient takes Celexa 20mg PO at home. It was re-started once she was able to tolerate PO medication. . #Hematuria: likely [**12-18**] to traumatic straight cath versus contamination from menses. considering patient had no si/sx of UTI, decision was made to hold off on empiric treatment or urine cx. #Hx of gastritis: patient was treated empirically with PPI while in house. No acute exacerbation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Greater [**Hospital1 **] Family Health Center. 1. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 2. Loratadine *NF* 10 mg Oral qd 3. Citalopram 20 mg PO DAILY 4. Ranitidine 150 mg PO DAILY 5. Propranolol 20 mg PO BID Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Gemfibrozil 600 mg PO BID RX *gemfibrozil 600 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. Ranitidine 150 mg PO DAILY 4. Propranolol 20 mg PO BID 5. Loratadine *NF* 10 mg Oral qd 6. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 7. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Primary- Acute pancreatitis Hypertriglyceridemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**First Name8 (NamePattern2) 13621**] [**Last Name (NamePattern1) 1004**], It was a pleasure to treat you at [**Hospital1 18**] for your pancreatitis. Your pancreatitis occurred as a result of your high trigylceride levels. You were treated with bowel rest, fluids, and pain medication. When you were able to tolerate eating and drinking, we started you on a medication to decrease your triglycerides (called gemfibrozil). Please take the medications we have prescribed you, and keep the appointments we have made. Followup Instructions: Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 91317**] Phone: [**Telephone/Fax (1) 63099**] Appointment: Monday [**2156-6-7**] 10:50am Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2156-6-9**] at 2:00 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 79190**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2156-7-1**] at 8:00 AM With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], M.D. [**Telephone/Fax (1) 62**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2156-6-1**]

[ "272.1", "599.71", "278.00", "305.1", "535.50", "275.41", "785.59", "276.69", "271.3", "577.0", "584.9", "346.90" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10557, 10563

6768, 9825

307, 313

10662, 10662

4042, 4042

11366, 12401

2881, 2989

10191, 10534

10584, 10641

9851, 10168

10813, 11343

3004, 3657

3673, 4023

253, 269

341, 2351

4059, 6745

10677, 10789

2373, 2667

2683, 2865

8,569

167,127

9328+9329

Discharge summary

report+report

Admission Date: [**2113-7-29**] Discharge Date: [**2113-8-1**] Date of Birth: [**2044-11-30**] Sex: M Service: Urology REASON FOR ADMISSION: Admitted for observation after a nephroureteral stent placement on [**7-28**], after which he had an episode of hypotension. HISTORY OF PRESENT ILLNESS: A 68-year-old male with a ileal loop urinary diversion, who presented with distal left ureteral obstruction with hydronephrosis and a minimally functioning right kidney, who had a left nephroureteral stent placed by IR. Status post procedure, the patient experienced chills and a drop in blood pressure and became tachycardic but was afebrile at that time in the operating room. In the Postanesthesia Care Unit temperature came up to was admitted for observation. PAST MEDICAL HISTORY: 1. Bladder [**Last Name (un) 3711**] rwith positive LN's. 2. Hypertension. PAST SURGICAL HISTORY: Radical cystectomy, ileal loop diversion. ALLERGIES: HALDOL and AMBIEN. MEDICATIONS ON ADMISSION: Atenolol, Prilosec, Colace, vitamin, psyllium, Benadryl. PHYSICAL EXAMINATION ON ADMISSION: Physical examination was unremarkable except for the urostomy which was bloody, status post stent placement. LABORATORY ON ADMISSION: Admission white blood cell count was 11.4. HOSPITAL COURSE: Later on during the night he became hypotensive and was bolused until his pressure was re-established. On [**7-29**], he had a temperature maximum of 100.3, and 99.5 was his current temperature in the morning. His blood pressure dropped to 82/45 with a white blood cell count which increased to 23.8. He was immediately transferred to the Medical Intensive Care Unit for a more monitored setting where he was bolused, and his pressures came up to 100/60, eventually reaching 130s/70s to 150s/70s, with a heart rate around 90 the following day. Infectious Disease was consulted, and they advised that we start the patient on ceftazidime and vancomycin, which was done. Cultures taken from the patient were still pending and were negative. The patient was taken to the Medical Intensive Care Unit on [**7-30**] where it was again noted that his baseline creatinine was in fact 5, and there was no acute renal insufficiency. In the Medical Intensive Care Unit, even though his pressure was kept up, he was receiving normal saline at 250 cc an hour and received two to three boluses. His pressures remained good, and his urine output remained sufficient as well. On [**7-30**], the patient was then transferred back to the floor out of the Intensive Care Unit continuing his regimen of vancomycin and ceftazidime, and his pressure remained good. On hospital day three, we found that his 4 a.m. laboratories returned with a white blood cell count of 23.4 which was up from a [**7-30**] complete blood count white blood cell count of 22.7. The decision was made to keep him one more day for intravenous antibiotics and to discharge him home on [**8-1**] with p.o. antibiotic regimens. Follow up with Dr. [**Last Name (STitle) 9125**]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2113-7-31**] 10:23 T: [**2113-8-2**] 14:07 JOB#: [**Job Number 31909**] Admission Date: [**2113-7-29**] Discharge Date: [**2113-8-1**] Date of Birth: [**2044-11-30**] Sex: M Service: ADDENDUM TO DICTATION DONE ON [**2113-7-31**]: Mr. [**Known firstname **] [**Known lastname 31910**] was discharged today on [**2113-8-1**] with ten days good and stable condition and had remained afebrile for the previous 24 hours. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2113-8-3**] 19:00 T: [**2113-8-3**] 19:00 JOB#: [**Job Number 31911**]

[ "593.89", "458.9", "V12.59", "997.5", "591", "V10.51", "593.4", "285.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "59.8" ]

icd9pcs

[ [ [] ] ]

1007, 1086

1300, 3979

905, 980

313, 780

1237, 1281

802, 880

7,628

194,402

26622

Discharge summary

report

Admission Date: [**2170-1-2**] Discharge Date: [**2170-1-6**] Date of Birth: [**2113-1-28**] Sex: M 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: [**2170-1-2**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary to left anterior descending, radial artery to obtuse marginal and vein graft to diagonal. History of Present Illness: Mr. [**Known lastname **] is a 56 year old male with known coronary artery diseae and prior stent placements in [**2169-4-24**]. Followup exercise tolerance test in [**2169-10-25**] revealed new ischemic changes. Subsequent cardiac catheterization in [**2169-11-24**] showed a 50% ostial left main lesion, 70% ostial LAD stenosis, 70% ostial cirucmflex lesion, and patent stents in the PDA and RCA. LV gram at that time, showed an LVEF of 57%. Based upon the above, he was referred for cardiac surgical intervention. Patient is asymptomatic. He denies chest pain, shortness of breath, dyspnea on exertion, orthopnea, PND, palpitation, syncope, and pedal edema. Past Medical History: Coronary artery disease, Prior placement of drug eluding stent to RCA in [**2169-4-24**], Prior placment of bare metal stent to proximal PDA in [**2169-4-24**], History of Bilateral Vein Stripping, s/p Bilateral Hernia Repair as infant, s/p Tonsillectomy Social History: Quit tobacco over 20 years ago. He denies ETOH. Patient is unemployed. He is married and lives with his wife. Family History: Mother CABG at 65. Uncle underwent heart transplant. Physical Exam: Vitals: BP 114/74, HR 64, RR 14 General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, no carotid bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, Pulses: 2+ distally, normal Allens Test Neuro: nonfocal Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent three vessel coronary artery bypass grafting by Dr. [**Last Name (STitle) 1290**]. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated.Transferred to the floor on POD #1 to begin increasing his activity level.Chest tubes and pacing wires removed on POD #2 and #3. Beta blockade titrated and he made good progress. Cleared for discharge to home with services on POD #4. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: Toprol XL 50 qd Plavix 75 qd Aspirin 325 qd Zocor 40 qd Zinc, Vitamin C, MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. 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:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Coronary artery disease - s/p CABG, Prior placement of drug eluding stent to RCA in [**2169-4-24**], Prior placment of bare metal stent to proximal PDA in [**2169-4-24**], History of Bilateral Vein Stripping, s/p Bilateral Hernia Repair as infant, s/p Tonsillectomy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**3-29**] weeks Dr. [**Last Name (STitle) 5874**] in [**1-27**] weeks Dr. [**Last Name (STitle) **] in [**1-27**] weeks Completed by:[**2170-1-19**]

[ "414.01", "412", "V15.82", "V17.3", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.04", "99.05", "39.61", "89.60", "36.12" ]

icd9pcs

[ [ [] ] ]

4379, 4441

2077, 2724

332, 520

4751, 4758

5077, 5266

1631, 1685

2851, 4356

4462, 4730

2750, 2828

4782, 5054

1700, 2054

280, 294

548, 1210

1232, 1488

1504, 1615

27,634

196,120

2828

Discharge summary

report

Admission Date: [**2137-7-1**] Discharge Date: [**2137-7-4**] Date of Birth: [**2103-1-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Nausea, vomiting. Reason for admission: Diabetic ketoacidosis. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 34 year old woman with type I DM who initially presented to an OSH ICU with nausea and vomiting. Had been feeling unwell for ~1wk with complaints of N, V, polyuria. She left OSH AMA as she was not pleased with the care. She still had nausea and vomiting, however, and presented to [**Hospital1 18**] ED. In ED the pt was exhibiting Kussmaul breathing and was tachycardic. BP and oxygenation was normal. Aggressive IVF was started and she received units of insulin. Initial laboratories were notable for at gap of 28 and a bicarbonate of 6, glucose of 239. Insulin drip was started. Ondansetron was given for persistant nausea. Pts breathing appeared more comfortable a few hours later. Repeat chemistries revealed AG of 21, bicarbonate of 8 and a glucose of 139. Potassium repletion was started and pt was transferred to the MICU for further monitoring. . On arrival to MICU, pt reported feeling better, however she was still nauseous and had dry heaves while being interviewed. She denied any recent infection, fever, chest pain, dyspnea, melena or BRBPR. No dysuria or urgency. There were no changes to medications and she reported compliance with her insulin and denied dietary indiscretion. . Past Medical History: 1) Type I diabetes, diagnosed at age ~16yo. Has retinopathy & nephropathy. [**11/2135**] A1c 8.5. On insulin, followed by Dr. [**Last Name (STitle) 3273**] of [**Hospital **] clinic. 2) Hypothyroidism, no longer on thyroid replacement. Unclear why. 3) Depression, on no medications. Had been referred to [**Hospital1 **] psychiatry by social work several years ago but pt did not follow up. 4) Hyperlipidemia. Social History: Has a boyfriend. Father living, mother died years ago. Has not worked for over 10yr. She does not smoke or take alcohol, nor does she use recreational drugs. Has struggled with depression and social isolation for years. Was previously student at [**State 350**] College of Art, stopped before graduating as it was apparently very stressful. Family History: Her mother died of sarcoidosis some two years ago. There is no significant other family history of note. Physical Exam: T 99.4 BP 116/76 P 88 RR 16 O2 100 on RA Gen: Thin, unhappy appearing Caucasian woman. NAD except when retching. Eyes: Anicteric, non injected Mouth: MM dry, no lesions. Neck: Supple Chest: CTA anteriorly Cor: RR, nl S1S2, no murmur Abd: Flat, NT/ND. Ext: No edema Neurol: Alert, oriented x 3. MAE Pertinent Results: Admission CBC: WBC-15.6* RBC-4.15* Hgb-14.3 Hct-40.5 MCV-98# MCH-34.6*# MCHC-35.4* RDW-13.9 Plt Ct-289 Admission Chemistries: 02:08PM BLOOD Glucose-239* UreaN-9 Creat-1.2* Na-144 K-4.8 Cl-110* HCO3-6* AnGap-33* 06:20PM BLOOD Glucose-139* UreaN-7 Creat-1.0 Na-144 K-3.5 Cl-115* HCO3-8* AnGap-25* [**2137-7-2**] 04:11AM BLOOD Glucose-101 UreaN-7 Creat-1.0 Na-143 K-3.3 Cl-118* HCO3-14* AnGap-14 . Endocrine TSH-97* Free T4-0.23* Cortsol-17.0 Stim p 0.5 hr Cortsol-33.3* Stim p 1 BLOOD Cortsol-41.5* . CXR [**7-1**]: No acute cardiopulmonary process. Stable thoracolumbar scoliosis. . Discharge labs: [**2137-7-3**] 03:58AM BLOOD WBC-7.7 RBC-3.38* Hgb-11.2* Hct-31.3* MCV-93 MCH-33.2* MCHC-35.8* RDW-13.8 Plt Ct-215 [**2137-7-3**] 12:19PM BLOOD Glucose-145* UreaN-4* Creat-0.7 Na-137 K-3.8 Cl-106 HCO3-17* AnGap-18 Brief Hospital Course: This is a 34 year old type I diabetic female with history of hypothyroidism and depression. She presented with nausea and vomiting and was found to be in diabetic ketoacidosis. . 1) Diabetic ketoacidosis: Initial anion gap was 28, ketones were present in her serum and urine. Mental status appeared normal though the patient was very lethargic. Initially tachypneic and tachycardic but this quickly resolved with insulin and IVF. She was admitted to MICU for management of DKA. She was maintained on insulin drip and IV fluids until the morning of HD 2 when her anion gap closed. Long acting insulin was started, the patient started to eat, albeit reluctantly. [**Last Name (un) **] was consulted and her NPH insulin was uptitrated to 14 units qam and 12 units qpm with a humalog sliding scale. She was discharged home on this regimen with close [**Last Name (un) **] follow up. Prior to discharge she received insulin teaching and the importance of her taking her medication was reinforced. The patient expressed an understanding of this. . 3) Nausea/vomiting. Most likely DKA related, though viral gastroenteritis or other infection possible. There was no evidence of obstruction. Blood cultures and urine cultures were unrevealing. Patient was initially given PRN zofran and compazine, however her nausea quickly resolved and she began tolerating a regular diet. . 4) Hypothyroidism: diagnosis established many years ago, yet not on replacement at home. Found to have markedly elevated TSH of 97. Endocrine was consulted and recommended loading with T4 IV and then she was restarted on levothyroxine 100mcg daily. She will have repeat TFTs in 6 weeks. . 5) Depression/social issues: chronic issue for over a decade. Patient was not on anti-depressants on admission. Patient has a h/o social isolation. She denied SI/HI. Of note, the patient and her boyfriend attempted to sign out AMA the night of HD2, psychiatry was consulted and did not believe she was competent to make this decision--section 12 was implemented. Following transfer to the floor psychiatry reevaluated the patient and did not feel there was any acute psychiatric need to keep the patient in the hospital. The patient expressed understanding of her illness and the importance of compliance with her medications. Neuro-psych testing was recommended as an outpatient and this was scheduled prior to discharge. . 6) PPX: TEDs, ambulation . 7) FEN: Diabetic diet. Electrolytes were closely monitored and aggressively repleted. . 8) Code: full Medications on Admission: Insulin--NPH and humalog--dose unknown. Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 3. Humulin N 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous with breakfast. Disp:*1 vial* Refills:*2* 4. Humulin N 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous with dinner. 5. Humalog 100 unit/mL Solution Sig: as directed as directed Subcutaneous four times a day: please administer with meals as directed by sliding scale provided to you. Disp:*1 vial* Refills:*2* 6. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] four times a day. Disp:*1 box* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Nausea/vomiting Hypothyroidism Discharge Condition: Afebrile. Tolerating PO. Nausea and vomiting resolved. Discharge Instructions: You were admitted to the hospital for complications due to your diabetes. Your blood sugar was found to be significantly elevated and you had multiple metabolic abnormalities because of this. . You were seen by the diabetes specialists at [**Last Name (un) **] and were put on an insulin regimen which you should adhere to at home. You should continue NPH 14 units at breakfast and 12 units at dinner. You should also follow the insulin sliding scale which has been provided to you. You should follow up at the [**Last Name (un) **] as detailed below. . While in the hospital your thyroid was found to be profoundly low. You were started on thyroid replacement and will need to continue this each day. You will need to have your thyroid function tests checked at [**Last Name (un) **]. . You were evaluated by psychiatry while in the hospital. They recommended follow up with them as an outpatient, however you declined this. They also feel that you will benefit from neuro-psychologic testing for further evaluation. You have been scheduled to have this done with [**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) **] on [**2137-8-6**]. . If you experience increased urination, increased thirst, inability to eat, high fevers or other concerning symptoms please return to the emergency department. . Please continue your medications as directed. Followup Instructions: Please follow up for neuro-psychological testing. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1387**] Date/Time:[**2137-8-6**] 12:00 . Please follow up with Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] at [**Last Name (un) **] on [**7-30**] at 2pm. Pleae call ([**Telephone/Fax (1) 4847**] with any questions. . You should schedule an appointment with a new PCP. [**Name10 (NameIs) **] you wish to be followed here you can call [**Company 191**] at [**Telephone/Fax (1) 250**] to schedule an appointment with a new PCP.

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52886

Discharge summary

report

Admission Date: [**2201-4-13**] Discharge Date: [**2201-4-24**] Date of Birth: [**2121-8-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: Altered mental status, s/p fall Major Surgical or Invasive Procedure: [**2201-4-19**] Pleural pigtail drain placement [**2201-4-20**] PICC line placement History of Present Illness: 79M with now approx 2mos s/p open AAA repair c/b ischemic colitis, Klebsiella MSSA VAP and readmission [**3-19**] w/ [**Female First Name (un) **] fungemia requiring Micafungin and was discharged on Fluconazole the course ended [**4-2**]. Patient transferred here today from rehab, per report fell from bed to floor this AM but was found to be neurologically intact. He underwent PT in the AM w/o difficulty and then fell asleep, after which he was found minimally responsive, altered mental status, c/o mild abdominal pain then became hypotensive w/ SBP 60-70s on transport. He denies any abdominal pain at this time, nl output from colostomy. No fevers/chills, cough, SOB, dysuria or other urinary Sx. His trach was decannulated approx 2wks ago. Past Medical History: 1. CAD s/p MI (EF 40%), CABG [**4-/2184**], multiple PCI's/stent to circ/RCA 2. Hyperlipidemia 3. HTN 4. Cervical myelopathy 5. s/p cervical fusion 6. GERD 7. Schatzki's ring 8. Mohs surgery 9. s/p open pararenal AAA [**2201-2-2**] ([**Doctor Last Name **]) 10. s/p takeback for retroperitoneal bleeding [**2201-2-2**] ([**Doctor Last Name **]) 11. s/p L colectomy [**2201-2-3**] ([**Doctor Last Name **]) 12. s/p completion sigmoid colectomy, proctectomy, transverse colectomy [**2201-2-4**] ([**Doctor Last Name **]) 13. s/p end transverse colostomy [**2201-2-6**] ([**Doctor Last Name **]) 14. s/p fascial closure [**2201-2-10**] ([**Doctor Last Name **]) 15. s/p bedside perc trach [**2201-2-17**] ([**Doctor Last Name **]) Social History: Married with three children and worked as a lawyer, rare alcohol Family History: NC Physical Exam: PE: 96.1 84 79/45 18 99% CV: RRR Resp: CTAB Ant GI: Abd soft/NT/ND, no pulsatile mass, colostomy pink w/ liquid stool and gas in bag, Lt thoracoabdominal incision w/ good granulation tissue at base no purulent drainage Pertinent Results: Labs on admission: [**2201-4-13**] 02:50PM BLOOD WBC-16.8*# RBC-2.97* Hgb-9.1* Hct-27.2* MCV-92 MCH-30.7 MCHC-33.5 RDW-17.0* Plt Ct-335 [**2201-4-13**] 02:50PM BLOOD Neuts-93.6* Lymphs-3.4* Monos-2.6 Eos-0.2 Baso-0.2 [**2201-4-13**] 02:50PM BLOOD Glucose-113* UreaN-30* Creat-1.3* Na-134 K-4.7 Cl-99 HCO3-25 AnGap-15 [**2201-4-15**] 04:30AM BLOOD ALT-12 AST-13 AlkPhos-177* Amylase-35 TotBili-0.7 [**2201-4-15**] 04:30AM BLOOD Lipase-29 [**2201-4-14**] 03:20AM BLOOD Calcium-8.2* Phos-4.9* Mg-1.7 [**2201-4-13**] 02:57PM BLOOD Lactate-2.1* Labs prior to discharge: [**2201-4-23**] WBC 12.4* HCT 30.9* plt 381 [**2201-4-23**] glc BUN 90 25* Cr 1.4* Na 141 K+ 4.7 Cl 109* HCO3 25 Imaging: ECG Study Date of [**2201-4-13**] 3:36:56 PM Sinus rhythm with premature ventricular contractions. Left axis deviation. Right bundle-branch block with left anterior fascicular block. Borderline prolonged P-R interval. Compared to the previous tracing of [**2201-3-18**] frequent ventricular premature beats are now appreciated. CTA PELVIS W&W/O C & RECONS Study Date of [**2201-4-13**] 2:50 PM IMPRESSION: 1. Persistent left pleural effusion with associated compressive atelectasis. 2. Unremarkable appearance of aortic graft, without evidence for leak. SMA and celiac are patent, through the [**Female First Name (un) 899**] is occluded. 3. Increased assymetric expansion of the left psoas muscle, with ill-defined central low-attenuation collection and peripheral rim enhancement. While this appearance can be seen in an organizing hematoma, the continued expansion on serial studies is atypical and thus concerning for development of a psoas abscess and phlegmon formation. 4. Status post partial colectomy with colostomy. 5. Unchanged perirectal lymph nodes. 6. Bilateral fat-containing inguinal hernias. 7. Persistent left abdominal wall defect, with extension adjacent to the lateral eleventh left rib, where a slight cortical irregularity is identified. Underlying osteomyelitis cannot be excluded, and clinical correlation is recommended. 8. Expansion and enhancement of the left flank musculature adjacent to the left abdominal wall defect. Findings may relate to post-surgical change, but again, infection of this tissue is not excluded. No discrete abscess is seen within this region. CHEST (PORTABLE AP) Study Date of [**2201-4-15**] 4:46 PM FINDINGS: As compared to the previous radiograph, there is a moderate increase in the size of the cardiac silhouette. Mild increase in extent of the pre-existing right-sided pleural effusion. In the right lung, there is a minimal unchanged parenchymal opacity at the bases of the right lung. Otherwise, no changes. CHEST (PORTABLE AP) Study Date of [**2201-4-18**] 4:34 PM There has been no appreciable reaccumulation of left pleural fluid and no pneumothorax is seen, pigtail catheter still projecting over the left mid chest. Small right pleural effusion and borderline edema persists in the right lung, though lung volumes have improved. Heart size is top normal. Mediastinal vascular engorgement suggests volume overload. CHEST (PORTABLE AP) Study Date of [**2201-4-20**] 7:29 AM Small left apical and tiny right apical pneumothoraces are unchanged. Left pigtail catheter in the chest is in similar position. Persistent retrocardiac opacity likely represents a combination of pleural effusion and atelectasis. Left basal atelectases are seen CHEST (PA & LAT) Study Date of [**2201-4-22**] 2:56 PM 1. Interval decrease of left-sided pleural effusion with slightly improved aeration and better diaphragmatic contour. Residual small bilateral pleural effusion. 2. Unchanged tiny apical left pneumothorax. 3. Interval placement of right PICC with tip at the mid SVC. CXR [**2201-4-14**] stable Brief Hospital Course: [**2201-4-13**] HD0: Transferred from rehab after patient fell from bed to floor. Found to be neurologically intact, although later had altered mental status and c/o mild abdominal pain. He then became hypotensive w/ SBP 60-70s on transport. Hypotensive upon arrival in ED where he was given fluid boluses and transfused with 2 units of PRBCs. BP stabilized and then admitted to the CVICU. Right groin temporary access central line, left EJ, and foley placed. PICC line from previous admission pulled, tip cultured. ECG and CXR done. Head, cervical, abdomen & pelvis CT done. Continued Vanco/Zosyn and Micafungin per ID recs. Continued DVT prophylaxis, RISS. Patient found to have coccyx decubiti and partially dehisced abdominal wound, incision-vac dressing applied. CT torso showed left pleural effusion with associated atelectasis, persistent left abdominal wall defect, unremarkable appearance of aortic graft, without evidence for leak, and increased assymetric expansion of the left psoas muscle. [**2201-4-14**] HD1 Patient continued to have low BP and was given more fluids. Blood cultures from 46/ showed GPC and GNRs. Swab from [**4-13**] eventually staph aureus, later found to be pansensitive. BP improved. Continuing daily blood cultures. Physical therapy was consulted for out of bed activity. Vanco d/c'd, continued on Zosyn and Micafungin. ID continued to actively follow. Source not immediately clear. Possible PNA in left lower lung field. Sputum culture was contaminated by OP flora. [**2201-4-15**] HD2 Vitals stable. Transfered to [**Wardname 10876**] VICU. T maxed 101, tachycardic (HR 108) treated with metoprolol prn and increased scheduled dose. Had some episodes of shortness of breath - ABG showed aPO2 of 74, CO2 35. [**2201-4-16**] HD3 Continues to be febrile T max 101.1. Continuing daily blood cultures, BP borderlinely low. Patient in and out of ventricular bigeminy. Electrolytes repleted. ID following- antibiotic coverage switched to Dapto/Fluconazole and Zosyn given GNR bacteremia. [**2201-4-17**] HD4 Continues to have episode of hypotension despite fluid boluses. CXR showed increasing left-sided pleural effusion. ID Late afternoon patient became agitated, tachypneic and hypotensive w/ BP 70's, and O2 sats 86-90%. ABG showed PO2 64 CO2 64. Transferred to the CVICU. Interventional pulmonary consulted, and performed a left thoracenthesis removing 75cc of "puss." Pleural pigtail chest tube placed. [**2201-4-18**] HD5 Remains in the CVICU. Now afebrile with stable BPs. Respiratory support with Venti mask-CPAP. Pleural drainage-purulent. Pan cultured. ID following-continued w/ Dapto/Fluconazole and Zosyn until pleural fluid culture data return. PICC placed for IV access, blood draws, possible TPN. [**2201-4-19**] HD6 Required intermittent BiPAP to maintain oxygen saturations. Mental status improved. Sputum cultures grew pan-sensitive Klebsiella. Pleural cultures showed 4+ PMNs, no micros. Cultures showed no growth. Concern for chyle leak, although pleural drainage lipids always <200 making this unlikely. Daptomycin and fluconazole discontinued given culture data. Nutrition consulted. Continued to apply dry dressings daily to abdominal wound. [**2201-4-20**] HD7 Patient continues to improve with stable vital signs and improved mental status. Transferred to CVICU. CT drainage decreasing. Abx continued. CXRs shows improved left pleural effusion. The rest of the hospital stay was significant for return of herpes zoster of left face - acyclovir restarted (had similar episode during prior hospital admission). Vitals signs remained stable with good O2 sats and adequate urine output. Creatinine improved from 1.9 to 1.4 prior to discharge. WBC mildly elevated but much improved. Calorie counts showed Mr. [**Known lastname 33667**] [**Last Name (Titles) 109043**]g ~1000kcal per day. Megestrol started to improve appetite. His appetite is improving, and we expect him to continue to increase his kcals per day over the coming weeks. Left chest tube was inadvertently pulled [**2201-4-23**] during PT therapy. Subsequent chest xrays showed very small left-sided apical ptx and small left pleural effusion. Patient eating well, ambulating with assistance, abdominal wound clean with dry dressings applied daily. Mr. [**Known lastname 33667**] is being discharged to rehab today. ID recommends continuing zosyn to [**2201-5-5**], remove PICC as soon as course completed. Cont valacyclovir 1 gram [**Hospital1 **] to [**2201-5-3**]. Weekly LFTs, BUN/CR, CBC with diff, fax to [**Telephone/Fax (1) 432**]. F/u with Dr. [**Last Name (STitle) 7443**] in [**Hospital **] clinic on [**2201-5-13**] at 12:00pm. Renal would like him to follow up in clinic next week with Dr. [**Last Name (STitle) **] (scheduled). Medications on Admission: Tobramycin 0.3% Ophth Soln 1 DROP LEFT EYE TID, Insulin SC Sliding Scale, Acetaminophen 325-650 mg PO Q6H:PRN, Metoclopramide 5 mg PO QIDACHS, Pantoprazole 40 mg PO Q24H, Metoprolol Tartrate 12.5 mg PO BID, Aspirin 81 mg PO DAILY, Ursodiol 300 mg PO BID, Heparin 5000 UNIT SC TID, Albuterol Inhaler 4 PUFF IH Q4H, Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS (once a day (at bedtime)). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-9**] Drops Ophthalmic [**Hospital1 **] (2 times a day). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Naphazoline-Pheniramine 0.025-0.3 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 13. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 17. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed. 18. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 19. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours): Cont to [**2201-5-3**]. 20. Megestrol 400 mg/10 mL Suspension Sig: One (1) PO DAILY (Daily). 21. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 22. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 23. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): Cont to [**2201-5-5**]. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital Discharge Diagnosis: Sepsis due to bacteremia Pneumonia- currently on zosyn Pleural effusion- required pigtail pleural drain placement and drainage. Herpes Zoster- treated with Acyclovir Hypotension Decubiti- Coccyx pre-existing (present on patient's arrival) Wound dehiscense- partial due to infection Discharge Condition: stable on room air afebrile Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-15**] 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 [**2-10**] 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 Followup Instructions: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2201-6-2**] 2:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-5-19**] 11:00 Dr. [**Last Name (STitle) 7443**] in [**Hospital **] clinic on [**2201-5-13**] at 12:00pm Completed by:[**2201-4-24**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2176-9-4**] Discharge Date: [**2176-9-8**] Date of Birth: [**2118-11-24**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: trasferred from OSH for cardiac cath Major Surgical or Invasive Procedure: Cardiac Cath with 2 Hepacoat stents placed in RCA History of Present Illness: 57 y/o M with h/o RBBB, DM2, HTN, s/p parathyroidectomy, presented with radiating substernal CP (initally [**2182-4-15**], increased to [**2182-8-19**]) to L shoulder that woke him from sleep, associated with numbness/diaphoresis/N and Vomitting that relieved the pressure. BS noted to be 450's. Went to outside hosp, and received asa, heparin gtt, integrelin, insulin 10 units, ntg gttasn compezine. [**Hospital **] transferred to [**Hospital1 18**] for emergent cath. Past Medical History: DM, Hyperchole, HTN, asbestose exposure, GERD, h/o kidney stones, s/p parathyroidectomy, h/o perirectal abscess, RBBB, h/o necrotizing fascitis Social History: quit tob 15 yrs ago. Family History: CAD, DM. Father w/ MI in 50's Physical Exam: T AFeb, BP 160/90, HR 90, RR 18 Gen: pale, s/p emesis Neck: JVD 10 cm Resp: CTAB CV: RRR, Nl S1S2, No murmers Abd: obese, hepatomegaly, pos BS Ext: 1 plus pittting edema Pertinent Results: [**2176-9-4**] 09:30PM O2 SAT-67 [**2176-9-4**] 09:25PM TYPE-ART PO2-70* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-0 [**2176-9-4**] 09:25PM GLUCOSE-262* [**2176-9-4**] 09:25PM HGB-15.1 calcHCT-45 O2 SAT-93 [**2176-9-4**] 06:38PM GLUCOSE-332* UREA N-21* CREAT-1.0 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [**2176-9-4**] 06:38PM ALT(SGPT)-64* AST(SGOT)-301* LD(LDH)-842* CK(CPK)-4203* ALK PHOS-87 TOT BILI-0.6 [**2176-9-4**] 06:38PM CK-MB-215* MB INDX-5.1 cTropnT-12.75* [**2176-9-4**] 06:38PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-1.7 CHOLEST-192 [**2176-9-4**] 06:38PM %HbA1c-11.7* [**2176-9-4**] 06:38PM TRIGLYCER-256* HDL CHOL-35 CHOL/HDL-5.5 LDL(CALC)-106 [**2176-9-4**] 06:38PM WBC-13.7* RBC-5.25 HGB-14.9 HCT-41.5 MCV-79* MCH-28.3 MCHC-35.9* RDW-13.2 [**2176-9-4**] 06:38PM PLT COUNT-216 [**2176-9-4**] 06:38PM PT-12.7 PTT-25.5 INR(PT)-1.0 [**2176-9-4**] 01:58PM TYPE-ART O2-100 PO2-96 PCO2-58* PH-7.20* TOTAL CO2-24 BASE XS--5 AADO2-572 REQ O2-93 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2176-9-4**] 01:58PM GLUCOSE-461* K+-4.5 [**2176-9-4**] 01:58PM HGB-15.4 calcHCT-46 O2 SAT-96 [**2176-9-4**] 12:45PM CK(CPK)-267* [**2176-9-4**] 12:45PM CK-MB-21* MB INDX-7.9* cTropnT-0.19* Brief Hospital Course: 57 y/o M with h/o RBBB, DM2, HTN, s/p parathyroidectomy, presented with radiating substernal CP to L shoulder. [**Hospital **] transferred to [**Hospital1 18**] for emergent cath. ECG on admission: RBBB, AV dissociation, STE III>II and AVF, STD V2,V3,I,AVL Echo ([**2174-2-24**]) [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) 3841**] dilated, LV- wall thickness, cavity, and systolic fxn normal, trivial TR Cath: HD: RA 23/25/21 PA Sat 57% RV 44/15/28 CO 3.46 PA 41/22/31 CI 1.43 PCW 28 LV 126/25 LMCA: Nl LAD: Mild dz prox, tubular 60% lesion in midsegment LCx: mild diffuse dz RCA: dominant vessel occluded proximally Intervention: stenting of RCA proximally w/ 3.5x18mm Cypher stent x2, residual 0% with TIMI III flow, after mulitple rounds of vasodilator therapy ECHO ([**2176-9-6**]): Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is mild global left ventricular hypokinesis. Lateral and apical hypokinesis and inferior akinesis are present. Overall left ventricular systolic function is moderately depressed. EF 35% to 40% 3. Compared with the findings of the prior report (tape unavailable for review) of [**2174-2-24**], LV function and wall motion abnormalities are new. CXR ([**2176-9-6**]): Possible slight LV decompensation. No other significant abnormality. Slight thickening of the pleura on the right side cannot be excluded. 1. CAD. Cath w/ stenting x2 of prox RCA requiring IABP for low CI. Pos enzymes. cath c/b bradycardia and hypotension secondary to RV involvement IPMI -- initially held antihypertensives and gave post cath hydration with nabicarb. Once hemodyanically stable restarted b-b and then added acei as tolerated. Initially kept PAD btw 15-17, pt required preload in setting of right heart ischemia. Swan was pulled and the pt was weaned off the IABP. He was continued on ASA, Plavix, Lipitor, integrilin x18hrs, and heparin while IABP in place and after the integrilin was off. 2. Pump. EF now 35% to 40% with mild global left ventricular hypokinesis. Lateral and apical hypokinesis and inferior akinesis which are new since previous study in '[**74**]. Increased right sided filling pressures secondary to RV infarct. Pt is preload dependent. PAD kept btw 15-19 while pt had a swan. Pt was carefully diuresed with goal 500 to 1L negative per day. 3. Rhythm. Pt initially presented with high degree AV block with a rate in the 40's. Pacing wire placed in cath lab and set at 50. Block most likely secondary to AV node ischemia from RCA occlusion. Pt w/o evidence of block in native rhythm since returned from cath. Temp pacer removed without further arrythmias. 4. DM. Insulin gtt initially started for elevated BS'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] followed pt and recommended Glargine 60 Units qhs with a regular insulin sliding scale. Arrangements were made for the pt to f/u at the [**Last Name (un) **]. 5. HTN. BP managed on acei and bb. Medications on Admission: Novolin N 60 U qam Discharge Medications: 1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day: please have primary care physician check you electrolytes. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 9. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day for 3 days. Disp:*3 Tablet Sustained Release 24HR(s)* Refills:*0* 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 12. glargine Sig: Sixty (60) Units at bedtime. Disp:*2400 U* Refills:*2* 13. Lancets Misc Sig: One (1) Miscell. three times a day. Disp:*90 * Refills:*2* 14. Alcohol Pads Pads, Medicated Sig: One (1) Topical three times a day. Disp:*90 * Refills:*2* 15. Accu-Chek Active Care Kit Kit Sig: One (1) Miscell. once a day for 1 doses. Disp:*1 * Refills:*0* 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 3 days. Disp:*3 Capsule, Sustained Release(s)* Refills:*0* 17. Insulin Regular Human 300 unit/3 mL Syringe Sig: as directed Subcutaneous four times a day: please keep a log of blood sugars and bring to [**Hospital **] Clinic. Disp:*1 vial* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Posterior Inferior MI Insulin Resistant DM Discharge Condition: Stable Discharge Instructions: Take all medications as directed. In particular, do not stop taking aspirin or clopidogrel. Please return to the hospital or call your primary care physician if you experience chest pain, shortness of breath, vomitting, or any other symptoms. Followup Instructions: 1. Please call your pirmary care physician [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) 1683**] at [**Telephone/Fax (1) 19968**] to make an appointment for next week. 2. Please call [**Telephone/Fax (1) 62**] on Monday [**2176-9-9**] to schedule a cardiology appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] within the next 3-4 weeks. 3. Please call the [**Last Name (un) **] Diabetes Center at ([**Telephone/Fax (1) 3537**] to make an appointment within the next 2 weeks. Please check your glucose before meals and at bedtime. Bring your daily glucose readings as well as your insulin sliding scale to your appoinment. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "501", "288.8", "401.9", "785.50", "426.0", "414.01", "272.0", "410.31" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.56", "37.23", "36.07", "89.64", "88.53", "37.78", "38.91", "37.61", "36.01" ]

icd9pcs

[ [ [] ] ]

8002, 8008

2642, 2827

371, 423

8095, 8103

1379, 2619

8394, 9255

1143, 1174

5743, 7979

8029, 8074

5700, 5720

8127, 8371

1189, 1360

295, 333

451, 922

2841, 5674

944, 1089

1105, 1127

7,798

183,395

6847

Discharge summary

report

Admission Date: [**2166-2-24**] Discharge Date: [**2166-3-4**] Date of Birth: [**2111-8-2**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim DS / Ferrous Sulfate / Amoxicillin / carrots Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain x 1 month Major Surgical or Invasive Procedure: [**2166-2-24**] cardiac cath [**2166-2-28**] Coronary artery bypass grafting x4 with left internal mammary to the left anterior descending artery and reverse saphenous vein grafts to the right coronary artery, obtuse marginal artery, diagonal artery History of Present Illness: Patient is a 54-year-old Haitian male with a past medical history significant for hypertension, hyperlipidemia common hemorrhoids, DVT, HIV since [**2155**], coronary coronary artery disease status post STEMI (BMS to LAD [**2161**]), NSTEMI secondary to in stent thrombosis ([**2161**] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]), and ischemic cardiomyopathy with an ejection fraction of 45% who presents with one month of exertional chest pain. History of present illness begins approximately one month ago when the patient noted to have chest pain which he rated as ??????pressure, achey?????? And [**6-29**] which would occasionally radiate to left shoulder. This pain was caused by exertion and alleviated by resting. Pain was not relieved by sublingual nitroglycerin. Patient denies peroxisomal nocturnal dyspnea, orthopnea, dyspnea at rest. Patient reports strict compliance with all of his prescribed medications, including those he takes for HIV. Of note the patient has had HIV since [**2155**]. He denies IV drug use and blood transfusions. He reports that he got HIV from ??????sleeping with a lot of women.?????? Prior to admission, patient went for one month with chest pain because he said that he could not get an appointment to see his primary doctor. He was seen by outpatient cardiology on [**2166-2-21**] who told him to come in for cardiac catheterization. Prior to catherizations he was loaded with Plavix. Cardiac catheterization today showed 60% lesion in the LAD, left circumflex ostial branch 70% , obtuse marginal 1 90% stenosis, right coronary artery diffuse disease in proximally and mid-aspect with an ulcerated plaque at the vessel tapering to 70%. Past Medical History: 1) STEMI in [**1-25**] with overlapping bare metal stents to the LAD for a 90% ostial occlusion. Repeat stent occured in [**5-26**] for restenosis. Cath on [**8-26**] revealed 40% restenosis but was not opened. 2) Congestive heart failure, with EF 35%, with anterior wall, septal, and apical akinesis post-MI in [**2-25**]. Last echo [**11/2162**] revealed improved EF to 45-50%. 3) HIV, dx 15 yrs ago, last CD4 352 [**10-27**] (nadir 138 [**5-/2161**]), VL < 50 [**4-27**], on [**Month/Year (2) 2775**], managed by Dr. [**Last Name (STitle) **]. 4) DVT in the right common femoral and popliteal vein in [**2-25**], during admission for STEMI, on coumadin. 5) Hypereosinophilia 6) Hemorrhoids 7) Influenza during [**2-25**] hospitalization for STEMI Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of remature coronary artery disease or sudden death. Patient emigrated from [**Country 2045**] 22 years ago. Lives in Mission [**Doctor Last Name **] with wife and 4 kids. Works as a waiter. No previous hx of IVDU or transfusions. Patient reports that he got HIV by "sleeping with a lot of women?" Family History: No family hx of heart disease. Paternal uncle has DM. Paternal grandmother with breast cancer. Father has prostate cancer. Physical Exam: Pulse:58 Resp:16 O2 sat: 98/RA B/P Right:136/63 Left:127/63 Height8:5'8" Weight:145 lbs General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral 2 Right: 2 Left: DP 2 Right: 1 Left: PT 1 Right: 1 Left: Radial 2 Right: 2 Left: Carotid Bruit x Right: x Left: Pertinent Results: [**2166-2-25**] 06:25AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.8 Mg-2.1 Cholest-116 [**2166-2-24**] 12:45PM BLOOD %HbA1c-5.4 eAG-108 [**2166-2-25**] 06:25AM BLOOD Triglyc-126 HDL-34 CHOL/HD-3.4 LDLcalc-57 [**2166-3-4**] 05:05AM BLOOD WBC-5.8 RBC-3.12* Hgb-10.8* Hct-30.8* MCV-99* MCH-34.7* MCHC-35.2* RDW-14.4 Plt Ct-215 [**2166-2-24**] 12:45PM BLOOD Neuts-43.1* Lymphs-44.7* Monos-4.0 Eos-7.6* Baso-0.6 [**2166-3-4**] 05:05AM BLOOD Glucose-103* UreaN-15 Creat-1.2 Na-136 K-4.4 Cl-99 HCO3-28 AnGap-13 [**2166-2-25**] 06:25AM BLOOD ALT-18 AST-19 LD(LDH)-164 AlkPhos-79 TotBili-0.6 [**2166-3-4**] 05:05AM BLOOD Mg-2.4 TEE [**2166-2-28**]: PRE-CPB: 1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anteroapical hypokinesis. 4. Right ventricular chamber size and free wall motion are normal. 5. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine briefly. Sinus rhythm. Preserved biventricular systolic functionj with some improvement of the anteri0or wall. LVEF is now 50%. Trace MR, AI as before. The aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2166-2-28**] 11:51 Brief Hospital Course: On [**2166-2-24**] patient was admitted to the cardiology service status post cardiac catheterization which showed diffuse 3 vessel disease. Given the nature of his lesions, the patient was deemed more likely to benefit from coronary artery bypass grafting rather than stent. His metoprolol was increased so as to decrease his heart rate and myocardial oxygen consumption and demand. In addition, he was monitored on the [**Hospital1 1516**] service prior to surgery for Plavix wash out and pre-operative testing.Underwent surgery with Dr. [**Last Name (STitle) **] on [**2-28**] and was transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated neurologically intact later that day. Transferred to the floor on POD #1 to begin increasing his activity level. Chest tubes and pacing wires removed per protocol. Beta blockade titrated and gently diuresed toward his preop weight. Developed pericarditis and was started on a 2 week course of ibuprofen. Continued to make good progress and was cleared for discharge to home with VNA on POD#4. All f/u appts advised. Medications on Admission: CLOPIDOGREL 75 mg Daily PREZISTA 800 mg daily take with combivir and ritonavir KETOCONAZOLE 2% Shampoo - apply to scalp and eyebrows 2 to 3 times a week leave on for 5 min before washing COMBIVIR 150 mg/300 mg Tablet - 1 Tablet [**Hospital1 **] METOPROLOL SUCCINATE 25 mg Daily NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet sublingually can repeat in 5 minutes, twice as needed for chest pain if no relief after 3 total, go to Emerg. Dept. NORVIR 100 mg Daily Take with Darunavir CRESTOR 20 mg Daily ASPIRIN 325 mg Daily TERBINAFINE 1% Cream - apply to affected area twice a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*1* 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 3. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 10 days: while taking furosemide (lasix). Disp:*10 Tablet Extended Release(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or temp >38.4. Disp:*50 Tablet(s)* Refills:*0* 8. terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to affected areas. Disp:*2 tubes* Refills:*0* 9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 10. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*1* 11. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 12. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain management. Disp:*50 Tablet(s)* Refills:*0* 14. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Anterior ST elevation MI, BMS to LAD [**1-/2161**] NSTEMI treated with DES to in stent restenosis of LAD stent [**5-/2161**] HIV Hyperlipidemia Hemorrhoids DVT in the setting of hospitalization with his STEMI [**2161**] (was on Coumadin for 3-6 months after DVT, currently not on anticoagulation) Ischemic cardiomyopathy with reduced ejection fraction, EF 45-50% Coronary artery disease-s/p CABGx4 [**2166-2-28**] postop pericarditis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Recommended Follow-up: You are scheduled for the following appointments Surgeon:Dr. [**Last Name (STitle) **] [**4-3**] @ 1:00 PM, [**Hospital Ward Name **] 2A Cardiologist:Dr. [**First Name (STitle) **] [**3-24**] @ 2:40 PM,, [**Hospital Ward Name 23**] 7 Wound check : [**3-13**] @ 10:15 AM, [**Hospital Ward Name **] 2A Please call to schedule appointments with your: Primary Care Dr.[**Last Name (STitle) **] in [**4-24**] weeks Your Infectious Disease specialist (per Dr. [**Last Name (STitle) **] if needed) **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:[**2166-3-4**]

[ "420.90", "272.4", "V08", "997.1", "414.01", "401.9", "413.9", "412", "V12.51", "V45.82", "E878.2" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9866, 9924

6309, 7417

338, 590

10402, 10629

4346, 6286

11469, 12179

3556, 3680

8052, 9843

9945, 10381

7443, 8029

10653, 11446

3695, 4327

278, 300

618, 2313

2335, 3087

3103, 3539

47,632

150,752

45595

Discharge summary

report

Admission Date: [**2174-3-23**] Discharge Date: [**2174-3-29**] Date of Birth: [**2104-6-7**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Meningioma Major Surgical or Invasive Procedure: [**3-23**]: Right anterior craniotomy for tumor resection History of Present Illness: 69F electively admitted for resection of her intracranial mass. Past Medical History: Thyroid Disease(s/p partial resection [**10/2165**]) Anxiety(due to recent dx of meningioma) Hypertension s/p Right medial meniscectomy [**2161**] Social History: Rare ETOH, no tobacco/illicit substances Family History: Non-contributory Physical Exam: On Discharge: Alert, Oriented, to person, place and date. Pupils are round, and reactive to light symmetrically and bilaterally. Full motor strength in upper and lower extremities. Wound is clean, dry and intact. Pertinent Results: Labs on Admission: [**2174-3-23**] 01:23PM BLOOD WBC-8.5 RBC-4.56 Hgb-13.6 Hct-40.0 MCV-88 MCH-29.9 MCHC-34.1 RDW-14.3 Plt Ct-223 [**2174-3-23**] 01:23PM BLOOD Glucose-127* UreaN-13 Creat-1.1 Na-138 K-3.7 Cl-103 HCO3-26 AnGap-13 [**2174-3-23**] 01:23PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 Labs on Discharge: [**2174-3-28**] 05:30AM BLOOD WBC-6.6 RBC-4.19* Hgb-12.6 Hct-37.3 MCV-89 MCH-30.1 MCHC-33.8 RDW-14.2 Plt Ct-211 [**2174-3-27**] 01:35PM BLOOD PT-11.5 PTT-23.5 INR(PT)-1.0 [**2174-3-28**] 05:30AM BLOOD Glucose-81 UreaN-17 Creat-0.9 Na-141 K-3.9 Cl-106 HCO3-28 AnGap-11 [**2174-3-28**] 05:30AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.3 Mg-2.2 [**2174-3-28**] 05:30AM BLOOD Phenyto-14.8 Imaging: MRI WAND [**3-19**]: FINDINGS: A comprehensive evaluation of the brain was not performed, as this limited study was targeted for surgical planning. The 2.6 x 1.9 x 2.5 cm right frontal parasagittal extraaxial mass has not significantly changed (images 3:3 and 4:10). It shows avid enhancement after contrast administration, suggestive of a meningioma. The extent of edema in the right frontal lobe is grossly similar, allowing for differences in technique. No additional masses are seen. Calculated tumor volume on the postcontrast T1W images is 7.54 cm3. IMPRESSION: The right frontal extraaxial mass is again demonstrated for surgical planning. MRI Head [**3-23**](post-op) CLINICAL INFORMATION: Patient is status post craniotomy for removal of the extra-axial mass. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images of the brain were acquired before gadolinium. T1 axial and MP-RAGE sagittal images obtained following gadolinium. Comparison was made with the previous MRI of [**2174-3-23**]. FINDINGS: Since the previous study, the patient has undergone right frontal craniotomy for removal of previously seen extra-axial mass indicative of meningioma. Small amount of blood products are seen in the surgical site with acute and subacute components. Mild surrounding edema is seen, which has not significantly changed. There is evidence of slow diffusion at the margin of surgical cavity, which is limited to the margin and appears to be secondary to surgical procedure. There is no hydrocephalus or midline shift identified. Mild new soft tissue swelling in the right temporoparietal scalp region appears to be secondary to the surgery. Mild meningeal enhancement is seen in the falx and at the site of surgery, which appears postoperative in nature. No nodular residual areas of enhancement are identified. A small linear area of enhancement along the medial aspect of the right frontal region also appears to be meningeal in nature. IMPRESSION: Status post resection of a right frontal lobe mass. Small amount of expected blood products and air are seen in the surgical region. Mild meningeal enhancement is identified. No residual mass is seen. Evidence of slow diffusion at the margin of surgical cavity appears to be related to surgical procedure and no acute infarcts or hydrocephalus seen. Brief Hospital Course: Patient was electively admitted on [**3-23**] for right sided craniotomy for tumor resection. (See operative note for further details). Post-operatively the patient was transferred to the ICU for monitoring overnight. Within four hours post-op, a CT scan of the head was performed and found to have normal post operative changes. Post-operative MRI was performed within 36 hours. On POD#1, patient was transferred to the neurosurgical floor. She was seen and evaluated by physical and occupational therapy who determined that she was safe to discharge home with home safety evaluation. Pt finished physical therapy on [**2174-3-28**]. Medications on Admission: Atenolol [Tenormin] (25mg Daily) Clonazepam [Klonipin] (0.25mg Daily, PRN QHS) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue to take daily as long as you require narcotic pain medication. Disp:*60 Capsule(s)* Refills:*0* 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed: Caution not to exceed more than 4GM(4,000mg) in a 24hour period. 5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Meningioma Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? You are being sent home on steroid medication(tapering dose), make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**8-5**] days (from your date of surgery) for removal of your sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2174-4-25**] with [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] @1:00PM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain, as this was done during your acute hospitalization. **Please call to make and appointment with your PCP within one week to discuss your dosing of your hypertensive medication. This was discontinued during your hospital stay, as your blood pressure was in adequate control. Completed by:[**2174-3-29**]

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Discharge summary

report

Admission Date: [**2178-1-4**] Discharge Date: [**2178-1-10**] Date of Birth: [**2102-7-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: 75 yo man with past medical history significant for CHF (EF 20%), s/p Vtach arrest and PNA 2 weeks ago who now presents after being found unresponsive at rehab. Family called him as late as 10:30 the morning of admission, and he was alert and oriented at his baseline. When his wife arrived at 1:30pm, she found him with "agonal breathing" responding only to painful stimuli. He was placed on a face mask and slowly began to wake up. The pt states he remembers riding in the ambulance and by the time he arrived at [**Hospital1 18**] was A&Ox3. . Family states that he had been doing better at rehab and was off O2. However, three days PTA his BUN/Cr were elevated and they talked with Dr. [**Last Name (STitle) **] and agreed to give him a slow infusion of fluid. Family states he felt better that day, but then the following day was c/o increased trouble breathing and was placed back on O2 NC (they estimate 5-10L but are unsure). The daughter states that when she came to visit she would turn him down to 2L and he seemed comfortable. Pt also notes he felt like his abdomen was getting more distended (this is his normal symptom when he has a CHF exacerbation) and asked his wife to remove the top button from his pants. They note that since being at rehab he has kept the head of his bed up when sleeping. They also remark that in the past he has not always known when his AICD has fired. He denies any CP, LH, dizziness, N/V today, but does not remember what happened. . In the [**Name (NI) **], pt received ceftriaxone 1g IV and 500mg azithromycin and 40mg IV lasix. Past Medical History: 1. Defibrillator generator replacement and upgrade to biv pacemaker ([**6-8**]) 2. AF/atrial tachycardia with block 3. History of AF on coumadin 4. Cardiomyopathy 5. Hypothyroid 6. Prostate cancer, treated with lupron/TURP 7. HTN 8. [**2170**]: s/p cardiac arrest w/anoxic encephalopathy (resolved), NSVT 9. Elevated cholesterol 10. MVP/MVR [**83**]. s/p hernia repair 12. [**2177**] left ankle fx after a fall Social History: Was sent to rehab ([**Hospital6 28672**] - [**Location (un) 246**]) 2 weeks ago after admission for Vtach arrest. Before this had lived w/ wife. [**Name (NI) **] to perform ADL's - walked without any assistance at home and with a cane when going out. Since last admission has been very weak and only a few days ago was able to be helped up and walked with a walker. Denies tobacco, alcohol, drugs. Retired manager. Family History: CAD Physical Exam: Vitals: T 97.2 BP 84/34 HR 70 RR 30 O2sat 97% on 35% humidified FM Gen: appears in mild resp distress. Pleasant HEENT: PERRL. OP Clear Neck: Supple Cardio: RRR, nl S1, loud S2, [**3-9**] sys murmur @ apex Resp: CTAB Abd: soft, nt, mildly distended, +BS. no rebound/guarding Ext: no edema Neuro: AAO x 3 Pertinent Results: REPORTS: . CXR [**2177-1-4**]: IMPRESSION: 1. Diffuse increase in density in the right lung, which could represent asymmetric pulmonary. However, superimposed pneumonia cannot be excluded. 2. Patchy opacities in the left mid lung zone and lower lung zone could be secondary to asymetric pulmonary edema or could represent atelectasis or pneumonia. 3. Bilateral pleural effusions. . LABS: . [**2178-1-9**] 07:20AM BLOOD WBC-8.8 RBC-3.59* Hgb-11.4* Hct-33.1* MCV-92 MCH-31.7 MCHC-34.4 RDW-15.2 Plt Ct-211 [**2178-1-8**] 07:40AM BLOOD WBC-9.4 RBC-3.58* Hgb-11.2* Hct-33.1* MCV-92 MCH-31.2 MCHC-33.7 RDW-15.3 Plt Ct-202 [**2178-1-7**] 03:30AM BLOOD WBC-11.0 RBC-3.48* Hgb-10.8* Hct-32.0* MCV-92 MCH-31.0 MCHC-33.7 RDW-15.5 Plt Ct-216 [**2178-1-6**] 03:40AM BLOOD WBC-13.2* RBC-3.46* Hgb-11.1* Hct-32.6* MCV-94 MCH-32.0 MCHC-33.9 RDW-17.0* Plt Ct-223 [**2178-1-5**] 03:17AM BLOOD WBC-13.1* RBC-3.74* Hgb-11.7* Hct-34.4* MCV-92 MCH-31.4 MCHC-34.1 RDW-15.8* Plt Ct-228 [**2178-1-4**] 03:05PM BLOOD WBC-10.9 RBC-3.73* Hgb-11.9* Hct-35.1* MCV-94 MCH-31.8 MCHC-33.8 RDW-16.4* Plt Ct-236 [**2178-1-4**] 03:05PM BLOOD Neuts-77.8* Bands-0 Lymphs-10.9* Monos-3.1 Eos-7.6* Baso-0.7 [**2178-1-9**] 07:20AM BLOOD Plt Ct-211 [**2178-1-8**] 07:40AM BLOOD Plt Ct-202 [**2178-1-6**] 03:40AM BLOOD PT-18.8* PTT-33.2 INR(PT)-2.5 [**2178-1-5**] 03:17AM BLOOD PT-18.7* PTT-32.0 INR(PT)-2.5 [**2178-1-4**] 03:05PM BLOOD Plt Ct-236 [**2178-1-4**] 03:05PM BLOOD PT-18.0* INR(PT)-2.3 [**2178-1-9**] 07:20AM BLOOD Glucose-78 UreaN-32* Creat-1.1 Na-139 K-3.9 Cl-104 HCO3-26 AnGap-13 [**2178-1-6**] 06:42PM BLOOD Glucose-110* UreaN-30* Creat-1.1 Na-139 K-3.8 Cl-105 HCO3-26 AnGap-12 [**2178-1-4**] 03:05PM BLOOD Glucose-126* UreaN-30* Creat-1.4* Na-140 K-3.3 Cl-105 HCO3-23 AnGap-15 [**2178-1-4**] 03:05PM BLOOD proBNP-8245* [**2178-1-8**] 07:40AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9 [**2178-1-6**] 06:42PM BLOOD Calcium-8.0* Phos-2.5* Mg-2.0 [**2178-1-5**] 03:17AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8 [**2178-1-4**] 09:08PM BLOOD Type-ART Rates-/38 pO2-68* pCO2-33* pH-7.52* calHCO3-28 Base XS-3 Intubat-NOT INTUBA Comment-NON-REBREA [**2178-1-4**] 09:08PM BLOOD Lactate-1.2 [**2178-1-4**] 03:05PM BLOOD Lactate-2.1* . MICRO: [**2178-1-7**] 11:03 pm STOOL CONSISTENCY: SOFT **FINAL REPORT [**2178-1-8**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2178-1-8**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) 24448**] [**Last Name (NamePattern1) 24449**] ON [**2178-1-8**] AT 11:35A 11R. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). Brief Hospital Course: 75yo man with PMH significant for afib/atach, s/p AICD/pacer, cardiomyopathy, s/p cardiac arrest, s/p MVR, HTN, hypothyroidism, who was admitted for an episode of unresponsiveness at his rehab facility and respiratory distress. . Hospital course is reviewed below by problem: . #) respiratory distress - Pt was initially admitted to the ICU, and then transferred to the floor once his respiratory status stabilized. SOB most likely multifactorial with components of pneumonia and CHF exacerbation. Pt currently with decreasing O2 requirement (was up to 100%[**Date Range 597**]< now on 4L NC). Pt was diuresed with Lasix 40 IV on a prn basis. 1) pneumonia - - covered with azithro and ceftriaxone (now day #5) for atypicals, gram positives, gram negatives. Should continue for 14 day course. - flu was negative 2) CHF - BNP >8000 - continued lasix 40mg IV prn - baseline BP 90/60, and pt tolerated BP's in the 80's without symptoms . #) unresponsiveness at rehab - most likely cardiac vs respiratory. ABG on admission 7.52/33/68 on [**Last Name (LF) 597**], [**First Name3 (LF) **] have been worse w/o [**First Name3 (LF) 597**] at rehab, likely was hypoxic causing unresponsiveness (as improved with oxygen). Pt w/ AICD/pacer, but pacer spike occasionally occuring on QRS. - EP consulted, interrogated pacer, reported that they would not be able to pace the patient out of MAT - pt was monitored on tele - continued amiodarone at 400mg daily - continued [**First Name3 (LF) **], coumadin, carvedilol for cardiac issues . #) CRI - Cr 1.6 on last discharge, 1.4 on admission, but stable at 1.1 this am. Cr was monitored closely given aggressive diuresis. . #) Decubitus ulcer - continued miconazole powder, wound care . #) anorexia - likely secondary to underlying illness, nutrition consulted. Continued diet w/ soft foods and ensure. Pt does not like boost. . #) constipation - aggressive bowel regimen - colace, senna, dulcolax, lactulose prn. . #) low BP - pt's baseline 90/60. ACEI changed to captopril for better titration. . #) FEN: Cardiac diet. Continued diet w/ soft foods and ensure. Pt does not like boost. . #) PPX: continued coumadin, bowel regimen, ppi . #) Dispo: to rehab . #) Code: Full Code Medications on Admission: 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg Tablet PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Levothyroxine 88 mcg Tablet PO DAILY 5. Multivitamin 6. Mexiletine 150 mg PO Q8H 7. Quetiapine 25 mg Tablet PO HS 8. Carvedilol 3.125 mg PO BID 9. Warfarin 1 mg PO QMOWEFR (Monday -Wednesday-Friday). 10. Warfarin 2 mg Tablet PO QTUTHSA ([**Doctor First Name **],TU,TH,SA). 11. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours). 12. Lisinopril 5 mg PO DAILY 13. Furosemide 60 mg PO QAM. 14. Potassium Chloride 20 mEq PO DAILY 15. Sodium Chloride 0.65 % Aerosol, Spray Nasal QID 16. Levofloxacin 250 PO once a day for 7 days: until [**12-26**]. 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for Insomnia. 10. Warfarin 2 mg Tablet Sig: 0.5 Tablet PO QMOWEFR (Monday -Wednesday-Friday). 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QTUTHSA ([**Doctor First Name **],TU,TH,SA). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal QID (4 times a day) as needed. 16. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 7 days. 17. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 22. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO TID (3 times a day). 24. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO once a day. 25. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 26. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gm Intravenous Q24H (every 24 hours) for 7 days. 27. Lasix 20 mg Tablet Sig: Three (3) Tablet PO QAM. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: CHF Pneumonia C.dif colitis Discharge Condition: Stable. Taking good PO. Able to ambulate with assistance. Discharge Instructions: Seek medical attention immediately if you experience chest pain, shortness of breath, nausea, vomiting, fever, chills, or dizziness. Please take all medications as prescribed. Please attend all follow-up appointments. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500cc Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2178-1-30**] 1:30 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2178-2-16**] 2:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2178-3-24**] 1:00 Please call to make appointment with your PCP [**Name Initial (PRE) **] 1-2 weeks after discharge.

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icd9cm

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2180-4-21**] Discharge Date: [**2180-4-28**] Service: NSU HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old woman, with neck pain and C1 on C2 instability, with grade 2 anterolisthesis, who had a C2 fracture with gait disturbance. The patient has been in a hard collar since [**2180-3-3**]. She is admitted for occipitocervical fusion. PAST MEDICAL HISTORY: CAD. The patient had a PTCA in [**2174**] at [**Hospital1 2025**]. Dyspnea secondary to COPD and emphysema. The patient had an echo in [**2175-2-1**] with an EF of 55%, 1+ mitral regurgitation and tricuspid regurgitation. MEDICATIONS: 1. Diltiazem 90 mg once daily. 2. Ditropan XL 10 mg. 3. Serevent diskus 2 b.i.d. 4. Spiriva b.i.d. 5. Albuterol nebs. 6. Isosorbide 30 mg once daily. 7. Lisinopril 5 mg once daily. 8. Folic acid 1 mg p.o. once daily. 9. Multivitamin 1 p.o. once daily. 10. Neurontin 100 mg b.i.d. The patient was on Ecotrin and Celebrex which was discontinued. PAST SURGICAL HISTORY: Tonsillectomy, appendectomy, hysterectomy, cataract surgery and right CEA. PHYSICAL EXAM: She is an elderly woman in no acute distress in a hard collar. The patient is somewhat forgetful but pleasant. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender, positive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. Pupils equal, round and reactive to light. The patient has a longstanding history of urinary frequency and constipation. Her strength in her upper extremities is [**4-6**] bilaterally. Lower strength is [**4-6**]. Her MRI shows no overt cord compression or signal abnormality. However, on x-rays there is gross C1 on C2 instability. HOSPITAL COURSE: The patient was admitted status post occiput to C3 fusion without intraoperative complication. Postoperatively, her vital signs were stable. She was monitored in the recovery room. Her strength was [**4-6**] in all muscle groups. Her sensation was intact to light touch. She was in a hard collar. She was extubated in the recovery room. She was kept on q 1 h. neuro checks. Her SBP was kept at less than 150. On postoperative day 1, her incision was clean and dry, and her strength continued to be [**4-6**] in all muscle groups. She was in a hard collar. She was out-of-bed ambulating. She was in for a PT and OT evaluation, and continued to be ruled out for an MI. On her postoperative EKG, she had ST depression with also elevated CPKs into the 500 range. ST depression was laterally without chest pain. She was treated with IV Lopressor and Lasix. She was transferred to the CCU for MI management, and treated with Lopressor and lisinopril for rate control. She was in the CCU for 2 days and then transferred back to the regular floor. The patient was started on aspirin and continued on Lopressor for rate control. She was transferred to the regular floor on [**2180-4-26**]. She also had an x-ray on [**4-24**]. She had a bedside swallow evaluation which she failed with thin liquids. She was not even able to tolerate 2 tsp of liquid without coughing. She was kept n.p.o., and they felt that she should just be reevaluated in a couple of days when some of her swelling from surgery subsided. She was seen by physical therapy and occupational therapy, and felt to require a short rehab stay. She did have a couple of bouts of short runs of V-tach. Her electrolytes were stable. She will require continued cardiology follow-up, and will require a catheterization as an outpatient. About 2 weeks after discharge is when she can be safely catheterized and anticoagulated per Dr. [**Last Name (STitle) 1327**], the neurosurgeon. Her hard collar was removed, and a video swallow was repeated on [**4-26**], and she again failed with thin liquids, and she continues to have a Dobbhoff feeding tube in for nutrition. She will need to have a video swallow or bedside swallow repeated in 1 week. If she passes at bedside, she may need a video swallow to assure there is no aspiration. Neurologically, she remained stable. Cardiovascular stable. Vital signs are stable. DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg p.o. daily. 2. Metoprolol 150 mg p.o. t.i.d.--hold for SBP less than 90; heart rate less than 55. 3. Percocet 1-2 tabs p.o. q. 4 h. p.r.n. pain. 4. Olanzapine 5 mg p.o. at bedtime p.r.n. 5. Nitroglycerin 0.3 mg sublingually p.r.n. 6. Metamucil 1 package p.o. daily. 7. Vitamin D 800 units p.o. daily. 8. Calcium carbonate 500 p.o. t.i.d. 9. Atorvastatin 80 p.o. daily. 10. Lansoprazole 30 p.o. daily. 11. Aspirin 325 p.o. daily. 12. Heparin 5,000 units subcutaneous t.i.d. 13. Gabapentin 100 mg p.o. t.i.d. 14. Folic acid 1 p.o. daily. 15. Tiotropium bromide 1 cap inhaler daily. 16. Oxybutynin 10 mg p.o. daily. 17. Colace 100 mg p.o. b.i.d. 18. Salmeterol diskus 50 mcg 1 inhaler q. 12 h. CONDITION ON DISCHARGE: Stable. FOLLOW UP: She will follow-up with Dr. [**Last Name (STitle) 1327**] in 1 week for staple removal. She will need to follow-up with cardiology in 2 weeks for outpatient cardiac catheterization. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2180-4-27**] 11:59:02 T: [**2180-4-27**] 12:34:35 Job#: [**Job Number 33225**] Name: [**Known lastname **],[**Known firstname 1013**] Unit No: [**Numeric Identifier 5805**] Admission Date: [**2180-4-21**] Discharge Date: [**2180-5-12**] Date of Birth: [**2099-10-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5806**] Addendum: See discharge summary. Chief Complaint: This discharge summary covers period [**Date range (1) 5807**] (for [**Date range (1) 5808**] please see the previous d/c summary) Major Surgical or Invasive Procedure: 1. C3-occiput fusion 2. PEG placement 3. Cardiac catheterization, s/p two Cypher stents placement History of Present Illness: The patient is an 80-year-old woman, with known CAD (s/p PTCA in [**2164**] and stents x 2 during this admission), who initially presented with neck pain and C1 on C2 instability due to cervical stenosis. She was initially admitted to neurosurgery service for an occipitocervical fusion. She underwent C3-occiput fusion on [**4-21**]. Her post-op course was complicated by NSTEMI in the setting of tachycardia HR 110's. EKG with V4-V6 ST depressions and elevated cardiac enzymes. The patient was transferred to CCU on [**2180-4-23**]. Patient remained asymptomatic without complaints of chest pain or shortness of breath. She was started on ASA, BB, statin, ACEI and was transferred back to the regular hospital floor to cardiology service. She failed multiple speech and swallow consults due to aspiration. She was then transfered to general medicine service for question of persistent leukocytosis w/o localizing source of infection and was also found to have pharyngeal edema. Past Medical History: 1. CAD (PTCA in early [**2164**]'s at [**Hospital1 2239**]). Dobutamine Spect [**2180-4-20**]: Fixed inferolateral wall defect 2. COPD 3. H/O MI x 1 4. EF 32% 5. DJD 6. s/p CEA, right 7. AAA, 4 cm 8. osteopenia 9. Tonsillectomy 10. appendectomy 11. hysterectomy 12. cataract surgery Social History: long h/o smoking; quit [**2160**] no ETOH no drugs Family History: +CAD in family Physical Exam: Tm 99.7/Tc 98.6 137/50 (115-154/42-90) 75 (61-92) 18-24 96%RA General: alert, pleasant, elderly woman HEENT: Hearing aids, NC, AT, OP clear with thrush Neck: ecchymoses post neck, well healed scar c/w NS procedure Pulm: minimal bibasilar crackles CV: regular, nl S1S2, systolic murmur Abd: +BS, protuberant, soft, NT, PEG in place with dressing c/d/i, no sorrounding erythema LE: no edema, +1 pulses bilaterally Pertinent Results: [**2180-4-21**] 11:28AM BLOOD WBC-14.4* RBC-3.99* Hgb-11.8* Hct-35.6* MCV-89 MCH-29.7 MCHC-33.3 RDW-13.1 Plt Ct-279 [**2180-4-23**] 03:04AM BLOOD Neuts-90.6* Lymphs-4.9* Monos-4.4 Eos-0.1 Baso-0.1 [**2180-4-21**] 11:28AM BLOOD Plt Ct-279 [**2180-4-21**] 11:28AM BLOOD Glucose-158* UreaN-18 Creat-0.8 Na-139 K-4.2 Cl-104 HCO3-24 AnGap-15 [**2180-4-21**] 11:28AM BLOOD CK-MB-9 cTropnT-<0.01 [**2180-4-21**] 07:00PM BLOOD CK-MB-11* MB Indx-5.4 cTropnT-<0.01 [**2180-4-22**] 04:15AM BLOOD CK-MB-27* MB Indx-10.0* cTropnT-0.04* [**2180-4-22**] 12:45PM BLOOD CK-MB-80* MB Indx-15.9* cTropnT-.21* [**2180-4-22**] 08:21PM BLOOD CK-MB-79* MB Indx-15.4* cTropnT-0.49* [**2180-4-23**] 11:41AM BLOOD CK-MB-29* MB Indx-10.2* cTropnT-0.78* [**2180-4-25**] 06:20AM BLOOD CK-MB-NotDone cTropnT-1.31* [**2180-5-5**] 09:00PM BLOOD CK-MB-NotDone [**2180-4-23**] 03:04AM BLOOD Mg-2.4 Cholest-158 [**2180-4-23**] 03:04AM BLOOD Triglyc-160* HDL-57 CHOL/HD-2.8 LDLcalc-69 LDLmeas-87 [**2180-5-12**] 06:50AM BLOOD WBC-14.8* RBC-3.52* Hgb-10.3* Hct-31.1* MCV-88 MCH-29.2 MCHC-33.1 RDW-13.6 Plt Ct-591* [**2180-5-12**] 06:50AM BLOOD Glucose-139* UreaN-18 Creat-0.5 Na-136 K-4.3 Cl-98 HCO3-30* AnGap-12 [**2180-5-9**] 2:48 pm SWAB Source: PEG tube site. WOUND CULTURE (Preliminary): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). STAPH AUREUS COAG +. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. SECOND STRAIN. 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. Please contact the Microbiology Laboratory ([**6-/2481**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | STAPH AUREUS COAG + | | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- <=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=0.5 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S VANCOMYCIN------------ <=1 S CT abdomen and pelvis: 1) 4.5 x 4.8 cm infrarenal aortic aneurysm with 13 mm neck between renal arteries and proximal aneurysm sac. 2) Deep area of ulceration anteriorly within the superior aspect of the aneurysm sac. No evidence of active extravasation or dissection. 3) Dilated descending thoracic aorta above diaphragmatic hiatus, maximal axial dimensions of 4.3 x 4.5 cm. 4) G-tube located appropriately in stomach. No evidence of free air or free fluid within the abdomen. 5) Stenotic origins of the celiac artery and SMA. These vessels are also heavily calcified. 6) No evidence of acute diverticulitis. No evidence of retroperitoneal hemorrhage. CATH [**2180-5-5**]: 1. Selective coronary angiography revealed a right dominant system with two vessel coronary artery disease. The LMCA had mild distal disease. The moderately calcified LAD had mild luminal irregularities. The large D1 and D2 branches had no angiographically apparent flow limiting lesions. The LCX had totally occluded ostium with collaterals from the left and right coronary arteries. The RCA had diffuse, long serial 70 to 80% stenoses. 2. Resting hemodynamics demonstrated normal right sided and left sided pressures with mildly elevated pulmonary pressures (PA 34/12 mmHg) and no gradient upon movement of the catheter from the ventricle to the aorta. The cardiac index was normal (2.7 l/min/m2). 3. Successful PTCA/stenting of the proximal and mid RCA with overlapping 3.0x33 and 3.0x23mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5809**] to 3.5mm with excellent results (see PTCA comments). CXR [**2180-5-8**]: No acute cardiopulmonary process. VIDEO SWALLOWING [**2180-5-8**]: Prevertebral soft tissue swelling predominantly posteriorly and to the left, interfering with the mechanics of swallowing. Please refer to the report of speech pathologist for further details. CT C-spine [**2180-5-9**]: 1) Slight thickening of the posterior nasopharyngeal mucosa and thickening of the prevertebral soft tissues anterior to C3 and C4 without evidence of discrete fluid collection. Clinical correlation is recommended. 2) Displaced cerclage wire adjacent to the arch of C1 on the right and left C4 screw not located in the osseous lamina but at the edge of the C3-4 facet. 3) Multilevel cervical spinal stenosis. CT sinuses/mandible/maxilla [**2180-5-10**]: There is no sinus fluid to indicate acute sinusitis. C-spine plain films [**2180-5-10**]: Suboptimal assessment posterior cervical/occipital fusion. Possible interval C1-2 subluxation. Brief Hospital Course: 1. NSTEMI: Patient had a NSTEMI post-operatively. She underwent cardiac catheterization on [**2180-5-5**] which revealed a two vessel CAD and two Cypher stents placed to RCA. Patient tolerated the procedure well. She did have a 12 beat run of asymptomatic NSVT on tele on [**5-8**]. Patient was discharged on ASA, B-blocker (maximum dose), Plavix, Lipitor, and an ACE inhibitor. Patient never exhibited bronchospasm on B-blocker despite h/o COPD. She should not stop taking Plavix unless approved by her cardiologist. 2. CHF. Pt has systolic dysfunction with EF 32%. Post MI echo showed no decrease in EF. Her weight was checked daily to assess volume status and has decreased over the course of her hospital stay. She had no evidence of decompensated heart failure on exam. She was continued on lisinopril, beta-blocker with low threshold to give Lasix boluses as needed. Her volume status will need to be closely monitored with strict ins/outs and daily weights. 3. COPD: Patient was continued on albuterol IH, tiatropium and Salmeterol. Patient satting well on RA and had no evidence of bronchospasm on exam. 4. Post C3-occiput fusion: Had mild complaints of neck soreness s/p C3 occiput fusion. Post-procedure CT of neck done to assess pharyngeal swelling revealed incidental finding of misplaced hardware and vertebral fractures. Neurosurgery were consulted. The patient was placed in cervical collar and additional images including plain films of C-spine and CT C-spine were obtained. Neurosurgery recommended that the patient should wear soft cervical collar on when in bed and a custom made hard collar when out of bed. She was scheduled to follow up with Dr. [**Last Name (STitle) **] in neurosurgery. She has no limitations in activities as long as she is wearing cervical collar. 5. Pharyngeal swelling. This was noted on oropharyngeal swallowing study. ENT was consulted and their exam also revealed ulceration warranting biopsy. CT neck was done to investigate the area of concern further and showed soft tissue thickening anterior to C3-4 but no fluid collection. The patient will need to f/u with ENT and will have biopsy of this in the future (currently not a candidate for biopsy due to recent MI and being on Plavix). A follow up appointment was scheduled for her. 6. FEN: Patient was had significant amount of swelling post-op which made it difficult for patient to swallow. An NGT was placed for feeding, initially. However, a consult by speech and swallow revealed that the patient was likely aspirating and a more permanent mode of transmission for feeding needed to be established secondary to the fact that the swelling would take months to resolve. Swallow study ordered on [**5-8**]. A PEG was placed without incident, and pt was able to receive feeds successfully in-house. Patient was discharged with speech and swallow follow up. 7. Leukocytosis: The patient was admitted to [**Hospital Unit Name 319**] service with elevated WBC and low grade fever x 2 days. She was empirically started on Levo/Flagyl for possible GI infection (recent PEG, c/o loose stools), however, CT scan of abdomen and pelvis was negative for fluid collections, abscesses, and stools have been neg for C diff. Work up for potential source of infection including urine and CXR was unrevealing. There was no evidence of infection at PEG site. Patient became afebrile [**2180-5-7**]. Antibiotics were discontinued. Wound culture from PEG site then grew Pseudomonas and MRSA, however, the patient had no evidence of cellulitis and had leukocytosis prior to having PEG placed. After discussing this case with ID consultants, the decision was not to treat her with Abx given lack of clinical signs of infection. Should she develop signs of infection at this site of PEG tube or become febrile further investigation and treatment may be warranted. 8. HTN. BP were controlled on maximum dose Metoprolol and Lisinopril. Amlodipine was added and titrated to 10 mg po daily. Goal SBP <130. 9. Osteopenia. Vitamin D and Calcium supplements. 10. AAA. Stable. Continue strict BP control. Medications on Admission: 1. Diltiazem 90 mg once daily. 2. Ditropan XL 10 mg. 3. Serevent diskus 2 b.i.d. 4. Spiriva b.i.d. 5. Albuterol nebs. 6. Isosorbide 30 mg once daily. 7. Lisinopril 5 mg once daily. 8. Folic acid 1 mg p.o. once daily. 9. Multivitamin 1 p.o. once daily. 10.Neurontin 100 mg b.i.d. The patient was on Ecotrin and Celebrex which was discontinued. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Gabapentin 250 mg/5 mL Solution Sig: One (1) PO twice a day: Please taper down slowly. 9. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): For dvt proph. 10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 11. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for Pain. 16. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for to itchy areas on stomach and under breast. 18. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily). 19. speech and swallow Sig: One (1) follow up appointment : Please call for an appointment as an outpatient. Disp:*1 appointment* Refills:*2* 20. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 21. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop without consulting a cardiologist. 22. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 23. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day): Please hold if SBP <110 or HR <55. 24. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed: Please give supp if pt does not have BM within 2-3 days with regular regimen . 25. Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times a day. 26. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] Discharge Diagnosis: Primary diagnoses: 1. Cervical fracture, s/p C3 occiput fusion 2. Non-ST elevation MI 3. Coronary Artery Disease 4. Pharyngeal soft tissue swelling and ulceration. Secondary diagnoses: 1. Congestive heart failure, systolic, compensated 2. Osteopenia 3. Abdominal aortic aneurysm 4. Chronic obstructive pulmonary disease 5. Hypertension Discharge Condition: Afebrile. Vital signs stable. Discharge Instructions: Please take all medications as directed. It is very important that you take Plavix for at least 3 months without interruption. Do not stop Plavix without consulting your cardiologist. Please keep all follow up appointments. You need to wear soft cervical collar at all times. Please return to care immediately if you develop fevers, chest pain, shortness of breath, weakness or numbness in any part of your body or other concerning symptoms. Followup Instructions: 1. You need to follow up with Dr. [**Last Name (STitle) **] in the neurosurgery clinic at [**Hospital 2047**]. You have an appointment [**2180-6-13**] at 10:00 am. YOU WILL NEED X-RAYS prior to appoitment. Please call Dr.[**Name (NI) 5810**] office before appointment for instructions. Provider [**Name Initial (PRE) **]. ADDRESS: 750 [**State **], 7 th floor. Phone:[**Telephone/Fax (1) 5811**] Date/Time:[**2180-6-13**] 10:00 am 2. You need speech therapy at rehab. Once you leave the rehab you need to follow up with speech and swallow. Please call [**Telephone/Fax (1) 5812**] to schedule an appointment once you know you're leaving the rehab. 3. Please follow-up with Dr. [**Last Name (STitle) **] (ENT surgeon) on [**2180-5-30**] 5:15 pm at [**Street Address(2) 5813**] ([**Telephone/Fax (1) 5814**]). You may need biopsy of ulcerated area in your pharynx in the future. 4. Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 189**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5815**] Date/Time:[**2180-5-26**] 2:30 [**Name6 (MD) **] [**Last Name (NamePattern4) 5816**] MD [**MD Number(1) 5817**] Completed by:[**2180-5-16**]

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icd9pcs

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Discharge summary

report

Admission Date: [**2202-11-4**] Discharge Date: [**2202-11-16**] Date of Birth: [**2145-7-27**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: esophagogastroduodenoscopy [**2202-11-4**] colonoscopy [**2202-11-9**] History of Present Illness: 57 year old female well known to our service. She underwent redo sternotomy, MVR (St. [**Male First Name (un) 923**] mechanical), TVrepair on [**2202-10-11**]. Post operative course was complicated by complete heart block, which resolved by POD 3, and subsequent A-flutter which was successfully cardioverted. The patient was anti-coagulated for her mechanical valve with a goal INR 2.5-3.5. The patient was discharged on POD 9 with INR 2.4. Follow up was arranged for Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] (PCP) to manage INR and coumadin dosing. The patient presented to the ED on [**11-4**] with fatigue, and lightheadedness/near syncope. Initial work up reveals INR 6.3, hematocrit 13, and guaiac positive stool. She was admitted for further workup and management. Past Medical History: mitral regurgitation tricuspid regurgitation s/p aortic valve replacement systemic lupus erythematosis systemic hypertension pulmonary hypertension raynaud's disease s/p cholecystectomy lupus nephritis rheumatic heart disease portal hypertension anemia Social History: Patient is married with one son, denies tobacco, minimal EtOH Family History: Grandmother died from a CVA at age 50. Father died at age 70 from complications of diabetes. Physical Exam: Admission: Vitals: pulse 90, BP 76/43 General: pasty, lying on ER stretcher HEENT: PERRL, EOMI, mucous membranes- dry Neck: no bruit, JVD or LAD Chest: CTAB Heart: RRR, sharp click Abd: soft, non-distended, non-tender, NABS, blood tinged drainage from NGT Ext: cool, no edema, pulses palpable Varicosities: none Neuro: non-focal/grossly intact Discharge: Vitals: General: WF, NAD, appears stated age Lungs: CTAB CV: RRR, no murmur or rub Abd: NABS, soft, non-tender, non-distended Ext: no edema Sternal incision: c/d/i, no erythema or drainage Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 103924**]Portable TTE (Focused views) Done [**2202-11-4**] at 1:53:52 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 645**] E. [**Last Name (LF) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2145-7-27**] Age (years): 57 F Hgt (in): 65 BP (mm Hg): 78/56 Wgt (lb): 120 HR (bpm): 124 BSA (m2): 1.59 m2 Indication: H/O cardiac surgery. Tamponade ICD-9 Codes: 423.3, V43.3, 424.1, 424.0, 424.2 Test Information Date/Time: [**2202-11-4**] at 13:53 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] Doppler: Limited Doppler and color Doppler Test Location: [**Location 56698**] Contrast: None Tech Quality: Adequate Tape #: 2008W00-0:00 Machine: Vivid i-3 Echocardiographic Measurements Results Measurements Normal Range Findings LEFT VENTRICLE: Small LV cavity. Hyperdynamic LVEF >75%. PERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic signs of tamponade. Conclusions The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2202-11-4**] 15:58 ?????? [**2197**] CareGroup IS. All rights reserved. [**2202-11-4**] 12:45PM BLOOD WBC-12.4* RBC-1.45*# Hgb-4.1*# Hct-13.0*# MCV-89 MCH-28.5 MCHC-31.9 RDW-15.5 Plt Ct-431# [**2202-11-4**] 12:45PM BLOOD PT-54.4* PTT-40.2* INR(PT)-6.3* [**2202-11-4**] 12:45PM BLOOD Glucose-126* UreaN-117* Creat-1.5* Na-134 K-4.8 Cl-107 HCO3-16* AnGap-16 [**2202-11-4**] 12:45PM BLOOD WBC-12.4* RBC-1.45*# Hgb-4.1*# Hct-13.0*# MCV-89 MCH-28.5 MCHC-31.9 RDW-15.5 Plt Ct-431# [**2202-11-4**] 12:45PM BLOOD PT-54.4* PTT-40.2* INR(PT)-6.3* [**2202-11-15**] 05:40AM BLOOD PT-19.9* PTT-83.1* INR(PT)-1.9* [**2202-11-15**] 05:40AM BLOOD WBC-4.9 RBC-2.84* Hgb-8.4* Hct-25.0* MCV-88 MCH-29.6 MCHC-33.6 RDW-15.3 Plt Ct-263 Brief Hospital Course: Ms. [**Known lastname 9996**] was admitted to the CVICU where TEE revealed no tamponade, and EGD revealed no evidence of upper GI bleed. The patient was transfused five units of fresh frozen plasma, as well as two units of packed red blood cells. Hematocrit rose to 21 and INR began to fall. The patient remained stable and was transferred to the step down unit on hospital day 4. Sternal drainage was cultured and revealed coag positive staph aureus, the patient was started on vancomycin given her history of MRSA. EGD was performed on [**11-4**] and was normal. Heparin was started when INR dropped below 2. Colonoscopy was performed on [**11-9**]. Two polyps were removed and sent for biopsy, however, remainder of exam was normal. Pathology reveals: 1.Fragments of adenoma, and 2. Condyloma acuminatum with low grade dysplasia (anal intraepithelial neoplasia I). The GI team referred Ms. [**Known lastname 9996**] to a ZGI [**Known lastname 5059**] for outpatient work-up of these findings. Following these procedures, heparin and coumadin were resumed. The patient's hematocrit remained stable throughout the hospital course. She was discharged to home when her INR became therapeutic on hospital day 13. Medications on Admission: lopressor colace 100'' zantac 150'' asa 81' plaquenil 200'' MVI daily niferex 150' ultram 50 q4h prn percocet prn warfarin (thurs 4, fri 4, sat 2, sun 2) ativan 0.5'' lisinopril 20' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: please take 4mg (two 2mg tablets) daily until directed otherwise by the office of Dr. [**First Name (STitle) 437**]. Disp:*60 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Please draw an INR on Friday [**2202-11-19**] with results sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the office of Dr. [**First Name (STitle) 437**] at ([**Telephone/Fax (1) 9410**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: anemia, hct 13 supratherapeutic INR (6.1) hypertension Rheumatic heart disease systemic lupus erythematosis Raynaud's phenomenon Lupus nephritis portal hypertension hepatic enlargement/ fibrosis s/p mitral valve replacement (St. [**Male First Name (un) 923**] mechanical), tricuspid valve ring [**2202-10-6**] s/p aortic valve replacement (tissue) [**2197**] s/p cholecystectomy esophageal spasm rheumatoid arthritis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No lifting more than 10 pounds for 10 weeks from surgery date Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (GI surgery) in [**2-7**] weeks. ([**Telephone/Fax (1) 96488**]) please call for an appointment. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] [**Telephone/Fax (1) 62**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1579**] (new PCP, [**12-31**] 8:30am) An INR should be drawn on Friday [**2202-11-19**] with results sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the office of Dr. [**First Name (STitle) 437**] at ([**Telephone/Fax (1) 9410**]. Plan confirmed with [**Doctor First Name **] on [**2202-11-16**]. Completed by:[**2202-11-16**]

[ "998.59", "E878.1", "572.3", "571.5", "E934.2", "714.0", "790.92", "582.81", "211.3", "041.12", "416.8", "285.1", "V43.3", "710.0", "397.0", "V58.61", "578.9", "998.0", "394.1", "078.11", "443.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.25", "99.07", "45.13" ]

icd9pcs

[ [ [] ] ]

7601, 7659

4783, 6004

338, 411

8120, 8127

2298, 4760

8618, 9337

1624, 1718

6236, 7578

7680, 8099

6030, 6213

8151, 8595

1733, 2279

283, 300

439, 1252

1274, 1528

1544, 1608

66,831

115,882

8448

Discharge summary

report

Admission Date: [**2130-7-10**] Discharge Date: [**2130-7-14**] Date of Birth: [**2047-4-25**] Sex: F Service: SURGERY Allergies: Penicillins / Morphine / Codeine Attending:[**First Name3 (LF) 148**] Chief Complaint: Jaundice and abdominal pain. Major Surgical or Invasive Procedure: [**2130-7-10**] - ERCP with stent removal and new stent placement. History of Present Illness: 83 year-old female presents as transfer from [**Location (un) 620**] with jaundice and abdominal pain. The patient has a known peri-ampullary cancer. She had an ERCP in [**4-/2130**] that revealed a bulky/friable major papilla and a 15 mm shouldered stricture at the ampullary level. She was stented at that time. EUS 2 days later revealed pancreas parenchyma with changes of chronic pancreatitis. Changes of acute on chronic pancreatitis noted in the head of the pancreas, and dilated pancreatic and bile duct to the ampulla. Distal CBD brushings were positive for malignancy. The patient is scheduled to have Whipple next week by Dr. [**Last Name (STitle) **]. Patient was seen for preadmission testing last week and was doing well. . However, she now presents 3 days of severe RUQ abdominal pain and jaundice. Her urine has been dark, and she has been having small brown bowel movements. She also reports vomiting on and off for 4 days. She went to the ED at [**Hospital1 18**] [**Location (un) 620**] today where she was found to be jaundiced and slightly hypotensive with SBP in 80s. Her BP responded well to IVF. She was diagnosed with cholangitis and transferred to [**Hospital1 18**] main campus for ERCP. At the time of transfer, she was mentating well and not complaining of any chest pain. She only felt slight abdominal pain. SBP ranged from mid 80s to 110. Past Medical History: PMHx: AF (not on coumadin), CAD, HTN, Hypothyroidism, Type II DM, Hypercholesterolemia, Anemia, h/o Myasthenia [**Last Name (un) **], GERD, Dysphagia, h/o Bronchitis, chronic pancreatitis, periampullary cancer. . PSHx: TAH, Sinus surgery, ORIF UE fx w/ bone grafting Social History: Retired from work in accounting office and as florist. No tobacco, alcohol, drugs. Patient will be discharged to a skilled nursing facility, where her husband resides. Family History: Non-contributory Physical Exam: On Admission: VS: 98.0 116 104/62 18 96%2L Gen: NAD. A&Ox3. HEENT: Scleral icterus. Moist mucus membranes Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: Soft. NT. ND. +BS. DRE: Normal tone. No masses. No gross or occult blood. Ext: Warm and well perfused. No peripheral edema. Neuro: Motor and sensation grossly intact. Pertinent Results: [**2130-7-10**] 10:48PM GLUCOSE-132* UREA N-35* CREAT-1.1 SODIUM-137 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-12 [**2130-7-10**] 10:48PM CALCIUM-7.3* PHOSPHATE-3.3 MAGNESIUM-2.0 [**2130-7-10**] 10:48PM WBC-10.7 RBC-2.65* HGB-8.7* HCT-25.7* MCV-97 MCH-32.9* MCHC-33.9 RDW-18.7* [**2130-7-10**] 10:48PM NEUTS-94* BANDS-2 LYMPHS-3* MONOS-0 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2130-7-10**] 10:48PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL [**2130-7-10**] 10:48PM PLT SMR-NORMAL PLT COUNT-232 [**2130-7-10**] 10:48PM PT-15.1* PTT-25.9 INR(PT)-1.3* [**2130-7-10**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-6.5 LEUK-NEG [**2130-7-10**] 05:50PM URINE RBC-0-2 WBC-[**1-26**] BACTERIA-FEW YEAST-NONE EPI-[**1-26**] [**2130-7-10**] 04:45PM GLUCOSE-143* UREA N-39* CREAT-1.3* SODIUM-135 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11 [**2130-7-10**] 04:45PM ALT(SGPT)-96* AST(SGOT)-155* CK(CPK)-72 ALK PHOS-828* TOT BILI-8.4* [**2130-7-10**] 04:45PM LIPASE-64* [**2130-7-10**] 04:45PM cTropnT-0.29* [**2130-7-10**] 04:45PM CK-MB-NotDone [**2130-7-10**] 04:45PM ALBUMIN-2.4* . Cardiology Report ECG Study Date of [**2130-7-10**]: Sinus tachycardia with atrial premature beats. Non-specific diffuse low amplitude T waves. Compared to the previous tracing of [**2130-7-6**] sinus tachycardia is new and the Q-T interval is no longer prolonged. Intervals Axes: Rate PR QRS QT/QTc P QRS T 108 116 90 362/446 38 -2 12 . [**2130-7-10**] ERCP: Distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer. 10F 7cm Cotton [**Doctor Last Name **] biliary stent placed for drainage. Otherwise normal EGD to third part of the duodenum. . Cardiology Report ECG Study Date of [**2130-7-11**]: Sinus rhythm. T wave inversions in leads V1-V6. Cannot exclude myocardial ischemia. Prolonged Q-T interval. Low QRS voltage in the precordial leads. Compared to tracing #1 of [**2130-7-10**] sinus tachycardia and atrial premature beats are absent. The T wave inversion is new. Intervals Axes: Rate PR QRS QT/QTc P QRS T 69 0 84 458/473 0 -9 -142 . [**2130-7-11**] CXR: Mild pulmonary edema with low lung volumes and bibasilar atelectasis. Brief Hospital Course: The patient with a history of peri-ampullary cancer was admitted from [**Hospital1 **] [**Location (un) 620**] ED to the SICU on [**2130-7-10**] in stable condition for treatment of cholangitis. She was made NPO, started on IV fluids and IV Cipro and Flagyl, a foley was placed, and she was transfused 1 unit PRBC for a HCT 24.5 prior to ERCP. She then underwent ERCP, which revealed distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer was seen. A new stent was placed. The patient was then transferred to the [**Hospital Unit Name 153**]. . [**Hospital Unit Name 153**] Course [**Date range (3) 29786**]: The patient was transferred to the [**Hospital Unit Name 153**] post ERCP for monitoring of respiratory status and continued intubation given her history of myasthenia [**Last Name (un) 2902**]. She was hypotensive, and CVL and A-line were placed. She received LR boluses and was started on levophed drip with improvement in her CVP to 16-18 and MAPs>70. UOP was approximately 20-25cc/hr. Troponin's elevated 0.19-0.29 range; no EKG changes or ST elevation. Recent persantine stress test normal. Believed to be due to demand ischemia secondary to hypotensive episode and/or sepsis. No acute cardiac events. The patient was extubated without events and transferred to the SICU for continued management. . SICU Course [**Date range (3) 29787**]: Returned to SICU NPO except medications, on IV fluids and IV antibiotics in good condition and hemodynamically stable. Electrolytes repleted, started on sips and home medications, ambulated. Cleared for transfer to the floor. . Floor Course [**Date range (3) 29788**]: Tranferred to the floor; was hemodynamically stable. Diet abvanced to clears, then regular by [**2130-7-13**] with good tolerability. Experienced no significant pain. IV fluids discontinued. Foley catheter was discontinued; the patient was able to void on her own without problem. Restarted on remaining home medications with the exception of Metoprolol, which was prescribed as 100mg [**Hospital1 **] as blood pressure and heart rate well controlled, instead of home dose of Toprol XL 250mg daily. Physical Therapy evaluated and worked with the patient prior to discharge. At the time of discharge on [**2130-7-14**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assistance, voiding without assistance, and not experiencing any significant pain. The patient was discharged to the same skilled nursing facility, where her husband has been admitted. She will return for planned Whipple surgery [**2130-8-2**]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin EC 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO as needed for Anxiety. 11. Imuran 50mg PO BID. 12. Metoprolol SR 250mg (200mg + 50mg) PO daily. 13. HCTZ 25mg PO QAM. Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold Aspirin starting [**2130-7-19**] (two weeks prior to surgery). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Qday-[**Hospital1 **] as needed for Anxiety. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: [**Month (only) 116**] increase to 200mg [**Hospital1 **] if indicated by BP & HR. 15. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-27**] hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Location (un) 29789**] Country Manor - [**Location (un) 29789**] Discharge Diagnosis: 1. Periampullary cancer 2. Cholangitis 3. [**First Name9 (NamePattern2) **] [**Last Name (un) **] 4. Anemia Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. 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 [**4-2**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: You have been scheduled for Whipple surgery on [**2130-8-2**]. Please take nothing by mouth after midnight on [**8-2**]. Stop your Aspirin on [**2130-7-19**]. Please do NOT take your Metformin and hydrochlorothiazide the morning of surgery. You will be contact[**Name (NI) **] with other pre-operative instructions prior to this date. Please call Dr.[**Name (NI) 2829**] Office at ([**Telephone/Fax (1) 2828**] with any questions. Please call ([**Telephone/Fax (1) 7761**] to arrange a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP) in [**11-25**] weeks. Completed by:[**2130-7-14**]

[ "156.1", "785.52", "577.1", "038.9", "358.00", "584.9", "995.92", "401.9", "576.2", "244.9", "427.31", "250.00", "576.1" ]

icd9cm

[ [ [] ] ]

[ "51.10", "38.93", "38.91", "97.05" ]

icd9pcs

[ [ [] ] ]

10524, 10618

5208, 8114

320, 389

10770, 10779

2683, 5185

12280, 12883

2294, 2312

9013, 10501

10639, 10749

8140, 8990

10803, 12257

2327, 2327

252, 282

417, 1801

2341, 2664

1823, 2092

2108, 2278

27,034

153,786

32702

Discharge summary

report

Admission Date: [**2133-9-30**] Discharge Date: [**2133-10-10**] Service: NEUROSURGERY Allergies: Codeine Attending:[**First Name3 (LF) 1854**] Chief Complaint: "I want to go home" s/p fall. Major Surgical or Invasive Procedure: s/p crani for SDH evacuation History of Present Illness: Pt not a good historian / history from chart HPI: Asked to evaluate this 87 year old white male, on ASA, for acute on chronic SDH on left. Pt is resident of an [**Hospital3 12272**] community. He describes going to step into the shower tonight and when he reached with one hand, his other hand was "flying all over" and "I lost my balance". Pt denies LOC / sz/ incontinence. He was brought to [**Hospital **] Hospital for initial eval. He was transferred to [**Hospital1 18**] for further eval after head CT showed interval increase in size of SDH when compared with images from [**2133-9-5**]. Additionally, there is subacute blood that is noted on this new study. Past Medical History: temporal lobe epilepsy subdural hematoma multiple falles bilateral knee repair UTI prostate surgery HTN Social History: Hx: lives in [**Hospital3 **] / [**Hospital2 **] [**Hospital3 **] in [**Location (un) **] Family History: unkown Physical Exam: PHYSICAL EXAM ON ADMISSION: T: afebrile 166/94 /86 hr /21 resp /95% ra Gen: WD/WN, comfortable, NAD. HEENT: Pupils: right pupil 2.0 mm reactive, left 3.0mm reactive, EOMIs Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 on left and 2.1 on right mm. Visual fields are grossly intact. 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 [**3-21**] throughout, except left tricep [**2-19**]. No pronator drift Sensation: Intact to light touch No clonus Pertinent Results: [**2133-9-30**] 03:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2133-9-30**] 03:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2133-9-30**] 03:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2133-9-30**] 12:10AM GLUCOSE-114* UREA N-21* CREAT-0.8 SODIUM-135 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-28 ANION GAP-13 [**2133-9-30**] 12:10AM PHENYTOIN-7.3* [**2133-9-30**] 12:10AM WBC-7.1 RBC-3.65* HGB-12.3* HCT-35.7* MCV-98 MCH-33.7* MCHC-34.4 RDW-13.6 [**2133-9-30**] 12:10AM NEUTS-60.7 LYMPHS-29.6 MONOS-5.4 EOS-3.9 BASOS-0.4 [**2133-9-30**] 12:10AM PLT COUNT-284 [**2133-10-2**] 04:12AM BLOOD WBC-10.1 RBC-3.57* Hgb-12.0* Hct-35.1* MCV-98 MCH-33.5* MCHC-34.1 RDW-13.5 Plt Ct-301 [**2133-10-2**] 04:12AM BLOOD Plt Ct-301 [**2133-10-1**] 03:35PM BLOOD PT-13.2 PTT-25.1 INR(PT)-1.1 [**2133-10-2**] 04:12AM BLOOD Glucose-133* UreaN-18 Creat-0.7 Na-138 K-3.9 Cl-103 HCO3-25 AnGap-14 [**2133-10-2**] 04:12AM BLOOD Phenyto-2.6* [**2133-9-30**] 12:10AM BLOOD Phenyto-7.3* CT HEAD W/O CONTRAST [**2133-9-30**] IMPRESSION: Stable size of the large subdural hemorrhage tracking along the left convexity. Increasing high-density component may reflect evolution or redistribution of blood products. Stable rightward subfalcine herniation. CT C-SPINE W/O CONTRAST [**2133-9-30**] IMPRESSION: Status post left frontal craniotomy and evacuation of subdural hematoma. Compared to prior exam from [**2133-9-30**], there is decreased size of extra-axial collection along the left convexity. No new intracranial hemorrhage. Brief Hospital Course: The patient was admitted with a SDH that was acute on chronic. He went to the OR on [**10-1**] for evacuation of the SDH and the post-op CT showed improvement in the hemorrhage. On [**10-3**] the patient developed a fever. On [**10-4**] he was somnolent and a repeat CT revealed new hemorrhage into the previous area of the SDH. He was evaluted by OT on [**10-5**] and they recommended rehab. He was also seen by PT who [**Hospital 5901**] rehab as well. On [**10-6**] the patient had sinus tachycardia and developed low grade fevers. He was transferred to the ICU and received fluid recuscitation which resolved his tachycardia. He was found to have a UTI and started on a 7 day course of Cipro. He was transferred back to the step down unit and found to be neurologically at his baseline confusion following commands, full motor strength. He was tolerating a regular diet. He was given two units of PRBCs for a crit of 25.6. He was felt safe for discharge on [**10-10**] Medications on Admission: Metoprolol and Zantac Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: Subdural Hematoma Discharge Condition: Neurlogically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? 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 Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 4 weeks with a head Ct call office at [**Telephone/Fax (1) 3231**] Completed by:[**2133-10-10**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2116-1-17**] Discharge Date: [**2116-1-30**] Date of Birth: [**2054-3-15**] Sex: F Service: MEDICINE Allergies: Thorazine / Penicillins Attending:[**First Name3 (LF) 800**] Chief Complaint: SOB Major Surgical or Invasive Procedure: Bipap History of Present Illness: 61F h/o COPD and CO2 retention (baseline pCO2 60s), schizoaffective disorder, with recent MICU admission for COPD flare, hypercarbia, and pneumonia discharged [**2116-1-13**] on levofloxacin and prednisone taper presents from home with SOB. . Developed SOB this morning and activated EMS. Found to be hyperventilating and hypoxic, placed on NRB and developed AMS. Also emesis x2 but no chest or abdominal pain. . In the ED, vitals 33.9, 69, 116/53, 24. ABG 7.19/89/99 on NRB, changed from NRB to BiPAP with O2sat 88%. MS improved and repeat ABG 7.23/71/59. Other labs notable for WBC 16 without bands and Na 112 (on [**1-12**] was 132). CXR with ?RLL infiltrate and given vanc/ceftaz/azithro. Also solumedrol 125 and nebulizers. . ROS per above but otherwise limited due to impaired mental status. Past Medical History: * COPD - patient denies h/o intubation * Schizoaffective disorder, bipolar * Chronic low back pain, followed at pain clinic * duodenal polyp, adenoma on bx [**9-/2114**] * esophageal stricture s/p dilatation * h/o urinary retention * h/o ovarian cysts * s/p ccy Social History: Lives alone, long history of smoking ~1ppd since age 14, denies EtoH or ilict drug use. Family History: no h/o cardiac or pulmonary disease Physical Exam: Physical Exam: T HR BP RR SaO2 Weight General: WDWN, NAD, breathing comfortably on RA HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD Cardiac: RRR, s1s2 normal, no m/r/g, no JVD Pulmonary: CTAB Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: [**2116-1-17**] 07:59AM HGB-15.4 calcHCT-46 O2 SAT-76 [**2116-1-17**] 07:59AM LACTATE-0.9 K+-4.0 [**2116-1-17**] 07:59AM PO2-99 PCO2-89* PH-7.19* TOTAL CO2-36* BASE XS-3 [**2116-1-17**] 08:20AM PT-12.1 PTT-34.5 INR(PT)-1.0 [**2116-1-17**] 08:20AM NEUTS-92.4* LYMPHS-4.0* MONOS-3.3 EOS-0.3 BASOS-0 [**2116-1-17**] 08:20AM WBC-16.0* RBC-4.87 HGB-14.3 HCT-42.9 MCV-88 MCH-29.5 MCHC-33.4 RDW-13.2 [**2116-1-17**] 08:20AM CORTISOL-48.2* [**2116-1-17**] 08:20AM T4-6.7 [**2116-1-17**] 08:20AM TSH-1.2 [**2116-1-17**] 08:20AM CALCIUM-8.5 PHOSPHATE-3.4# MAGNESIUM-1.7 [**2116-1-17**] 08:20AM CK-MB-22* MB INDX-3.3 cTropnT-<0.01 [**2116-1-17**] 08:20AM ALT(SGPT)-38 AST(SGOT)-49* CK(CPK)-670* ALK PHOS-85 [**2116-1-17**] 08:20AM GLUCOSE-110* UREA N-15 CREAT-0.6 SODIUM-112* POTASSIUM-4.3 CHLORIDE-72* TOTAL CO2-33* ANION GAP-11 [**2116-1-17**] 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2116-1-17**] 10:38AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2116-1-17**] 10:38AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2116-1-17**] 09:20AM NA+-114* [**2116-1-17**] 02:19PM URINE 24Creat-980 [**2116-1-17**] 02:19PM URINE OSMOLAL-174 [**2116-1-17**] 02:19PM URINE pH-7 HOURS-24 VOLUME-7000 CREAT-14 SODIUM-10 [**2116-1-17**] 04:47PM OSMOLAL-263* [**2116-1-17**] 01:08PM LACTATE-0.8 NA+-120* K+-4.2 CL--81* . CXR: The cardiomediastinal silhouette appears stable, accounting for technique. No focal consolidation is detected within the lungs. There is little if any pulmonary edema. There is a small right pleural effusion. Diffuse osteopenia. . CT head: No acute intracranial pathology including no hemorrhage. . DFA for influenza negative urine legionalla negative blood cultures no growth . [**2116-1-17**] 08:20AM BLOOD WBC-16.0* RBC-4.87 Hgb-14.3 Hct-42.9 MCV-88 MCH-29.5 MCHC-33.4 RDW-13.2 Plt Ct-210 [**2116-1-22**] 06:55AM BLOOD WBC-10.0 RBC-4.28 Hgb-12.4 Hct-39.5 MCV-92 MCH-29.1 MCHC-31.4 RDW-14.0 Plt Ct-178 [**2116-1-29**] 06:30AM BLOOD WBC-16.5* RBC-4.39 Hgb-12.9 Hct-39.4 MCV-90 MCH-29.5 MCHC-32.8 RDW-16.0* Plt Ct-343 [**2116-1-30**] 06:15AM BLOOD WBC-17.7* RBC-4.49 Hgb-13.3 Hct-40.3 MCV-90 MCH-29.7 MCHC-33.1 RDW-15.9* Plt Ct-379 [**2116-1-17**] 08:20AM BLOOD Neuts-92.4* Lymphs-4.0* Monos-3.3 Eos-0.3 Baso-0 [**2116-1-17**] 10:38AM BLOOD Neuts-94.9* Lymphs-3.1* Monos-1.9* Eos-0.1 Baso-0 [**2116-1-29**] 06:30AM BLOOD Neuts-74.8* Lymphs-20.0 Monos-4.1 Eos-0.8 Baso-0.2 . CXR [**1-26**]: Compared with [**2116-1-24**], there are slightly improved inspiratory volumes. Otherwise, no significant change is detected. Again seen is linear but somewhat patchy density at left base, with possible minimal increased density at the right base. No new infiltrates are identified. There is minimal blunting of the left costophrenic angle posteriorly. No gross effusion. No CHF. Background COPD again noted. Cardiomediastinal silhouette is stable. Probable diffuse osteopenia. Small focus of pleural thickening along the right lower chest wall is again noted. IMPRESSION: Bibasilar opacities, unchanged compared with [**2116-1-24**]. . [**1-29**]: CT chest: FINDINGS: Several small, less than or equal to 5 mm diameter lung nodules are without change from the prior examination, including a 5-mm right lower lobe nodule (151, 4) and several smaller nodules located in the right middle lobe (151, 4), lingula (153, 4), right middle lobe (41, 3) and left lower lobe (34, 3). Apparent partial fat attenuation in the periphery of the left lower lobe (156, 4) is likely unchanged but is difficult to directly compare due to a new area of adjacent consolidation within the left lower lobe. Streaky peribronchovascular opacities are again demonstrated within the posterior segments of both lower lobes, and there are also new linear opacities within the right middle lobe and lingula. Previously reported bronchiolitis pattern in right lower lobe has resolved. Areas of bronchial wall thickening persist in the posterior segments of both lower lobes and are now associated with areas of peribronchiolar consolidation within the left lower lobe. Upper lobe-predominant emphysema, moderate in severity, is again demonstrated. No enlarged mediastinal or hilar lymph nodes are identified. Heart size is normal. Small amount of pericardial fluid is slightly changed in distribution but unchanged in amount since the prior CT. A small hiatal hernia is again demonstrated. New trace left pleural effusion has developed. Exam was not tailored to evaluate the subdiaphragmatic region, but adrenal glands are well visualized and normal in appearance. Remaining imaged upper abdomen is remarkable for previous cholecystectomy. Skeletal structures are remarkable for healed right rib fractures. IMPRESSION: 1. Small noncalcified pulmonary nodules are unchanged. Considering the presence of emphysema, consider another followup CT scan in approximately 12 months to confirm further stability. 2. New focal area of consolidation and atelectasis in left lower lobe, which may be related to the patient's recent reported COPD flare. Brief Hospital Course: Assessment and Plan 61F h/o COPD and CO2 retention, schizoaffective disorder presents with hypercarbic resp failure. Improved with bipap, steroids, abx, nebs. . # SOB: Likely COPD flare brought on by a URI. Originally admitted to the ICU for Bipap because of hypercarbic respiratory failure. In the ICU, treated with vanco, ceftazidime, and azithromycin as well as IV MethylPREDNISolone. Upon transfer to the floor continud nebs, a slow prednisone taper, and a 5 day course of Azithromycin. On transfer to the floor she was stable on 1 to 3L oxygen without SOB at rest. Given her longstanding COPD and h/o MS alteration with non-rebreather we aimed for goal SaO2 between 88-92% with titration of oxygen. However, Ms. [**Known lastname **] continued to desat to the low 80s with minimal excertion, including up to the restroom. Upon discharge she will continue a Prednisone taper (started at 60mg daily decreasing by 10mg every 3 days), albuterol, and ipratropium. Unfortunately the patient refuses to consider quiting smoking and admits she would not use home oxygen and therefore is not a candidate for home oxygen. The medical team recommended respiratory rehab but the patient originally refused and demanded to leave AMA. When pt talked with her neice (now the HCP) and team she was more reasonable,and agreeed to [**Hospital **] rehab. Further efforts at smoking cessation should be attempted as an outpatient. . # Leukocytosis: WBC 16 on admission, nadired at 10 on [**1-22**]. Since that time WBC has slowly increased to 17.7. Etiology unclear at this time. Infection was considered. However, throughout her time on the medical floor she was been afebrile. There was concern for a pneumonia. Her [**1-26**] CXR should bibasilar opacities. A chest CT on [**1-29**] showed stable pulmonary nodules and New focal area of consolidation and atelectasis in left lower lobe. However the patient did not have a productive cough and clinically seemed to be slowly improving with increased exercise tolerance, stable oxygen requirement, and clearing lung exam. In addition the diff was not suggestive of infection. ON admission she had 92.4% neutrophils and 4% lymphs, however by [**1-29**] the left shift has resolved with 74.8% neutrophils, 20 % lymphs, 4.1% monos, 0.8% eos, 0.2% basophils. Therefore, we do not believe Ms [**Known lastname **] has a PNA. The opacities on imaging are felt to be radiologic remenants of previous infection (hospitalized 2x recently for COPD exacerbation) or atelectasis. C diff was also considered with the rising WBC. However the patient was without diarrhea and having norml BM's including on the day of discharge. She had no abdominal pain. Repeat urine analysis was not suggestive of infection. The leukocytosis may be secondary to prolonged steroid use. Fever curve, oxygen requirement, and WBCs should be trended after discharge. IF WBCs continue to rise would consider senting a stool for c diff. . # Hyponatremia: Na 112 on admission. Returned to 134 (baseline) without mental status changes. Low serum and urine OSM, U NA less than 10, suggestive of hypovolemia with pt drinking lots of water. The deficit corrected with IVF and remained stable for the remainder of the hospitalization. Her sodium should be followed as an outpatient. . # Schizoaffective disorder: After admission, she was restarted on her psych meds as mental status improved Continued on chlordiazepoxide, topiramate, and Thioridazine. Under Psychs recs topiramate was increased to 100mg am and 150mg pm. The pt requently threatened to leave AMA. Psych was consulted re: capacity if patient would like to leave AMA, or become DNR/DNI. Because of her inablility to explain her rationale to refuse medical treatment and understand the consequences of refusing treatment it was decided she does not have decision making capacity. However this is a changing opinion, basically if she is able to discribe reason for denying care and clearly understands the risk can have dicision making capacity and leave. After meeting with the pt and neice (and the topiramate adjustment) the pt remained pleasant and agreeable to presue pulmonary rehab. . # Pulmonary nodules: First noded on [**3-22**] CT chest. ON [**1-29**] CT nodules were stable but 12 month follow up imaging was suggestive given her COPD and active smoking . # FEN: Regular diet . # Code: FULL (pt without capacity to decide) . # Communication: niece [**Name (NI) 50528**] [**Name (NI) 4135**] [**Telephone/Fax (3) 110848**]. As of [**1-24**] she is the HCP. Pt clearly had capacity to make her the HCP, was able to discribe her close relationship with her neice and her belief she would do thing in her best interest. Medications on Admission: Meds: ** per [**1-12**] d/c summary ** Albuterol Inhaler 1-2 Puffs Q2H as needed Chlordiazepoxide 10 mg PO BID Thioridazine 100 mg PO BID Topiramate 100 mg PO BID Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **] Pantoprazole 40 mg PO Q12H Prednisone 20 mg with taper to 5 mg then off on [**2116-1-21**] Albuterol Nebulization Q4H as needed for shortness of breath Tiotropium Capsule Inhalation once a day Nicotine 21 mg/24 hr Patch Transdermal DAILY Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml (5000 U) Injection TID (3 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation every six (6) hours as needed for SOB, wheezing. 5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane every six (6) hours as needed for sore throat. 8. Chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. 10. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Thioridazine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 14. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): ongoing while on steroids for ppx. 16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily () for 1 days: [**1-30**]. 17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [**1-31**] - [**2-2**]. 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: [**Date range (1) 40042**]. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: COPD exacerbation hypovolemic hyponatremia . secondary dx: schizoaffective disorder Discharge Condition: improved breathing, to continue therapy at pulmonary rehab. Discharge Instructions: You were admitted to the hospital for difficulty breathing. You were treated in the intensive care unit with Bipap for your breathing and fluids for your low sodium. You were than transfered to a medical floor where you were treated with steroids, antibiotics, nebulizers, and oxygen with gradual improvement in your breathing. You will continue your recovery at pulmonary rehabilitation. . The best thing you can do for your breathing is to quit smoking. . The following changes were made to your medications: Prednisone taper was added Topamax was increased to 100mg in the morning and 150mg at night. . Please follow up with your doctors as detailed below. . If you develop wosening shortness of breath, cough, lightheadness or dizziness, chest pain, Fevers or chills, abdominal pain, or any other worrisome symptoms please call your doctor or go to the emergency room. Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2205**]. Monday [**2116-2-17**] at 10:15am. . Psych: Dr. [**First Name8 (NamePattern2) 18890**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 110849**]). Please call to make an appointment within one month after discharge from rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2116-1-30**]

[ "338.29", "295.72", "724.2", "491.21", "518.81", "276.1", "518.89" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2111-10-11**] Discharge Date: [**2111-10-26**] Date of Birth: [**2047-1-2**] Sex: F Service: SURGERY Allergies: Cephalosporins Attending:[**First Name3 (LF) 1234**] Chief Complaint: Ruptured abdominal aortic aneurysm,question mycotic aneurysm. Major Surgical or Invasive Procedure: PROCEDURE: 1. Abdominal aortogram. 2. Percutaneous transluminal angioplasty of right common iliac, percutaneous transluminal angioplasty of right external iliac. 3. Ultrasound guidance for common femoral artery access. 4. Right external iliac artery balloon and self-expanding stent grafts. 5. Repair of ruptured abdominal aortic aneurysm with 16-mm rifampin-soaked tube graft. History of Present Illness: 74F transferred from [**Hospital3 10310**] Hospital. [**Name (NI) 1094**] husband reports that she had been feeling "weaker" for the past [**2-18**] days, dozing off in front of the TV. She normally is very active - walks around and gardens. This afternoon, she collapsed in the bathroom. He helped her into a chair, where she "listed" and was "out of it." She was verbalizing, but disoriented. No tactile fevers at home. No nausea/vomiting/abdominal pain. She had been having headaches, for which she was taking Excedrin/ASA - dose unknown. On arrival at [**Hospital3 10310**], pt's temp was 101.8. LP and pan CT was done. She received vanc and acyclovir. She was transferred after CTA abd demonstrated a bleeding aortic ulcer. EMT reports pt became tachy and hypoxic in the ambulance. She received 1U PRBC in ambulance; a 2nd is hanging now. Past Medical History: PMH: HTN, hypercholesterolemia, ?LLE arterial narrowing ~60% (no intervention) PSH: C-section [**2073**] Social History: SocHx: Has smoked since college, 2-3 packs per day. Has [**4-22**] alcoholic drinks/day. Family History: FamHx: mother had CAD w/ MI in mid-60s, died of lung ca; father had CAD, died in 50s; no siblings Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: Decreased at bases CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2111-10-25**] 05:46AM BLOOD WBC-8.5 RBC-3.51* Hgb-10.5* Hct-31.3* MCV-89 MCH-29.9 MCHC-33.6 RDW-14.7 Plt Ct-692* [**2111-10-25**] 05:46AM BLOOD Glucose-102 UreaN-7 Creat-0.4 Na-141 K-2.9* Cl-102 HCO3-30 AnGap-12 [**2111-10-19**] 02:06AM BLOOD ALT-20 AST-15 AlkPhos-161* TotBili-0.9 [**2111-10-23**] 05:19PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-[**11-6**]* WBC->50 Bacteri-FEW Yeast-NONE Epi-0-2 [**2111-10-10**] 9:43 pm BLOOD CULTURE Blood Culture, Routine (Final [**2111-10-23**]): NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. IDENTIFIED AS ALCALIGENES SPECIES BY [**Hospital1 4534**] LABORATORIES. FINAL SENSITIVITIES. Levofloxacin <=2 MCG/ML. PIPERACILLIN > 64 MCG/ML. Cefepime <=2.0 MCG/ML. MEROPENEM <=1.0 MCG/ML. sensitivity testing performed by Microscan. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- <=0.5 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- S MEROPENEM------------- S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=2 S CXR: FINDINGS: Left lower lobe opacity has partially improved and favors resolving atelectasis over an infectious pneumonia. Minimal linear atelectasis is also present at the right base. Small bilateral pleural effusions are again demonstrated ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. 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. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: hyperdynamic left ventricle; no obvious vegetations CTA: CT CHEST WITH CONTRAST: The airways are notable for a small amount of retained secretions seen in the right mainstem bronchus and otherwise patent to subsegmental levels bilaterally. Note is made of a small calcified granuloma in the right apex. Lungs reveal bilateral emphysematous change. There is a small amount of atelectasis seen in the right lung base. There is no pleural or pericardial effusion. The heart and great vessels are difficult to assess secondary to patient motion. The thoracic aorta is notable for scattered atherosclerotic disease involving both calcified and noncalcified plaques throughout. The thoracic aorta is normal in caliber. There is no axillary or mediastinal lymphadenopathy. CT ABDOMEN WITH CONTRAST: There is a small axial hiatal hernia, and otherwise, the stomach and duodenum are unremarkable. The spleen, pancreas, and adrenal glands are unremarkable. The gallbladder contains small dependent gallstones and is otherwise unremarkable. The liver is diffusely hypodense with sparing in a pericholecystic distribution, suggestive of diffuse fatty nfiltration. The kidneys enhance and excrete contrast in a symmetric fashion. There is no free gas in the abdomen. Regional vascular structures are notable for extensive atherosclerotic disease of the abdominal aorta as well as many of its primary branches. In addition, there is an infrarenal aneurysm of the aorta measuring up to 3 cm (1:68). A few centimeters below this level, there is a posterior irregularity and discontinuity of the posterior aortic wall with extraluminal contrast in the retroperitoneum. There is a large amount of retroperitoneal hematoma, which appears contained. Slightly cephalad to the level of discontinuity (1:73) are other areas of mural irregularity (1:71) suggesting pentrating ulcer. Though difficult to precisely marginate, the area of extra-aortic extravasated blood measures ~50x30x60 mm. The aortic discontinuity is noted ~3cm below the origin of the renal arteries. CT PELVIS WITH CONTRAST: The urinary bladder contains a Foley catheter and a small amount of free gas. The uterus, adnexa, and rectum are unremarkable. The colon is notable for extensive diverticulosis without evidence to suggest acute diverticulitis. There is no free gas or fluid in the pelvis. The regional vascular structures are notable for extensive atherosclerotic calcification along the common external and internal iliac arteries, without evidence of critical stenosis. BILATERAL LOWER EXTREMITY CT ANGIOGRAM: Please note that the provided images are not of a diagnostic angiographic quality. Nevertheless, in both lower extremities, note is made of a moderate amount of inflow atherosclerotic disease at the external iliac arteries bilaterally, again without critical stenosis. Thereafter, a small amount of atherosclerotic calcification is seen at the common and superficial femoral arteries as well as at the popliteal arteries bilaterally, again without evidence of critical stenosis. In the distal lower extremities, there is evidence of grossly patent three-vessel runoff bilaterally. The included soft tissues of the distal lower extremities are notable for bilateral, though more prominently on the left, subcutaneous edema. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic lesion. Mild degenerative changes with subchondral cysts are visualized bilaterally at the hips. Degenerative changes are also present at the sacroiliac joints bilaterally. A sclerotic focus in the right iliac bone is consistent with a bone island. Mild degenerative changes are present throughout the visualized spine. IMPRESSION: 1. Ruptured infrarenal abdominal aorta with a large contained retroperitoneal hematoma. The area of aortic rupture begins ~3cm caudal to the origin of the renal arteries. Given the irregular contour of the aorta at the site of rupture and the patient's clinical history, mycotic aneurysm with rupture is suspected. 2. Extensive atherosclerotic disease as previously characterized. 3. Cholelithiasis. 4. Small axial hiatal hernia. 5. Fatty infiltration of the liver. 6. Extensive diverticulosis. 7. Subcutaneous edema in the lower extremities, left greater than right. Brief Hospital Course: [**2111-10-10**] Pt admitted for Ruptured abdominal aortic aneurysm, question mycotic aneurysm. Emergently taken to the OR: PROCEDURE: 1. Abdominal aortogram. 2. Percutaneous transluminal angioplasty of right common iliac, percutaneous transluminal angioplasty of right external iliac. 3. Ultrasound guidance for common femoral artery access. 4. Right external iliac artery balloon and self-expanding stent grafts. 5. Repair of ruptured abdominal aortic aneurysm with 16-mm rifampin-soaked tube graft. Pt with open abdomen. Transfered to CVICU, intubated Stat ID consult: Meropenum, Cipro, Vanco started [**2111-10-11**] Fluids, BP control, Sedated and vented, JP drain monitered - awaiting abdominal closure, AB [**2111-10-12**] Abdomen closed, BP control, Sedated and vented, BP control Elevated liver enzymes Post operative Anemia Fevers - pan cx AB continued VENT [**2111-10-13**] Abdomen closed, BP control, Sedated and vented, BP control Elevated liver enzymes, but decreasing Post operative Anemia - recieved 2 units PRBC Fevers - pan cx AB continued - Rifampin added Wound care nurse consulted for decub's TF started CIWA scale started VENT TEE - negative [**2111-10-14**] Sedated, Intubated Anemia stable after 2 units AB continued CVICU care TF Afebrile CIWA [**2111-10-15**] Intubated, sedated AB continued CVICU care TF at goal Afebrile Wound care CIWA Diuresis [**10-16**] - [**2111-10-18**] Intubated, sedated AB continued CVICU care TF Afebrile Wound care CIWA Diuresis [**2111-10-19**] Extubated, speech and swallow AB continued CVICU care TF Afebrile - WBC trending down Wound care LFT normalizing CIWA Diuresis [**2111-10-20**] Transfered to VICU PICC placed AB continued PO intake, TF DC'd Afebrile - WBC normalizes Wound care CIWA Diuresis [**10-21**] - [**2111-10-23**] Aline DC'd AB continued Taking PO Wound care CIWA weaned, Clonidine patch DC'd, Valium decreased, ativan prn c/w diuresis PT / OT consult ID final recs - [**Last Name (un) 2830**] and rifampin 6 weeks, Cipro for life [**2111-10-24**] Staples DC'd Febrile, no increase in WBC Pan cx'd Pt / OT No DT's Wound care Case Management - screen for reahb [**10-25**] - [**2111-10-26**] Afebrile stable for DC f/u arranged Medications on Admission: simvastatin, flunisolide, NasalCrom, Excedrin/ASA, Sudafed Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 6 weeks. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Please wean . 7. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): for life. 12. Flunisolide 250 mcg/Actuation Aerosol Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 6 weeks. 16. Cromolyn 5.2 mg/Actuation Spray, Non-Aerosol Sig: One (1) Spray Nasal Q8H (every 8 hours). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing: prn. 18. PICC 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. 19. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day) for 7 days. 20. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical DAILY AND/OR EVERY THIRD CLEANSING WITH CRITICAID CLEAR MOISTURE BARRIER OINTMENT AS SECOND LAYER () as needed for fungal. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Ruptured abdominal aortic aneurysm, question mycotic aneurysm. pleural effusions Anemia from post p blood loss - trnasfused Decubitus ulcer - stage 111 coccyx Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-25**] 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 [**1-20**] 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 Completed by:[**2111-10-26**]

[ "562.10", "305.1", "511.9", "440.0", "568.81", "571.8", "574.10", "518.0", "567.89", "440.8", "441.3", "272.0", "707.23", "401.9", "707.03", "112.3", "285.1" ]

icd9cm

[ [ [] ] ]

[ "00.47", "38.44", "88.72", "00.41", "54.11", "96.6", "88.42", "96.72", "39.90", "88.48", "38.93", "39.50" ]

icd9pcs

[ [ [] ] ]

13367, 13410

9037, 11289

338, 734

13613, 13622

2481, 9014

1874, 1974

11398, 13344

13431, 13592

11315, 11375

13646, 15909

15935, 16369

1989, 2462

236, 300

762, 1621

1643, 1751

1767, 1858

12,178

184,184

23650

Discharge summary

report

Admission Date: [**2105-2-27**] Discharge Date: [**2105-3-2**] Date of Birth: [**2065-6-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: mental status change Major Surgical or Invasive Procedure: intubation History of Present Illness: 39 year old male w/ h/o low back pain on chronic narcotics presents after being found unresponsive at home. His daughter awoke him at 7 a.m., reports he said he felt "cold and shivery," vomited several times, then drove her to school. According to his wife, he came home and went to sleep. When she tried to awaken him at 11 a.m., she was unable to do so and called EMS. She did not notice any blood/urine/emesis/stool in the bed. EMS found him with agonal respirations and pinpoint pupils. FS 420. He received 1 mg IV Narcan (numerous bottles of oxycontin, percocet were found in room); his pupils dilated to ~ 8 mm and he became combative/agitated. He was then intubated for airway protection (etomidate/succinate); it was a traumatic intubation and one of his teeth was chipped. He was transported to [**Hospital1 18**] ED, where ABG 7.14/82/44 while bagging on 100% FiO2. Wife reports that he drank a large amt of alcohol (12 bottles of beer) night PTA. For 2 days PTA, he has expressed a wish to kill himself (no clear plan, but fixing things around the house "so things will be ready when I'm gone"). In [**Name (NI) **], pt received charcoal, 500 mg IV levofloxacin, 500 mg IV metronidazole for presumed aspiration pna. Past Medical History: chronic LBP, HTN, anxiety, depression, L arm surgeries (hardware in place) Social History: lives with wife and daughters. On disability secondary to work-related back injury. Heavy EtOH (12 beers several times a week). Smokes ~ 1 pk/week. No other known drug use other than Oxycontin/percocet. Family History: No family history of heart disease or cancer Physical Exam: PE: Tc 98.7, pc 88, bpc 120/60, AC 600/20, FiO2 100%, PEEP 10 Gen: young male, intubated, sedated, in hard collar. HEENT: Pupils pinpoint, equal, anicteric, normal conjunctiva, intubated, OGT in place, OMMM, normocephalic, atraumatic Cardiac: RRR, I/VI SM at apex, no R/G appreciated Pulm: coarse breath sounds throughout Abd: mildly distended, hypoactive BS, soft, no HSM Ext: trace LE edema at ankles, extremities cool w/ 2+ radial, 1+ DP/PT pulses. Well-healed scars over dorsal/lateral distal LUE Neuro: DTR 3+ upper and lower extremities, symmetric bilaterally. Toes equivocal bilaterally. (+) gag Pertinent Results: EKG NSR @ 92 bpm, nl axis, borderline QT (QTc 0.442), J Pt elevtation V3, TWF II, III, avF, I, avL (no prior EKG for comparison) [**2105-2-27**] 03:39PM TYPE-ART PO2-122* PCO2-38 PH-7.43 TOTAL CO2-26 BASE XS-1 [**2105-2-27**] 03:39PM LACTATE-2.0 [**2105-2-27**] 01:30PM URINE HOURS-RANDOM [**2105-2-27**] 01:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2105-2-27**] 01:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2105-2-27**] 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2105-2-27**] 01:30PM URINE RBC-[**2-14**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2105-2-27**] 01:30PM URINE MUCOUS-FEW [**2105-2-27**] 12:22PM PO2-44* PCO2-82* PH-7.14* TOTAL CO2-30 BASE XS--4 [**2105-2-27**] 12:22PM GLUCOSE-296* LACTATE-4.8* NA+-140 K+-5.2 CL--101 [**2105-2-27**] 12:20PM UREA N-20 CREAT-1.1 [**2105-2-27**] 12:20PM ALT(SGPT)-30 AST(SGOT)-38 LD(LDH)-217 CK(CPK)-1152* ALK PHOS-52 AMYLASE-426* TOT BILI-0.4 [**2105-2-27**] 12:20PM LIPASE-22 [**2105-2-27**] 12:20PM CK-MB-45* MB INDX-3.9 cTropnT-<0.01 [**2105-2-27**] 12:20PM ALBUMIN-4.4 [**2105-2-27**] 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2105-2-27**] 12:20PM WBC-8.9 RBC-3.93* HGB-12.1* HCT-36.7* MCV-93 MCH-30.8 MCHC-33.0 RDW-13.0 [**2105-2-27**] 12:20PM NEUTS-84.7* LYMPHS-13.1* MONOS-1.5* EOS-0.3 BASOS-0.4 [**2105-2-27**] 12:20PM PLT COUNT-227 [**2105-2-27**] 12:20PM PT-14.1* PTT-21.0* INR(PT)-1.2 [**2105-2-27**] 12:20PM FIBRINOGE-375 [**2105-3-2**] 04:30AM BLOOD WBC-6.9 RBC-3.28* Hgb-9.8* Hct-29.0* MCV-89 MCH-29.7 MCHC-33.6 RDW-13.1 Plt Ct-206 [**2105-3-2**] 04:30AM BLOOD Plt Ct-206 [**2105-3-2**] 04:30AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-143 K-3.6 Cl-108 HCO3-28 AnGap-11 [**2105-3-2**] 04:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9 [**2105-3-1**] 04:00AM BLOOD calTIBC-237* Ferritn-534* TRF-182* Brief Hospital Course: A: 39 year old male w/ HTN, chronic LBP on narcotics presents after being found unresponsive at home. * P: 1) Unresponsiveness: This is likely due todrug overdose (known oxycontin use, (+) BNZ on tox screen). Ddx: cardiac ischemia (no ischemic EKG changes noted), seizure w/ post-ictal state, CVA (head CT neg). His cardiac enzymes include only elevated CK, but not [**Last Name (LF) **], [**First Name3 (LF) **] he ruled out for MI. His mental status gradually improved from [**2-27**] to [**2-28**]. He was able to communicate appropriately as his level of narcotic medications waned in his blood. He was able to maintain a stable mental level for extubation on [**2-28**]. As of [**3-2**], he was alert, appropriate and answers questions and follows command on exam. 2) Pulmonary infiltrates: THere was initially concern that he was developing ARDS from aspiration pneumonia in the setting of being found unconscious. He was intubated and was on mechanical ventilation from [**Date range (1) 60486**], but he was started on levofloxacin and flagyl for total of 4 days. ON [**3-2**], his antibiotics were started as this most likely represent a transiet aspiration episode and not ARDS. 3) Airway protection: He was intubated in the field for airway protection He was extubated on [**2-28**] and was weaned off oxygen slowly from [**2-28**] to [**3-2**] without significant event. * 4) Hypertension: He was restarted on his atenolol and verapamil once his blood pressure stabilized on [**3-1**]. * 5) Depression:He was restarted on his paxil on [**3-1**] and was given 1:1 sitter for suicidal ideation leading up to his suicide leading up to this admission. He has not had further episodes while he was in the hospital. - plan to restart Paxil when taking PO * 6) Hyperglycemia: Although he has no known history of diabetes, his elevated FS noted in field with glycosuria prompted fingerstick check but he has not required insulin coverage. * 7) High amylase: He was admitted on [**2-27**] with elevated amylase but non-elevated lipase. This likely is not concerning of pancreatic process. His amylase trended down. He was restarted on regular diet on [**4-26**] after his extubation 8) Anemia- He was admitted with borderline anemia with Fe studies suggestive of anemia of chronic disease and his hct decreased in the setting fluid resucitation. His hct has stabilized and improved to close to 30 at the time of [**3-2**]. He reports that his primary physician is aware of his anemia and was in the process of [**Date Range 4939**]. * Medications on Admission: Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition: Extended Care Discharge Diagnosis: benzodiazipine overdose Discharge Condition: stable Discharge Instructions: please take your medications and call your doctor if you experience chest pain, abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else. [**Date Range **] Instructions: please call your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 4939**] once your are discharge from the hospital

[ "304.01", "E850.2", "724.2", "507.0", "518.81", "300.4", "305.01", "965.09", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7272, 7287

4631, 7176

333, 345

7355, 7363

2625, 4608

1940, 1986

7308, 7334

7202, 7249

7387, 7724

2001, 2606

273, 295

373, 1605

1627, 1704

1720, 1924

20,460

142,791

8770

Discharge summary

report

Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-3**] Date of Birth: [**2079-1-26**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2712**] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 30656**] is a pleasant 73 year old male with hx liver [**Known lastname **] on chronic steroids, UC who presented to the ED today with a chief complaint of fainting after colonoscopy, during which time he received 150 of fentanyl and 3 of versed. Pt states that he had no difficulty tolerating the prep and was not feeling dizzy or ligheaded prior to the procedure. The colonoscopy was a routine screening for colon cancer in setting of UC. Following the procedure, he sat up in bed at which time he felt like he was going to faint and his vision became obfuscated. He doesn't remember if he blacked out. He was given 500 ccs of fluid. Following the syncopal episode, the patient was found to have a sustained heart rate less than 40 and low BP to 70s, was therefore referred to the ED for further evaluation. In the ED, initial vitals were 96.8 54 125/86 18 99% 4L. On one occasion, his HR dipped to 30s sinus and SBP in the 50s systolic, however the patient was mentating ok, aaox3 and mildly diaphoretic. He improved with 2 L off fluid and positioning in trendelenberg. He was given 100 mg IV hydrocort because he did not take the 5 mg of prednisone which he usually takes for hx liver [**Known lastname **], and there was concern for adrenal insufficiency given the hypotension. Labs were unremarkable. Ekg showed sinus bradycardia with mildly prolongued QT. No imaging was performed. On the floor, pt is comfortable and asymptomatic. He states that he had one similar epidsode in [**Month (only) **], during which time he was feeling lightheaded while making breakfast, he sat down and his vision became blurry. He was taken to the hospital and was monitored on tele for 6 days, treated for pseudogout, but not diagnosed with any cardiac problems. [**Name (NI) **] did take his prednisone but did not take his cellcept and tacrolimus. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Liver [**Name (NI) **] for primary sclerosing cholangitis and hepatocellular carcinoma ([**2146**]), complicated by portal [**Year (4 digits) 5703**] thrombosis requiring thrombolysis [**2147-6-6**] & [**2147-6-8**] and anticoagulation with coumadin -UC -Hx biliary stricture, s/p stenting -CCY -CBD excision [**2113**] -s/p splenorenal shunt '[**24**] -ventral hernia repair [**2148-7-3**] -ERCP for ductal dilation [**2148-7-8**] with sphincterotomy/stent bilioma [**7-9**], infected [**Female First Name (un) 564**] Glabrata, Veillonella, Enterobacter cloacae -[**2149-4-8**] ERCP-4 stents, sphincterotomy -splenectomy -pseudogout [**2152-5-3**] -stomach varices Social History: Lives in [**Location (un) 30657**]with wife. Was previously an electrical engineer. Denies use of ETOH, tobacco or IVD Family History: Mother died of stroke in 80s, father died of heart disease at age 89. Kids are healthy. Physical Exam: ADMISSION EXAM: Vitals: T:98.2 BP:110/72 P:98 R: 24 O2:95% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: *** Pertinent Results: ADMISSION LABS: [**2152-10-2**] 11:30AM BLOOD WBC-9.1 RBC-4.28* Hgb-12.9* Hct-40.1 MCV-94 MCH-30.2 MCHC-32.2 RDW-13.7 Plt Ct-318 [**2152-10-2**] 11:30AM BLOOD Neuts-67.7 Lymphs-25.6 Monos-5.5 Eos-1.1 Baso-0.2 [**2152-10-2**] 11:30AM BLOOD PT-14.5* PTT-28.8 INR(PT)-1.3* [**2152-10-2**] 11:30AM BLOOD Glucose-106* UreaN-12 Creat-1.0 Na-144 K-4.1 Cl-110* HCO3-25 AnGap-13 [**2152-10-2**] 11:30AM BLOOD cTropnT-<0.01 MICRO: [**10-2**] MRSA screen: pending STUDIES: [**10-3**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is probably moderate posterior leaflet mitral valve prolapse (but not well seen). Moderate (2+) late systolic mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a very small pericardial effusion. Compared with the prior study (images reviewed) of [**2146-8-24**], mitral regurgitation is now more prominent and there is now slightly more evidence of mitral valve prolapse. DISCHARGE LABS: [**2152-10-3**] 04:07AM BLOOD WBC-12.6* RBC-4.14* Hgb-13.0* Hct-38.3* MCV-93 MCH-31.3 MCHC-33.9 RDW-13.8 Plt Ct-277 [**2152-10-3**] 04:07AM BLOOD Plt Ct-277 [**2152-10-3**] 04:07AM BLOOD Glucose-95 UreaN-14 Creat-0.9 Na-145 K-4.1 Cl-112* HCO3-26 AnGap-11 Brief Hospital Course: Mr [**Known lastname 30656**] is a pleasant 73 yo gentleman with history of UC, s/p liver [**Known lastname **], admitted with bradycardia following screening colonoscopy, concerning for vasovagal episode vs medication effect. # Bradycardia/hypotension/syncope: Patient with episode of bradycardia and syncope in the setting of colonoscopy, likely due to medication effect vs vasovagal episode. No e/o block on EKG. No further episodes of bradycardia while in the ICU. ECHO showed moderate mitral regurgitation, likely a chronic change from mitral valve prolapse. # Leukocytosis: WBC 12.6, likely elevated in the setting of receiving Hydrocortisone in the ED. No s/s infection. # Hx portal [**Known lastname 5703**] thrombosis: On Lovenox bridge until therapeutic on Warfarin. # Hx liver [**Known lastname **]: Continued Prednison, Cellcept, and Tacrolimus. # UC: continued asacol, ursodiol # Hx HTN: Home amlodipine held given hypotension. Patient now normotensive, can consider restarting amlodipine if BP increases. # Med rec: Continued pts home lansoprazole, pravastatin, calcium/vitD, folic acid, b12, glucosamine, MV Medications on Admission: ALENDRONATE - 70 mg Tablet - One Tablet(s) by mouth weekly, pt states not currently taking AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day LANSOPRAZOLE - 30 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day MESALAMINE [ASACOL] - 400 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice per day - No Substitution MYCOPHENOLATE MOFETIL [CELLCEPT] - 250 mg Capsule - 1 Capsule(s) by mouth twice a day - No Substitution PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day 3 month supply PREDNISONE - 1 mg Tablet - 5 Tablet(s) by mouth once a day SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day TACROLIMUS - 0.5 mg Capsule - One Capsule(s) by mouth twice a day For a total of 1.5 mg twice a day TACROLIMUS [PROGRAF] - 1 mg Capsule - 1 Capsule(s) by mouth twice a day Brand name medically necessary. No substituion - No Substitution URSODIOL [ACTIGALL] - 300 mg Capsule - one Capsule(s) by mouth three times a day WARFARIN [COUMADIN] - 5 mg Tablet - 1 Tablet(s) by mouth once a day alternating with 6 tablets Medications - OTC CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - 600 mg (1,500 mg)-200 unit Tablet - 1 Tablet(s) by mouth twice daily FOLIC ACID-VIT B6-VIT B12 [FOLTX] - (OTC) - 2 mg-2.5 mg-25 mg Tablet - One Tablet(s) by mouth daily GLUCOSAMINE SULFATE 2KCL - (OTC) - Dosage uncertain MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - One Tablet(s) by mouth daily Discharge Medications: 1. amlodipine 5 mg Tablet [**Known lastname **]: One (1) Tablet PO once a day. 2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. mesalamine 400 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 4. mycophenolate mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 5. pravastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 8. tacrolimus 0.5 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H (every 12 hours). 9. ursodiol 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3 times a day). 10. warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 11. warfarin 2 mg Tablet [**Doctor First Name **]: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 12. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet [**Doctor First Name **]: One (1) Tablet PO twice a day. 13. folic acid-vitamin B6-vit B12 2.3-24.5-2 mg Tablet [**Doctor First Name **]: One (1) Tablet PO once a day. 14. Centrum Silver Tablet [**Doctor First Name **]: One (1) Tablet PO once a day. 15. enoxaparin 100 mg/mL Syringe [**Doctor First Name **]: One (1) Syringe Subcutaneous Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Vasovagal syncope Symptomatic bradycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after a syncopal episode. There was concern because your heart slowed down a lot. However, after discussion with the cardiologist, we think that the syncope was what is called a vaso-vagal event, similar to what you have had in the past. You should talk to your primary care doctor about possibly seeing a cardiologist to do longer-term rhythm analyses of your heart. . No changes were made to your medications. You should continue taking Lovenox (enoxaparin) twice a day for five more days. Please have your INR (blood test) checked by your primary care doctor after returning to [**State 531**]. . If you feel lightheaded again, try to sit or lie down slowly. Wait until the symptoms pass before trying to get up and walk around. If you lose consciousness or the symptoms persist, you should go to the nearest hospital. Followup Instructions: Please see your primary care doctor within 1 to 2 weeks of returning home. Please take the paperwork we gave you to that appointment. You have a previously scheduled appointment tomorrow at the [**Hospital1 **]: Department: [**Hospital1 **] When: WEDNESDAY [**2152-10-4**] at 9:20 AM With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2152-10-4**]

[ "V10.07", "E932.0", "V58.65", "556.9", "780.2", "276.51", "427.89", "288.60", "401.9", "424.0", "V42.7" ]

icd9cm

[ [ [] ] ]

[ "45.25", "48.24" ]

icd9pcs

[ [ [] ] ]

10200, 10206

5918, 7050

281, 287

10291, 10291

4174, 4174

11305, 11828

3504, 3594

8590, 10177

10227, 10270

7076, 8567

10441, 11282

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3609, 4134

4150, 4155

2212, 2659

230, 243

315, 2193

4190, 5623

10306, 10417

2681, 3349

3365, 3488

76,327

138,429

33461

Discharge summary

report

Admission Date: [**2148-10-5**] Discharge Date: [**2148-10-16**] Date of Birth: [**2106-1-28**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Adhesive Bandage / Dicloxacillin / Linezolid Attending:[**First Name3 (LF) 943**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Diagnostic and Therapeutic Paracenteses x3 ([**2148-10-5**], [**2148-10-8**], [**2148-10-15**]) PICC line placement [**2148-10-8**] History of Present Illness: 41 year old man with cirrhosis secondary to EtOH and HCV, complicated by recurrent ascites, history of SBP and esophageal varices, who per family member, became febrile on the morning of admission and over the course of the afternoon became increasingly confused. Family member describes recent increase in abdominal distension over past several days as well as stating that he was "mumbling incoherently," over the last 24 hours. No report of abdominal pain. No recent changes in lactulose doses and patient continued to have multiple bowel movements daily over the past week. No reports of hematemesis, hemtochezia or melena. No recent changes in skin color, urine color, stool color. Denies any recent infections. Review of systems largely negative except for above. At home he had been doing well and had been getting care from his mother [**Name (NI) **]. . Patient has had numerous hospitalization in the last year for recurrent ascites and encephalopathy, most recently he was discharged from [**Hospital1 18**] on [**2148-9-26**] after being admitted for abdominal distension with hyponatremia and hyperkalemia. 2 L of fluid were tapped at that point with no evidence of SBP. . In the ED HR was 140, BP 98/68, RR 29, O2 sats of 94% on 100% NRB. Blood cultures were obtained. Got 2 L NS, and given 1 gm vancomycin, 1 gm ceftriaxone, and 500 mg IV flagyl. Right EJ placed. Past Medical History: - End Stage Liver Disease [**1-22**] alcohol and hepatitis C. Currently on the [**Month/Day (2) **] list. Course complicated by recurrent ascites, SBP, pulmonary hypertension. Currently on the [**Month/Day (2) **] list (s/p aborted liver [**Month/Day (2) **] given elevated pulmonary pressures in OR [**2148-2-28**]) - Sepsis w/ Enterococcus Avium and Group B Step, recent discharge on [**2148-7-5**] - Spontaneous bacterial peritonitis early [**7-27**] on Cipro prophylaxis - Grade II esophageal varices - Recurrent hepatic encephalopathy on vegetarian diet - Pulmonary hypertension - Hypothyroidism - Anxiety disorder - History of alcohol and IVDU - Osteoporosis of hip and spine per pt - Anemia with history of guaiac positive stool Social History: He lives with his mother. Remote history of smoking [**12-23**] ppd. Quit drinking 11 years ago. Prior history of IVDU as a teenager. Family History: Mother with diabetes and hypertension. Father with rheumatic heart disease. Physical Exam: PHYSICAL EXAM GENERAL: cachectic, ill-appearing middle aged man, dobhoff in place HEENT: Bitemporal wasting, cleral icterus. MMM. OP clear. Neck Supple, No LAD or thyromegaly CARDIAC: tachycardic, normal rhythm, nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated LUNGS: CTAB (anterior exam only) ABDOMEN:+BS, Soft, tender to palpation (difficult to assess where, given patient's AMS and only intermittently verbalizing), no rebound or guarding EXTREMITIES: 1+ pitting edema to ankles b/l R>L, 1+ dorsalis pedis pulses SKIN: Jaundiced, No rashes/lesions, ecchymoses. NEURO: Not oriented and only answering questions intermittently. Somnolent. Unable to participate in neuro exam. 2+ reflexes, gait assessment deferred (per mother, needs [**Name2 (NI) **] and assistance), +asterixis . Pertinent Results: [**2148-10-5**] 05:00PM BLOOD WBC-11.6*# RBC-3.22*# Hgb-10.4*# Hct-34.1*# MCV-106* MCH-32.4* MCHC-30.6* RDW-19.3* Plt Ct-111*# [**2148-10-5**] 05:00PM BLOOD Neuts-93* Bands-2 Lymphs-0 Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* [**2148-10-7**] 04:30AM BLOOD WBC-7.2 RBC-2.20* Hgb-7.3* Hct-23.3* MCV-106* MCH-33.3* MCHC-31.5 RDW-19.2* Plt Ct-63* [**2148-10-5**] 09:49PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Target-OCCASIONAL Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**2148-10-5**] 05:00PM BLOOD PT-20.6* PTT-39.4* INR(PT)-1.9* [**2148-10-7**] 04:30AM BLOOD PT-28.0* PTT-49.0* INR(PT)-2.8* [**2148-10-5**] 05:00PM BLOOD Glucose-139* UreaN-56* Creat-1.4* Na-132* K-4.6 Cl-101 HCO3-20* AnGap-16 [**2148-10-5**] 05:00PM BLOOD ALT-28 AST-72* AlkPhos-286* TotBili-8.7* [**2148-10-5**] 05:00PM BLOOD Albumin-3.0* [**2148-10-5**] 09:49PM BLOOD Calcium-7.7* Phos-3.5 Mg-2.4 [**2148-10-5**] 10:58PM ASCITES WBC-4900* RBC-845* Polys-87* Lymphs-1* Monos-12* . [**2148-10-5**] CXR: IMPRESSION: Markedly limited study as above. Bilateral atelectasis again noted and relatively stable with no definite focal consolidation or signs of failure. . [**2148-10-6**] Abdominal U/S: ABDOMINAL ULTRASOUND HISTORY: 42-year-old male with liver failure and worsening ascites. COMPARISON: CT abdomen and pelvis [**2148-9-10**]. ABDOMINAL ULTRASOUND: The study is limited due to patient's difficulty cooperating with the exam and holding his breath, as well as ascites and abdominal tenderness. The liver remains nodular and heterogeneous consistent with cirrhosis. There is a moderate to large amount of ascites. Flow is identified within a segment of the main portal vein, although the main portal vein is not completely visualized. There is no hydronephrosis. The pancreas and aorta are not well seen due to bowel gas. The spleen is enlarged, measuring 13.3 cm. IMPRESSION: 1. Suboptimal visualization of the portal vein due to technical difficulties with the exam. Flow is identified within portion of the main portal vein. 2. Ascites, cirrhosis and splenomegaly. Brief Hospital Course: #. Goals of care: In the setting of worsening liver failure, prolonged encephalopathy and removal from the [**Year (4 digits) **] list the patient, his mother and health care team held a goals of care meeting ([**2148-10-16**]). With discussion of the current situation and prognosis it was decided to make the patient comfort measures only. His mother was agreeable with this decision. He was sent home with hospice care. . #. Culture Negative Peritonitis: The patient was admitted to the MICU with leukocytosis, tachycardia, AMS and abdominal pain. He had a diagnostic paracentesis which revealed SBP. He was started on IV vanc/zosyn/flagyl and given albumin per protocol. Later he was switched to IV vanc/ceftriaxone/flagyl. Abdominal ultrasound showed patent portal vein, ascites and stable cirrhosis. Mental status improved slightly with antibiotics. Upon transfer to floor a repeat diagnostic paracentesis was performed demonstrating continued SBP. Vancomycin was stopped and IV ceftriaxone and flagyl were continued for a total course of 10 days. A repeat paracentesis showed resolution of the SBP. The patient was started on PO bactrim for SBP prophylaxis. . #. Hepatic encephalopathy: The patient was treated with his home dose of lactulose and rifaximin and had [**3-25**] bowel movements per day. His mental status improved but did not return to baseline. . #. Hepatorenal Syndrome: The patient had an increased Cr to 1.5. He was treated for hepatorenal syndrome with albumin, midodrine and octreotide. His serum Cr improved to 1.2. . # ESLD: The patient was continued on his lactulose and rifaximin doses. Diuretics were held in the setting of suspected infection and then in the setting of hepatorenal syndrome. The patient is currently inactive on the [**Month/Day (3) **] list. The patient had worsening liver function tests and INR despite vitamin K therapy. . # Coagulopathy: The patient had elevated INR and low platelets in the setting of ESLD. He was treated with vitamin K PO in the setting of antibiotic use and malnutrition. . # Tachycardia: Patient had sinus tachycardia to 110 on arrival to the floor. He had one episode of SVT with a rate in the 170's. Metoprolol 5mg IV was given and the patient returned to sinus rhythm with a rate of 90. Blood pressure was stable and the patient was asymptomatic. Patient was started on nadolol 10mg PO daily and his heart rate remained in the 90s with no further episodes of SVT. . # Anemia: The patient required multiple transfusions during the hospitalization. Guaiac positive with no signs of bleeding. . # Hypothyroidism: Stable, patient was continued on home levothyroxine. . # Pulmonary HTN: The patient was continued on his own iloprost. . # Osteoporosis: Patient was continued on his home regimen of Vit D and Calcium Medications on Admission: 1. Caltrate 600-400 2. Ciprofloxacin 500 mg daily 3. Lactulose 30 - 60 mL qid titrate to 6 BM daily 4. levothyroxine 88 mcg daily 5. miconazole 2% TID rash 6. mycelex 10 mg five times a day 7. nutren 2.0 via ND tube 8. omeprazole 20 mg daily 9. simethicone 80 mg qid PRN gas pain 10. ursodiol 600 mg qam 11. ventavis 2.5 mL nebulized six times per day 12. xifaxan 400 mg TID 13. zinc sulfate 220 mg daily Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H (every 4 hours): titrate to pt comfort. 2. Iloprost 10 mcg/mL Solution for Nebulization Sig: 2.5 (two and a half) MLs Inhalation q6hr (). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary Diagnoses: 1. Culture Negative Spontaneous Bacterial Peritonitis 2. Hepatic Encephalopathy 3. Hepato-Renal Syndrome 4. Supra-Ventricular Tachycardia . Secondary Diagnoses: - End Stage Liver Disease [**1-22**] HCV and EtOH cirrhosis - Pulmonary Hypertension - Anemia Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with confusion and a distended abdomen. You were found to have spontaneous bacterial peritonitis, an infection of the ascites fluid in your abdomen. You were treated with intravenous antibiotics, and you completed a prolonged course. Your course was also complicated by hepatic encephalopathy, which initially improved, but your mental status was unable to return to baseline. You also developed hepato-renal syndrome, and you transiently needed medications including IV albumin, octreotide, and midodrine. These were stopped as your kidney function improved, but the kidney function stablized and also did not return to your baseline. After you completed your course of IV antibiotics, your liver function continued to deteriorate, and after multiple discussions with your family, the decision was made to make you comfortable and set you up with home hospice care. You are being discharged to home with hospice care. . You should take your medications as prescribed by the home hospice group. Followup Instructions: None.

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icd9cm

[ [ [] ] ]

[ "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

9403, 9459

5863, 8656

341, 475

9777, 9787

3736, 5840

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280, 303

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5,050

188,906

5509

Discharge summary

report

Admission Date: [**2104-1-7**] Discharge Date: [**2104-1-12**] Date of Birth: [**2028-2-28**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfonamides / Dilaudid / Morphine Attending:[**First Name3 (LF) 1505**] Chief Complaint: none healing wound Major Surgical or Invasive Procedure: [**1-7**] Sternal debridement with VAC dressing [**1-9**] Sternal debridement and left pectoralis major muscle advancement flap, skin and subcutaneous tissue random advancement flap History of Present Illness: 75yoW s/p CABGx2 [**10-26**], discharged home on [**11-2**]. Returned for wound check and was found to have small open wound at base of sternum, initially tx with oral antibx without resolution. Wound sharp debrided on [**11-21**] and pt returned home w/VNA to change W-D dsg [**Hospital1 **]. VNA asked patient to return to wound clinic for assessment on day of admission. Patient admitted for further debridement and assessment for VAC dressing and was discharged with VAC and continued antibiotics. Wound not healing and presents for wound closure with plastic surgery Past Medical History: Sternal Wound infection Sternal debridement Coronary Artery Disease s/p coronary artery bypass graft Diabetes Mellitus Hypertension Elevated Cholesterol s/p Hysterectomy s/p Bladder suspension surgery Social History: The patient lives alone and is employed part-time as real estate broker. She has 3 adult children. She denies ETOH or tobacco abuse. Family History: (-) FHx CAD: unknown as pt is adopted Physical Exam: Discharge Vitals: 98, 100 SR, 156/70, 20, RA Sat 94% Neuro alert and oriented x3, MAE RUE [**5-16**], LUE [**4-15**], LE [**5-16**] Pulmonary lungs clear to ausculation Cardiac: RRR, no murmur/rub/gallop Sternal incision: midline, staples, no erythema, JP left chest serosangous drainage Abdomen: soft, nontender, nondistended Extremeties: warm, pulses palpable, edema +1 Pertinent Results: [**2104-1-11**] 07:30AM BLOOD WBC-9.3 RBC-2.95* Hgb-10.2* Hct-29.2* MCV-99* MCH-34.5* MCHC-34.9 RDW-13.9 Plt Ct-154 [**2104-1-8**] 07:40AM BLOOD WBC-5.5 RBC-3.59* Hgb-12.2 Hct-35.0* MCV-97 MCH-34.1* MCHC-35.0 RDW-14.0 Plt Ct-233 [**2104-1-11**] 07:30AM BLOOD Plt Ct-154 [**2104-1-11**] 07:30AM BLOOD Glucose-212* UreaN-12 Creat-0.9 Na-135 K-4.4 Cl-100 HCO3-23 AnGap-16 [**2104-1-8**] 07:40AM BLOOD Glucose-263* UreaN-9 Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-26 AnGap-14 [**2104-1-11**] 07:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.6 [**2104-1-8**] 07:40AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.6 CHEST (PA & LAT) [**2104-1-11**] 11:37 AM CHEST (PA & LAT) Reason: evaluate effusion left please do this am thank you [**Hospital 93**] MEDICAL CONDITION: 75 year old woman s/p CABGx2 [**10-26**], s/p sternal wound debridement REASON FOR THIS EXAMINATION: evaluate effusion left please do this am thank you EXAMINATION: PA and lateral chest. INDICATION: Status post CABG. Two views of the chest are obtained on [**2104-1-11**] and compared with the previous study of [**2103-9-3**]. The left-sided pleural effusion has increased in size. This is particularly obvious on the lateral view of the chest. The patient shows evidence of prior thoracic surgery. Skin clips are present in the anterior skin. There is a drain overlying the anterior part of the chest on the left side. A right-sided PICC line has its tip projected over the expected location of the cavoatrial junction. IMPRESSION: Left pleural effusion, increasing since prior examination. Brief Hospital Course: 75 year old female with sternal wound infection admitted to operating room and underwent sternal wound debridement with wire removal and VAC placement [**1-7**]. Please see operative report for further details. She recovered in the PACU and was transferred to floor for continued monitoring with VAC. Required insulin adjustment with [**Last Name (un) **] consult due to hyperglycemia. Then [**1-9**] returned to operating room for wound closure, underwent sternal debridement and left pectoralis major muscle advancement flap, skin and subcutaneous tissue random advancement flap, please see operative report for further details. She was transferred to the CSRU for continued management. She awoke neurologically intact and was extubated without complications. She required nitroglycerin for blood pressure management which was weaned off. She was transferred to the floor and physical therapy started. She continued to progress with no fevers, antibiotics adjusted per ID recommendations. She was ready for discharge to rehab on POD [**6-13**] with JP and follow up with plastic surgery in 1 week. Medications on Admission: Prilosec 20mg daily zofran 8mg TID prn Insulin Ativan Ambien prn ASA 81mg daily Lipitor 20mg daily Zinc 220mg daily Vitamin C 500mg [**Hospital1 **] Toprol XL 100mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Blood glucose Insulin Sliding Scale 9. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): continue until follow up with infectious disease . 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Sternal Wound infection Sternal debridement Coronary Artery Disease s/p coronary artery bypass graft Diabetes Mellitus Hypertension Elevated Cholesterol Discharge Condition: fair Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming (please cover JP site) 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 No lifting more than 10 pounds Please call with any questions or concerns Followup Instructions: Dr [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name (STitle) **] in 1 week ([**Telephone/Fax (1) 1416**]) please call for appointment Dr [**Last Name (STitle) 16308**] ([**Telephone/Fax (1) 22245**]) after discharged from rehab - please call for appointment Infectious disease clinic in 3 weeks ([**Telephone/Fax (1) 457**]please call for appointment Completed by:[**2104-1-12**]

[ "V45.81", "401.9", "998.32", "998.59", "E878.2", "998.83", "250.00", "272.0" ]

icd9cm

[ [ [] ] ]

[ "77.61", "86.74" ]

icd9pcs

[ [ [] ] ]

5895, 5984

3510, 4619

319, 503

6181, 6188

1945, 2650

6636, 7082

1498, 1537

4840, 5872

2687, 2760

6005, 6160

4645, 4817

6212, 6613

1552, 1926

261, 281

2789, 3487

531, 1107

1129, 1331

1347, 1482

70,226

180,930

45493

Discharge summary

report

Admission Date: [**2179-8-23**] Discharge Date: [**2179-8-27**] Date of Birth: [**2102-1-24**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Iodine Attending:[**First Name3 (LF) 22990**] Chief Complaint: Right sided facial pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 77 yo female with a PMH significant for COPD on 2L at home, vascular dementia, DMII, HTN, HL, who presents with 4 days of right sided ear/facial pain. . History is limited secondary to underlying dementia. Per report, patient developed right sided ear and upper and lower lip pain 4 days prior to admission. Primary care physician prescribed amoxicillin three days prior for suspicion of dental infection with plans to see dental today. Patient was seen by her daughters this morning, who noticed clusters of fluid filled vesicles on the right side of her lips. She has reportedly been with poor PO intake for the last several days due to pain surrounding her lips. She was brought into the [**Hospital1 18**] ED. Patient denies any trouble hearing, changes in vision, chest pain, nausea, vomiting, diarrhea, SOB, CP. No tinnitus. No sick contacts. . In the ED, intial vital signs were 97.4, 80, 110/52, 20, 99% RA. Patient given 1L NS, acyclovir 700mg IV X 1, morphine 4mg IV X 1, and tylenol 1gram PO X 1. As patient was in transit, reported to have temp of 100.6. . On floor after transfer from MICU, patient reports that she is no longer having any active pain. Reports that she is comfortable. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -COPD on 2L home O2 -DM2 -Dementia -HTN -Dyslipidemia -Goiter s/p RAI -R breast nodule -RUL opacity on CT, followed by pulmonary Social History: She continued to smoke one to two packs of cigarettes/day until [**Month (only) 404**] of this year. She is retired from the post office. She no longer drinks alcohol but has a remote history of alcohol abuse. Family History: The patient's father died at 71 of complications of diabetes. She is the oldest of seven siblings of whom only four are living. There is no history of known dementia in the family. Physical Exam: VS: T: 99.6, BP: 140/66, P: 98, 99% O2sat on 2L. GENERAL - NAD, comfortable HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous membranes. One vesicle noted in right external auditory meatus. NECK - supple, no thyromegaly, no JVD LUNGS - poor air movement with expiratory rhonchi and wheezing HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - No c/c/e, 2+ peripheral pulses. No pedal edema. SKIN - Fluid filled vesicles found in clusters along the right aspect of the lips. No ocular lesions. LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-26**] throughout, sensation grossly intact throughout Pertinent Results: Admission Labs [**2179-8-23**] 08:03PM LACTATE-1.2 [**2179-8-23**] 07:55PM GLUCOSE-144* UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-32 ANION GAP-11 [**2179-8-23**] 07:55PM CALCIUM-9.5 PHOSPHATE-2.6* MAGNESIUM-2.0 [**2179-8-23**] 07:55PM WBC-5.4 RBC-3.93* HGB-10.7* HCT-33.9* MCV-86 MCH-27.2 MCHC-31.5 RDW-14.5 [**2179-8-23**] 07:55PM NEUTS-76.0* LYMPHS-17.3* MONOS-5.2 EOS-1.2 BASOS-0.3 [**2179-8-23**] 07:55PM PLT COUNT-247 . Discharge Labs [**2179-8-27**] 09:00AM BLOOD WBC-6.3 RBC-3.63* Hgb-10.0* Hct-31.0* MCV-85 MCH-27.4 MCHC-32.1 RDW-15.5 Plt Ct-241 [**2179-8-26**] 07:10AM BLOOD WBC-6.0 RBC-3.71* Hgb-9.9* Hct-31.6* MCV-85 MCH-26.6* MCHC-31.1 RDW-15.5 Plt Ct-235 [**2179-8-25**] 03:30PM BLOOD WBC-5.4 RBC-3.54* Hgb-9.5* Hct-30.0* MCV-85 MCH-27.0 MCHC-31.8 RDW-14.8 Plt Ct-208 [**2179-8-25**] 02:00AM BLOOD WBC-7.0 RBC-3.67* Hgb-9.9* Hct-31.7* MCV-86 MCH-27.1 MCHC-31.4 RDW-14.9 Plt Ct-204 [**2179-8-25**] 02:00AM BLOOD Neuts-88.7* Lymphs-9.3* Monos-1.0* Eos-0.3 Baso-0.6 [**2179-8-23**] 07:55PM BLOOD Neuts-76.0* Lymphs-17.3* Monos-5.2 Eos-1.2 Baso-0.3 [**2179-8-27**] 09:00AM BLOOD Plt Ct-241 [**2179-8-27**] 09:00AM BLOOD PT-10.8 PTT-26.5 INR(PT)-0.9 [**2179-8-26**] 07:10AM BLOOD Plt Ct-235 [**2179-8-25**] 03:30PM BLOOD Plt Ct-208 [**2179-8-27**] 09:00AM BLOOD Glucose-150* UreaN-22* Creat-1.0 Na-137 K-4.0 Cl-97 HCO3-32 AnGap-12 [**2179-8-26**] 07:10AM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-137 K-3.7 Cl-97 HCO3-36* AnGap-8 [**2179-8-25**] 03:30PM BLOOD Glucose-132* UreaN-14 Creat-0.9 Na-135 K-4.3 Cl-97 HCO3-30 AnGap-12 [**2179-8-25**] 02:00AM BLOOD Glucose-166* UreaN-15 Creat-0.9 Na-132* K-4.7 Cl-95* HCO3-26 AnGap-16 [**2179-8-27**] 09:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8 [**2179-8-26**] 07:10AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 [**2179-8-25**] 03:30PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8 [**2179-8-25**] 02:00AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8 [**2179-8-23**] 08:03PM BLOOD Lactate-1.2 . Microbiology: Blood cultures no growth to date . Reports: EKG [**8-23**] Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2179-6-22**] the findings are similar. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 194 76 376/400 70 57 62 . [**8-23**] CXR FINDINGS: As compared to the previous radiograph, there is a relevant change. In the right upper lobe, a 1.5 cm rounded spiculated opacity has newly occurred. The opacity could be aligned along a lymphatic structure, reaching centrally to the hilus. On this basis, both a newly occurred lung neoplasm and tuberculosis must be excluded. Therefore, a CT examination and clinical evaluation is required. Normal size of the cardiac silhouette. Mild tortuosity of the thoracic aorta. Minimal atelectasis at the right lung base. No larger pleural effusions. Minimal calcified apical thickening bilaterally. The result was placed on the radiology dashboard. In addition, the referring physician was paged for information at the time of dictation. Brief Hospital Course: 77 yo female with a PMH significant for COPD on 2L at home, vascular dementia, DMII, HTN, HL, who presents with 4 days of right sided ear/facial pain. Transferred to MICU for one day out of concern for lip swelling and potential angioedema. After remaining stable was transferred back to the floors for further management. . #. Herpes Zoster: Fluid filled vesicles in clusters in a dermatomal distribution (T3) along the right jaw and oral cavity associated with pain appears consistent with herpes zoster infection. With associated poor PO intake secondary to pain. Involvement of ear canal suggests [**Last Name (un) **] hunt syndrome, though patient is unsure if she has new hearing changes. Some of the vesicles have yellow flakes on them. None are draining any fluid. Gave PO valacyclovir [**Hospital1 **] because of renal clearance. We monitored for symptomatic improvement with antiviral treatment which we observed.She remianed afebrile, and did not complain of neuropathic pain only mild headache at times which was treated with tylenol and acetaminophen. She was started on prednisone 20mg/daily which was started to be tapered on [**8-27**]. . # Lip swelling: Concern for angioedema vs. superinfection of Zoster. No tongue swelling was appreciated. ENT exam showed no laryngeal edema. Pt was on ACE-I as out pt which was held and not continued given the fact she was transferred to the MICU for 1 day because of concern of angioedema and increased bilateral lip swelling. She remained stable in MICU when she was transferred to floor where her lip swelling decreased. She presented to this admission on amoxicillin with no improvement of symptoms. She was started on clindamycin for any potential oral superimposed infection. and was given decadron 10mg x 1 in MICU with some improvement.Gave prednisone 20mg/daily and taper as above.We decided to avoid PCN's given concern for reaction to amoxicillin. Tylenol 325mg ordered for PRN pain . . # Otitis Externa: likely superinfection from zoster.Kept R ear dry.Cipro and dexamethasone 4 gtts TID x 10 days, continue for 7 more days. Removed wick on [**8-26**] PM which was in place for 2 days.Will need audiogram -(call [**Telephone/Fax (1) 6213**] ([**Hospital **] clinic) to arrange) once infection is improving. Made follow up ENT appointment. . # Right eye swelling-On adission the right eye was very mildly swelled compared to the left. The patient complained and exhibited no vision problems then, which remains the case now. There is slight worsening of this eye swelling today. -Had a opthalmology consult to rule out any ocular involvement. -Recieved Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID for any potential superinfection of the eye.Opthalmology follow up outpatient appointment made. . #Oral Thrush- the patient had developed thrush on the tongue since admission. She can speak and swallow. Could be due to prolonged mouth opening and drying of the oral mucosa as well as some degree of immunosuppression given her steroid medications. Continue Nystatin swish and swallow for 7 more days. . #. COPD: Appeared to be at baseline on home 2L O2. Recent PFTs demonstrate FEV1 of 0.52, which is 35% predicted. FVC of 1.34 and FEV1/FVC ratio of 38. Tolerates room air well and at times feels more comfortable on 2L NC.Albuterol nebs PRN were admin. Continued advair diskus daily,fluticasone nasal spray,and prednisone. . #. Vascular Dementia: Patient was alert and oriented to person and place. . #. DM2: -Continued home lantus and ISS. Monitored sugars in setting of steroids. Small amount of blood seen on UA [**8-27**] consistent with previous study. . #. Hypertension: Was mildly elevated in MICU with increased steriods.Continued home metoprolol. Holding lisinopril given concern for angioedema.Restarted Verapamil 180 ER . #. Hyperlipidemia:Continued home statin and aspirin. . #. RUL opacity on CT: Thought to be scarring from pneumonia. Last CT on [**7-1**]. Outpatient PCP and pulmonologist aware. Will require interval surveillance CT in the future. . #. GERD: Continued PPI, Omeprazole . #. Depression: continue home SSRI . Outstanding Issues We added Valacyclovir -which is the antiviral medication . Continue for 3 more days from [**8-27**] . -We added ciprodex which is a antibiotic and steroid combination droplet which will treat any potential ear infection. Please take this medication for 7 more days. -We added Nystatin solution for your mouth. This is a antifungal medication. -We added Clindamycin which is a antibiotic which will treat any mouth infection. Please take this medication for 7 more days. -We added Erythromycin eye drops is a antibiotic to treat for any potential antibiotic in the right eye. Please continue for 7 more days. . *********Will need audiogram -(call [**Telephone/Fax (1) 6213**] ([**Hospital **] clinic) to arrange) once infection is improving Medications on Admission: - Acetaminophen-Codeine - 300mg-30mg tablet - 1 tablet by mouth q6hour as needed for dental pain, don't take more due to breathing problems - Amoxicillin - 500 mg capsule - 1 capsule by mouth twice a day - Fluticasone - 50 mcg spray, suspension - 2 sprays per nostril once a day - Fluticasone-Salmeterol (Advair Diskus) - 250 mcg-50mcg/Dose Disk with device - 1 puff inhaled twice a day - Insulin Lispro (Humalog) - 100 unit/mL solution - inject per sliding scale up to QID/prn - Lisinopril - 2.5 mg tablet - 1 tablet by mouth once a day - Metoprolol Succinate - 25 mg tablet sustained release 24 hr - 1 tablet by mouth daily - Pravastatin - 20 mg tablet - 1 tablet by mouth at bedtime - Prednisone - 2.5 mg tablet - 1 tablet by mouth once a day, alternate 5 mg and 2.5 mg daily - Sertraline - 50 mg tablet - 1 tablet at bedtime - Tiotropium Bromide (Spiriva with HandiHaler) - 18 mcg capsule with inhalation device - 1 capsule inhaled once a day - Trazadone - 50 mg tablet - 1 tablet by mouth at bedtime (last filled [**2179-3-23**]) - ultrafine syringe/needle - 29 gauge - Verapamil - 180 mg tablet sustained release - 1 tablet by mouth once a day OTC - Aspirin - 81 mg tablet - 1 tablet by mouth once a day (never filled by patient) - Blood sugar diagnostic (One Touch Ultra Test) strip - Calcium Carbonate-Vitamin D3 (Calcium 600 + D3)- (dosage uncertain, patient filled Vitamin D 400 IU in [**2179-3-22**]) - NPH Insulin Human Recomb (Humulin N)- 100 unit/mL suspension - 28 units/am Discharge Medications: 1. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days: Please continue 3 days from [**8-27**]. 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 7 days: From [**8-27**] . 3. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic three times a day for 7 days: Please administer to right ear. End on [**9-3**]. 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Prednisolone 5 mg Tablet Sig: Three (3) Tablet PO once a day: Start Taper [**8-28**] -Day 1 -15mg/daily -Day 2-15mg/daily -Day 3-10 mg/daily -Day 4-10mg/daily . Day 5-Start 5mg/daily alternating with 2.5 mg/daily for chronic steroids fro COPD. . 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Up to QID please administer according to attatched sliding scale . 13. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day) for 7 days: From [**8-27**] Please admin. to right eye . 15. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty Four (34) Units Subcutaneous once a day: Please admin. In AM . 16. Sertraline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush for 7 days: Please continue for 7 more days from [**8-27**]. 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain . 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Right Facial Zoster Infection Otitis Externa Cellulitis of the face Conjuctavitis Discharge Condition: Mental Status: Clear and coherent. But orientated x 2. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure to care for you as your doctor. . You were brought to the hospital for right sided ear and facial swelling. This swelling most most likely caused by the zoster virus which reactivated in your facial nerves. We treated you with intravenous antiviral medication, steroids and pain medications. You improved clinically and your facial pain and swelling decreased. . -We made the following changes to your home medication list: -We added Valacyclovir -which is the antiviral medication -We added ciprodex which is a antibiotic and steroid combination droplet which will treat any potential ear infection. Please take this medication for 7 more days. -We added Nystatin solution for your mouth. This is a antifungal medication. -We added Clindamycin which is a antibiotic which will treat any mouth infection. Please take this medication for 7 more days. -We added Erythromycin eye drops is a antibiotic to treat for any potential antibiotic in the right eye. Please continue for 7 more days. -We Gave you Acetaminophen for any pain you experience. -We discontinued the Acetaminophen/codeine combination pill you were taking before -We added Gabapentin which helps to treat any facial pain. Your primary care physician will tell you when to stop this medication. -We increased your home prednisone dose, which will be gradually decreased to your normal home dose over the next 4 days. -We discontinued Lisinopril out of concern the drug could have contributed to your lip swelling. . Please continue to take the rest of your previous home medications as prescribed. . Please follow up with the following outpatient appointments below: . Followup Instructions: Provider: [**Last Name (NamePattern4) **].[**First Name (STitle) **] Date:Wednesday [**2179-9-1**] 1:45pm Service:Otolaryngology Location:[**Location (un) **] [**Location (un) **]. [**Numeric Identifier **] Telephone Number:[**Telephone/Fax (1) 2349**] . Provider:[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 4869**]: Ophthalmology Telephone Number:[**Telephone/Fax (1) 5120**] Date:Monday [**2179-8-30**] 9am Location: E/ [**Hospital Ward Name 23**] 5 . Provider:[**Last Name (NamePattern4) **].[**Last Name (STitle) **] Date:Monday [**2179-9-6**]:10AM Location:[**Location (un) **] of [**Hospital Ward Name 23**] Building Telephone Number: [**Telephone/Fax (1) 250**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14940, 15030

6236, 11114

326, 332

15156, 15156

3189, 6213

17027, 17731

2219, 2402

12654, 14917

15051, 15135

11140, 12631

15352, 17004

2417, 3170

263, 288

360, 1824

15171, 15328

1846, 1976

1992, 2203

5,008

113,807

24401

Discharge summary

report

Admission Date: [**2121-7-3**] Discharge Date: [**2121-7-6**] Date of Birth: [**2093-4-20**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Bee Sting Kit Attending:[**First Name3 (LF) 1835**] Chief Complaint: Malignant Melanoma Major Surgical or Invasive Procedure: Stereotactic Brain biopsy History of Present Illness: His oncological history started in 09/[**2118**]. He was treated in [**State 4260**]. He had biopsy of a polypoid 4.5 mm [**Doctor Last Name **] level III melanoma from the left eyelid. Had excision of left eyelid with reconstruction. In [**3-/2120**], lymph node recurrence was in the left jaw and a subsequent biopsy consistent with metastatic melanoma. In [**5-/2120**], a neck dissection revealed melanoma in four out of 76 nodes, no evidence of any extracapsular extension. Then, he had a repeat recurrence within his eyelid and conjunctivae which were resected with clear margins. He has been treated with interferon. However, on interferon which he was having done in [**Location (un) **], he developed a new lung nodule as well as an eyelid recurrence. Lung nodule was surgically biopsied and was found to be consistent with metastatic melanoma. He was then referred to the melanoma clinic here at [**Hospital1 69**]. As part of the screening he was found to have new single metastasis of 9 x 5 mm in the left frontal lobe. Past Medical History: childhood heart murmur history of peptic ulcer disease Social History: college graduate with a degree in culinary arts and works as a cook. He does smoke about a pack a day and has done do for the past eight to ten years. He drinks occasionally. He is divorced. Family History: Family history is remarkable for an aunt who died of cancer and his mother told him that there is a family history of melanoma. Physical Exam: GENERAL: He is alert, pleasant, cooperative young man in no acute distress. He is well developed, well nourished. He does have multiple tattoos. VITAL SIGNS: Blood pressure is 142/82, pulse of 80, respirations 16, temperature 97. CARDIOVASCULAR: He has regular rate and rhythm. No murmurs, gallops, or rubs. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: No clubbing, cyanosis, or edema. HEENT: Head, he has a well-healed scar in the left lower eyelid. There is no evidence of any melanoma or hyperpigmented area. He does have a partial left lid ptosis laterally because of the reconstructive surgery done there. Eyes, pupils equal, round, reactive to light. Because of the retraction of the lid, he does have some difficulties moving the left eye to the left as well but he has full extraocular movements on the right. Visual fields are full. There is no nystagmus. Mouth examination, tongue is midline, palate elevates symmetrically. Oral mucosa is pink and moist. NECK: Soft and supple. NEUROLOGIC: Cranial nerves II through VI, IX through XII are intact. He does have some diplopia interestingly more on rightward gaze as well as the leftward gaze he states because of the difficulty moving the eyes, although I cannot find any evidence of a CN III on examination. Medial gaze in the left eye appears to be intact as well as on the CN VI on the right eye. This is not complete. He cannot wrinkle the brow and close the eye fairly well and has some decreased excursion of the angle of the mouth. Motor is [**4-4**] bilaterally, normal tone, no drift. Sensation is intact to light touch, temperature, joint position sense, and vibration throughout. Cerebellar, he has normal appendicular coordination, normal gait, is able to toe tandem and heel walk quite well. Reflexes are [**12-2**]+ throughout with downgoing toes. Pertinent Results: [**2121-7-3**] 04:12PM PT-12.0 PTT-25.6 INR(PT)-1.0 [**2121-7-3**] 04:12PM PLT COUNT-195 [**2121-7-3**] 04:12PM WBC-12.5* RBC-4.36* HGB-13.0* HCT-35.4* MCV-81* MCH-29.8 MCHC-36.6* RDW-13.9 [**2121-7-3**] 04:12PM CALCIUM-8.4 PHOSPHATE-2.1*# MAGNESIUM-1.9 [**2121-7-3**] 04:12PM GLUCOSE-120* UREA N-13 CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-28 ANION GAP-10 Brief Hospital Course: Pt was admitted to the Neurosurgery Service and underwent a stereotatic biopsy without complication. He was monitored overnight in the PACU, a post op CT did not show any sign of hemorrhage. Overnight he complained of significant facial, head and pulmonary pain requiring him to be started on a PCA. Neurologically he was at baseline with Cranial nerves II through VI, IX through XII are intact. He does have some diplopia on rightward gaze and lefward gaze. Motor strenght was intact and no pronator drift. A chronic pain service consult was obtained. They recommended increasing neurontin to 600mg TID, methadone to 10mg po TID, cont oxycodone 25 po q3-4 PRN, d/c iv morphine. He was transferred to the surgical floor on POD#1 tolerating a regular diet, urinating without problems. An MRI of his brain showed: "Status post left frontal craniotomy. Blood products at the surgical site are noted without significant edema or mass effect. Subtle residual enhancement is identified at the inferior aspect of the surgical site in the left frontal lobe. No evidence of hydrocephalus." He will f/u in brain tumor clinic. He should be referred to [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Center if needed to control pain. Medications on Admission: Percocet and Neurotin Discharge Medications: 1. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day: take while on decadron. Disp:*6 Tablet(s)* Refills:*0* 3. Dexamethasone 1 mg Tablet Sig: take 2 tablets tid on [**7-5**] and one tablet tid on [**7-6**] Tablet PO see above for 2 days. Disp:*9 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Use while on narcotics. Disp:*60 Capsule(s)* Refills:*2* 5. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: Five (5) Tablet PO Q3H (every 3 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Malignant Melanoma Discharge Condition: Neurologically stable Discharge Instructions: Keep incision clean and dry do not get wet until staples are removed No heavey lifting No driving while on narcotics Watch incision for redness, drainage, swelling, bleeding, fever greater than 101.5 call Dr[**Name (NI) 9034**] office Followup Instructions: Follow up in Brain tumor clinic Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2121-8-11**] 11:00 Completed by:[**2121-7-6**]

[ "305.1", "V16.8", "198.3", "998.11", "V10.82", "197.0" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

6308, 6314

4118, 5379

309, 337

6377, 6401

3710, 4095

6684, 6888

1707, 1837

5451, 6285

6335, 6356

5405, 5428

6425, 6661

1852, 3691

251, 271

365, 1402

1424, 1481

1497, 1691

55,783

160,607

38224

Discharge summary

report

Admission Date: [**2104-7-24**] Discharge Date: [**2104-8-5**] Date of Birth: [**2037-8-7**] Sex: F Service: CARDIOTHORACIC Allergies: Clindamycin Hcl / Penicillin V Potassium / Ethionamide / Isoniazid / Lisinopril / Metformin Hcl / Niaspan / Pyrazinamide Attending:[**First Name3 (LF) 1406**] Chief Complaint: angina/DOE Major Surgical or Invasive Procedure: [**2104-7-24**] CABG x4 (LIMA to LAD, SVG to DIAG, SVG to PDA seq. to PLV)/sternal Talon closure/tracheal stent History of Present Illness: 66 year old female with multiple co-morbidities and severe multivessel coronary artery disease, who was recently found to have tracheobronchomalacia and excessive dynamic airway collapse. Prior to surgical revascularization, she will undergo central airway stabilization. She currently complains of exertional chest pain and dyspnea on exertion. She admits to [**2-6**] pillow orthopnea and worsening fatigue. Her routine ADLs are moderately to severely limited by the above symptoms. Of note, she has had multiple hospitalizations for "asthma", receiving repeat courses of antibiotics and steroids. She is currently taking neither. Referred for surgical evaluation. Past Medical History: -Coronary Artery Disease -Tracheobronchomalacia -Possible Asthma, Restrictive Lung Disease -Obstructive sleep apnea, on nocturnal CPAP -Hypertension -Hyperlipidemia -Diabetes Mellitus, Insulin Dependent -Morbid Obesity -History of GI Bleed, Duodenal Ulcer [**2092**] -Hiatal Hernia, GERD -Cervical/Lumbar Disc Disease -Arthritis -Fibromyalgia -History of Kidney Stones -TMJ Past Surgical History: -Polypectomy -Esophogeal Dilation -Hemorrhoidectomy Social History: Lives with: Originally from [**First Name9 (NamePattern2) 8880**] [**Country **]. Now lives in [**Hospital1 1559**] Tobacco: remote recreational smoker ETOH: denies Family History: Father died of MI at age 59. Sister [**Name (NI) 85198**] CABG in her 50's. Physical Exam: Pulse: 96 Resp: 22 O2 sat: 98% room air BP Right: 142/77 Left: 154/81 Height: 59.8 inches Weight: 220 lbs General: Obese female in no acute distress, ambulates with cane Skin: Dry [x] intact [x] HEENT: NCAT [x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: very obese, otherwise Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 1 Left: 1 DP Right: NP Left: NP PT [**Name (NI) 167**]: NP Left: NP Radial Right: 1 Left: 1 Carotid Bruit: None(patient had difficult time holding breath) Pertinent Results: [**2104-8-5**] 05:00AM BLOOD WBC-20.1* RBC-3.92* Hgb-10.5* Hct-33.6* MCV-86 MCH-26.9* MCHC-31.4 RDW-19.4* Plt Ct-645* [**2104-7-24**] 01:50PM BLOOD WBC-27.9*# RBC-4.30 Hgb-11.6* Hct-34.5* MCV-80* MCH-27.0 MCHC-33.6 RDW-15.9* Plt Ct-191 [**2104-7-28**] 02:30AM BLOOD PT-13.6* PTT-27.4 INR(PT)-1.2* [**2104-7-24**] 01:50PM BLOOD PT-14.1* PTT-31.3 INR(PT)-1.2* [**2104-8-5**] 05:00AM BLOOD Glucose-69* UreaN-15 Creat-1.0 Na-137 K-4.2 Cl-98 HCO3-27 AnGap-16 [**2104-7-24**] 02:44PM BLOOD UreaN-10 Creat-0.7 Na-141 K-3.0* Cl-106 HCO3-26 AnGap-12 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 85199**] (Complete) Done [**2104-7-24**] at 10:14:33 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-8-7**] Age (years): 66 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Coronary artery disease. Hypertension. Shortness of breath. ICD-9 Codes: 402.90, 786.05, 786.51 Test Information Date/Time: [**2104-7-24**] at 10:14 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Aorta - Annulus: 1.8 cm <= 3.0 cm Aorta - Sinus Level: 2.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aorta - Arch: 2.1 cm <= 3.0 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - LVOT diam: 1.4 cm Findings LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Mild to moderate [[**1-5**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. The patient is in a ventricularly paced rhythm. The patient has runs of a supraventricular tachycardia. Frequent atrial premature beats. Frequent ventricular premature beats. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions IMPRESSIONS: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. Mild-moderate ([**1-5**]+) mitral regurgitation is seen. POST-BYPASS: Pt is on a low dose phenylephrine infusion (<0.3 mcg/kg/min) and is normal sinus rhythm (not being paced). Preserved biventricular systolic function without wall motion abnormalities. Mild aortic regurgitation and mild-moderate mitral regurgation persist. Normal aortic contours. The surgeon, Dr. [**Last Name (STitle) **], was notified of the findings in person. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician ?????? [**2097**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [**7-24**] and underwent tracheal stenting with Dr. [**Last Name (STitle) **] and CABG with Dr. [**Last Name (STitle) **]. Please refer to Dr[**Doctor Last Name **] operative report for further details. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Bedside bronchoscopy done [**7-25**]. Chest tubes removed on [**7-26**]. Extubated on POD #4. Developed rapid atrial fibrillation and was started on amiodarone and lopressor titrated. Continued to improve and was transferred to the floor on POD #10. Physical therapy was consulted for strength and mobility evaluation. She had persistent fevers and leukocytosis. Urine culture revealed 100,000/mL colonies of enterococcus, and sputum grew coag+ staph. She was placed on vancomycin and bactrim. Per Dr.[**Last Name (STitle) **], upon discharge to rehab, antibiotics are to be changed to oral Levoquin x 2 week course with follow CBC in 1 week. She continued to progress and on POD#12 she was cleared by Dr.[**Last Name (STitle) **] for discharge to [**Hospital3 **] in [**Location (un) 1294**]. All follow up appoinments were advised. Medications on Admission: Advair 500/50 1 puff twice daily, Albuterol Inhaler PRN, Amytriptyline 50 qhs, Atenolol 50 qd, Diphenhydramine prn allergy, Cymbalta 60 qd, Vitamin D2, Fluticasone nasal spray Omeprazole 20 mg PO BID, Furosemide 20 mg PO daily, Novolin insulin 50units twice daily, Humalog sliding scale, Ipratropium bromide nasal spray, Isosorbide Mononitrate 30 qd, Metoclopramide 10mg prn meals, Singulair 10 mg PO QHS, Mupirocin nasal ointment [**Hospital1 **], Omeprazole 20 [**Hospital1 **], Oxycodone 5mg prn, Polyethylene Glycol daily, Simvastatin 80mg daily, Micardis 40mg daily, Aspirin 325 daily, Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscellaneous TID (3 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation TID (3 times a day). 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation/confusion. 16. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous AC: 25 units NPH with breakfast/Lunch/Dinner. 17. regular Sig: One (1) Subcutaneous ACHS: per Sliding Scale. 18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 19. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day). 21. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO tid (). 22. Metoclopramide 10 mg IV Q6H:PRN nausea 23. Furosemide 10 mg/mL Solution Sig: One (1) Injection TID (3 times a day). 24. levoquin Sig: Five Hundred (500) mg PO once a day for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: -Coronary Artery Disease s/p cabg x4 -Tracheobronchomalacia s/p tracheal stent -Possible Asthma, Restrictive Lung Disease -Obstructive sleep apnea, on nocturnal CPAP -Hypertension -Hyperlipidemia -Diabetes Mellitus, Insulin Dependent -Morbid Obesity -History of GI Bleed, Duodenal Ulcer [**2092**] -Hiatal Hernia, GERD -Cervical/Lumbar Disc Disease -Arthritis -Fibromyalgia -History of Kidney Stones -TMJ Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with po analgesic:Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Wednesday [**8-27**] @ 1:15 pm [**Hospital Ward Name **] 2A Please call to schedule appointments with your: Pulmonologist: Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks #([**Telephone/Fax (1) 85200**] Primary Care Dr. [**Last Name (STitle) 85201**] in [**1-5**] weeks [**Telephone/Fax (1) 85202**] Cardiologist Dr. [**Last Name (STitle) 85203**] in [**2-6**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2104-8-5**]

[ "V85.4", "458.29", "553.3", "519.19", "530.81", "V58.67", "493.20", "401.9", "599.0", "250.02", "278.01", "427.31", "733.00", "518.89", "327.23", "414.01", "518.5", "285.9", "041.04", "041.12", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "96.05", "36.13", "36.15", "39.61", "33.22" ]

icd9pcs

[ [ [] ] ]

11220, 11294

7268, 8410

396, 511

11743, 11974

2760, 5894

12812, 13481

1880, 1958

9052, 11197

11315, 11722

8436, 9029

11998, 12789

1627, 1681

5943, 7245

1973, 2741

346, 358

539, 1208

1230, 1604

1697, 1864

21,990

102,675

49135

Discharge summary

report

Admission Date: [**2171-5-28**] Discharge Date: [**2171-5-31**] Date of Birth: [**2098-6-13**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2840**] Chief Complaint: DKA, epigastric pain Major Surgical or Invasive Procedure: none History of Present Illness: 72F with hx DM, ESRD on HD presenting with DKA, epigastric abdominal pain. Pt was recently admitted on the surgical service from [**Date range (1) 103093**] with an infected AV fistula. She was started on vancomycin. She underwent debridement of skin and hematoma cavity with closure of the skin defect with a rhomboid flap. She developed bleeding post-op and a permacath was placed for access. She also had a period of decreased responsiveness during HD. Workup included a negative CT scan, negative CEs, CXR revelaed CHF, EEG could not be obtained. She was discharged to the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. . At HD today, she c/o N/V and ?coffee ground emesis. Heme positive at HD. She also had epigastric abdominal pain. She was transferred to the ED for evaluation. In the ED she was hemodynamically stable, Hct stable. Guiac negative. Was found to be in DKA with an anion gap 25. Started on an insulin gtt at 10 units/hr. Had a low grade temp to 99.8, mildly elevated WBC to 11 with a left shift. Started on Vanco/Levo/Flagyl. Left IJ line was placed. Per CXR, tip in right brachiocephalic vein, was pulled back and repositioned but still in brachiocephalic vein. BP was high with systolics in 200s. Given Anzement for nausea. Past Medical History: PMH: -ESRD on HD TThSat - left AV fistual s/p thrombectomy and revision -Type 2 diabetes c/b triopathy -Hypertension -CVA with vascular dementia -Anemia -congestive heart failure withejection fraction of 55%. -Osteoarthritis -Cataracts Social History: SH: no tob, ETOH, illicits, lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] Family History: noncontributory Physical Exam: PE: 98.7 90 208/71 16 99RA GEN: French Creole speaking, NAD HEENT: PERRL, EOMI, JVP not elevated CV: RRR, no m/r/g LUNGS: CTA B ABD: soft, minimal BS, +tenderness to palpation over RUQ and epigastrium EXT: no edema, 1+DPs NEURO: intact Pertinent Results: . EKG: NSR, 88 bpm, LAD, LAFB, peaked T's across precordium, no ST elevations or depressions, no change from previous . CXR [**5-28**]: Comparison is made to the study performed one hour earlier. Again seen is a right-sided central line with tip overlying the right atrium. Left-sided subclavian line appears to have been pulled back several centimeters. However, the distal tip is again seen within the right brachiocephalic vein pointed upwards. . CT Abd/Pelvis: preliminary read - c/w chronic pancreatitis with atrophy, course calcifications, GB distention without gallstones or ductal dilation. . TTE [**12-15**]: 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-11**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . PMIBI [**12-15**]: no ischemic changes [**2171-5-28**] 11:33PM TYPE-ART PO2-99 PCO2-30* PH-7.43 TOTAL CO2-21 BASE XS--2 [**2171-5-28**] 11:33PM LACTATE-2.4* [**2171-5-28**] 08:15PM GLUCOSE-339* UREA N-70* CREAT-10.3* SODIUM-140 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-17* ANION GAP-28* [**2171-5-28**] 08:15PM GGT-16 [**2171-5-28**] 08:15PM TRIGLYCER-33 [**2171-5-28**] 08:15PM CALCIUM-9.3 PHOSPHATE-6.2* MAGNESIUM-2.1 [**2171-5-28**] 02:46PM ACETONE-MODERATE [**2171-5-28**] 02:46PM WBC-11.1* RBC-4.76 HGB-14.7 HCT-46.9 MCV-99* MCH-31.0 MCHC-31.4 RDW-17.1* [**2171-5-28**] 02:46PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SCHISTOCY-1+ BURR-1+ [**2171-5-28**] 02:46PM PLT SMR-NORMAL PLT COUNT-213 [**2171-5-28**] 02:46PM PT-12.9 PTT-28.7 INR(PT)-1.1 [**2171-5-28**] 02:08PM ALBUMIN-4.5 CALCIUM-9.7 [**2171-5-28**] 02:08PM WBC-10.9 RBC-4.89# HGB-15.0# HCT-48.5*# MCV-99* MCH-30.7 MCHC-30.9* RDW-16.6* [**2171-5-28**] 02:08PM NEUTS-94* BANDS-0 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2171-5-28**] 02:08PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-1+ [**2171-5-28**] 02:08PM PLT SMR-NORMAL PLT COUNT-222 Brief Hospital Course: 72 yo woman with h/o ESRD on HD, type II diabetes mellitus, presenting with anion gap metabolic acidosis and abdominal pain. During her hospitalization the following issues were addressed: . # AG metabolic acidosis: Labs revealed a positive acetone, raising concern for DKA. DDx also included uremia. She was initially admitted to the ICU and placed on an insulin gtt. Hyperglycemia and acidosis resolved by day two. She was dialyzed on day two, and chemistries remained within normal range for the remainder of her hospitalization. She was continued on her outpatient insulin regimen of 15units 70/30 at breakfast and a regular insulin sliding scale. . # Abdominal pain: Pain resolved on admission. Abdominal CT showed signs of chronic pancreatitis including stranding, and lab studies revealed an elevated AST that resolved. DDx also included diabetic gastroparesis. . # ?GIB/coffee ground emesis: There was a question of coffee ground emesis on admission. Stool was guiaic negative, and hematocrit remained stable throughout her hospitalization 40-45. No further work-up was intiated. She will follow-up for outpatient EGD. . HTN: BP initially elevated on admission as patient missed hemodialysis. She was treated with iv lopressor and hydralazine, and BP normalized. HTN remained stable on outpatient regimen on metoprolol and lisinopril for remainder of her hospitalization. . # Dispo: she was discharged back to the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Communication is with the patient and her daughter [**Name (NI) **] [**Name (NI) 103090**] [**Telephone/Fax (1) 103094**]. She is a full code. Medications on Admission: - Tylenol prn - Venofer (iron) 100 mg IV Qweek - EPO [**Numeric Identifier **] u QHD - Zemplar 5 mcg QHD - Colace [**Hospital1 **] - Humulin 70/30 30 units QD - Lactulose 30 cc prn - Nephrocaps 1 tab daily - Percocet prn - ASA 325 daily - Phoslo 667 TID - Toprol XL 50 mg daily - Zestril 10 mg QHS - Sensipar 60 mg daily Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): TIW at hemodialysis. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Insulin Insulin 70/13; 30units at breakfast 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Hyperglycemia Metabolic acidosis Chronic pancreatitis Type II diabetes mellitus ESRD on hemodialysis Discharge Condition: stable Discharge Instructions: If you develop abdominal pain, chest pain, shortness of breath, fever, or any other concerning symptom, please call your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. Followup Instructions: Please follow-up with your primary care physician within the next 1-2 weeks to review your hospital course and medications.

[ "250.10", "V58.67", "403.91", "585.6", "250.40", "577.1" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

7611, 7684

4756, 6413

293, 299

7829, 7838

2297, 4733

8095, 8222

2001, 2018

6785, 7588

7705, 7808

6439, 6762

7862, 8072

2033, 2278

233, 255

327, 1600

1622, 1860

1876, 1985

7,613

190,737

8441

Discharge summary

report

Admission Date: [**2127-5-2**] Discharge Date: [**2127-5-6**] Date of Birth: [**2059-4-20**] Sex: M Service: MEDICINE Allergies: Imipenem/Cilastatin Sodium / Nsaids / Aspirin Attending:[**First Name3 (LF) 11040**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Placement of right subclavian HD line History of Present Illness: 68 yo M with ESRD on HD, COPD, AF w/ PCM, CHF, and h/o R colectomy, who presents from HD with non-functioning HD catheter and found to be in bigeminy by emergency physician's report. He did not recieving HD on day of admission. He recieved midodrine prior to HD. . In the ED, VS 102 rectal, HR 104, 96/55, Rr 16, 100% on vent. Exam in the ED was unremarkable. Given IV vancomycin and 500 cc IV in the ED. 2 PIV placed. Lowest BP documented was 72/45 in triage. . On arrival, pt had no complaints. Denied CP, pressure, SOB, cough, abd pain, nausea/vomiting or any other sxs. He was mentaing on arrival. . Admitted to MICU for hypotension. initally BP on arrival was in the 60's SBP, IVF hung with good result -- pt's bp increased and stabilized in 80's-90's which is his baseline. A left sided subclavian or supraclavicular was attempted without success, so interventional radiology was contact[**Name (NI) **] for imaging-guided line placement. Past Medical History: -[**2-/2127**] admit for hypoxemia and ARF, found to have perforation and right colon necrosis (possibly due to kayexylate); underwent right colectomy, complicated by ongoing ARF requiring HD, persistent respiratory failure requiring trach/peg -ESRD felt [**1-10**] ATN during [**2-/2127**] admit, HD initiated during admit -morbid obesity -COPD -bilateral lymphedema -a fib s/p pacer -CHF, felt diastolic with [**1-/2127**] echo showing EF > 55% -dyslipidemia -sleep apnea -iron deficiency anemia -h/o LE cellulitis [**1-15**] with polymicorbial orgs -C diff in [**1-15**] -PEG tube--nepro TFs at 50 cc/hr Social History: Gleaned from both patient and OMR: lived at home alone prior to most recent admin on [**1-22**]. He uses crutches at home, does activities of daily living. Denies ETOh, tobacco or drug use. Family History: noncontributory Physical Exam: Upon Arrival to ICU: 100.8, 101/46, 81, 100%, 4% Fio2 obese trach/vented man, pleasant, oriented trach site clean OP clear, PERRLA, EOMI R SCL line RRR, nl s1/s2, unable to hear murmurs coarse bs bilaterally soft NT/D, +BS, J tube in place, site C/D/I; abd wound in midline with vac dressing in place LE with blueish hue with chornic venous stasis changes, right post calf with open wound with min grnaulation tissue neuro: grossly non focal Pertinent Results: Labs: [**2127-5-2**] 03:15PM BLOOD WBC-12.1* RBC-3.86*# Hgb-11.3*# Hct-34.3*# MCV-89 MCH-29.2 MCHC-32.9 RDW-17.6* Plt Ct-218 [**2127-5-5**] 03:10AM BLOOD WBC-9.2 RBC-3.46* Hgb-10.0* Hct-31.0* MCV-90 MCH-28.9 MCHC-32.3 RDW-17.7* Plt Ct-188 [**2127-5-6**] 03:53AM BLOOD WBC-9.4 RBC-3.55* Hgb-10.3* Hct-32.2* MCV-91 MCH-29.1 MCHC-32.0 RDW-18.0* Plt Ct-199 . [**2127-5-2**] 03:15PM BLOOD Glucose-98 UreaN-49* Creat-6.5*# Na-138 K-4.0 Cl-106 HCO3-23 AnGap-13 [**2127-5-4**] 02:13AM BLOOD Glucose-90 UreaN-52* Creat-7.2* Na-136 K-3.9 Cl-108 HCO3-19* AnGap-13 [**2127-5-6**] 03:53AM BLOOD Glucose-84 UreaN-58* Creat-8.4* Na-130* K-4.2 Cl-103 HCO3-17* AnGap-14 . . Microbiology: Blood cx's no growth [**5-14**] (still pending at time of d/c), c. diff negative. . . Imaging: [**2127-5-2**]: CXR - There is no evidence of pneumothorax. The lungs remain clear with prominent hila bilaterally which may suggest underlying pulmonary arterial hypertension. No evidence of pulmonary edema or pleural effusions. Cardiomediastinal silhouette is within normal limits. Positions of right-sided single-lead pacemaker device and tracheostomy tube are unchanged. . [**2127-5-2**]: TIB/FIB/soft tissue xray - Probable lateral soft tissue loss or ulcer along lateral mid and distal fibula, with amorphous calcification or foreign material proximally, and focal periosteal reaction distally. Brief Hospital Course: 68 yo M with multiple medical problems, here with hypotension and fever found in the setting of a non-working HD line. . #hypotension: The patient was admitted with hypotension, though per his nursing home his pressure runs low usually. The patient's blood pressure responded to IVF, and he continued to mentate well. Given his initial temperature, concern was for infection. The patient had a normal cxr making pna unlikely, LE wounds that were chronic (cellulitis unlikely), and a chronic line (possible line infection). Given his history of VRE and concern for line infection or other sources the patient was broadly covered with vancomycin (dosed by level), levaquin, and linezolid while his cultures were pending. His blood cultures are negative to date, and as he evinced no signs of infection (fever, tachycardia, change from baseline bp, or wbc) the antibiotics were stopped, and the patient remained stable. He never required pressors during his stay; the initialy fluid bolus was sufficient to raise his bp from the 60's up to his baseline 80's-90's. His midodrine dose was increased to 10mg tid (from 10mg AM, 5mg [**Hospital1 **] noon and HS) for help supporting his bp during HD. . #Fevers: The patient had a fever on admission, though remained afebrile for the majority of his course. He had a normal white count, though given his intitial temperature and hypotension the patient was covered broadly with levaquin, linezolid and vancomycin, while awaiting the RIJ tip to be cultured and have negative cultures for 24 hours. All cultures remained negative for 96 hours, and he remained hemodynamically stable, without leukocytosis, so antibiotics were stopped. At the time of discharge, he had 96 hours of negative blood cultures and a negative C. difficile antigen. . #ESRD on HD: The patient presented with a non functioning line that did not respond to TPA. He had a groin line placed by surgery and this did not work either, so the patient had his labs followed closely and did not require urgent dialysis while waiting for his tunnelled line. A tunnelled right subclavian line was placed by IR and he was sucesfully dialyzed through it before discharge. . # Abdominal wound after right colectomy: The patient has a chronic wound and vac in place. Surgery did not feel this was a source of infection, and he was followed by the wound care nurse for weekly vac changes. This should be continued and he should see his surgeon in [**Month (only) **] at the appointment described in the discharge paperwork. . # LE ulcers: The patient has bilateral ulcers that appear chronic and not actively infected. Vascular recommended wet to dry dressings with ace wraps and the patient had this wound care with no developing signs of cellulitis. . # AF: The patient has a history of atrial fibrillation but remained well rate control and paced. . #Respiratory failure: The patient is chronically vented, but had difficulty weaning at rehab secondary to high gastric residuals. The patient was weaned to trach mask at 40% fio2 during his course and tolerated this well with no episodes of desaturation. A Passy-Muir valve was fitted which also worked well. . # Nutrition: The patient came in on tube feeds, but he was able to eat on his own. He remained on oral feeds and did well. The GJ tube was tested in IR and found to be working, so was left in place should his po's prove insufficient. A calorie count is recommended to evaluate adequacy of oral intake. Medications on Admission: insulin scale FW flush 200 ml tid ambien 5 mg qhs nephrocaps 1 cap qd wellbutrin 100 mg [**Hospital1 **] epogen 5,000 qhd heparin sq [**Hospital1 **] midodrine 10 mg tiw preHD prevacid 30 mg qd albuterol neb atrovent neb mucomyst 2ml q 6 dilaudid 2 mg q4 prn morphine 2 mg IV q2 prn zofran 4 mg IV q6 prn simethicone 2 tabs tid reglan 10 mg q6 renagel 1600 mg tid Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Blocked dialysis catheter Hypotension . Secondary: -[**2-/2127**] admit for hypoxemia, ARF, found to have perforation and right colon necrosis; underwent right colectomy, complicated by ongoing ARF requiring HD, persistent resp failure requiring trach/peg -ESRD felt [**1-10**] ATN during [**2-/2127**] admit, HD initiated during admit -morbid obesity -COPD -bilateral lymphedema -a fib s/p pacer -CHF, felt diastolic with [**1-/2127**] echo showing EF > 55% -dyslipidemia -sleep apnea -iron deficiency anemia -h/o LE cellulitis [**1-15**] with polymicorbial orgs -C diff in [**1-15**] -PEG tube--nepro TFs at 50 cc/hr Discharge Condition: Stable, with functioning HD line At baseline bp (80's-90's systolic) Paced Discharge Instructions: Pt was admitted for blocked HD line, found to be hypotensive to 60's (baseline bp 80's), with no evidence of infection found; hypotension felt due to hypovolemia and autonomic neuropathy. . Please call pt's doctor or return to ED for high fevers/chills, trouble breathing, significant blood pressure drop, low oxygen saturaiton, or other concerning signs/symptoms. . Patient should be seen by his surgeon at the time and day below. Followup Instructions: Dr. [**Last Name (STitle) **], surgery, Friday [**5-16**] at 11:15, [**Hospital Unit Name 29748**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1864**]. . Once you are ready for discharge from rehab, they will arrange outpatient nephrology follow-up for you. . Please see your PCP upon finishing your rehab course.

[ "V44.0", "428.30", "V44.1", "707.13", "V45.1", "518.83", "996.1", "427.31", "428.0", "276.52", "496", "998.83", "585.6", "V45.01", "280.9", "458.9", "E878.3", "V44.2", "272.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "00.14", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

8900, 8981

4072, 7556

317, 357

9644, 9721

2681, 4049

10201, 10555

2186, 2203

7971, 8877

9002, 9623

7582, 7948

9745, 10178

2218, 2662

266, 279

385, 1332

1354, 1962

1978, 2170

73,530

122,185

12763

Discharge summary

report

Admission Date: [**2185-8-29**] Discharge Date: [**2185-9-14**] Date of Birth: [**2104-2-23**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: CABG x4 (LIMA-LAD, SVG to [**Last Name (LF) **], [**First Name3 (LF) **], PDA) History of Present Illness: 80 yo M with CHF (LVEF 40%), CAD s/p PTCA LCx and LAD [**2167**], DES x3 to the LAD in [**5-/2184**], dyslipidemia, DM, HTN, AF on coumadin, s/p pacemaker [**2179**], presented to [**Hospital3 1443**] Hospital with about a month of worsening exertional angina. Underwent a stress test on [**2185-8-25**] which showed a largely fixed defect. ECG paced without appreciable ST changes. Troponin negative x1 on [**8-25**]. Found to have elevated Cr to 1.6 which was thought to be prerenal, improved to 1.1 with gental hydration. Transferred to [**Hospital1 18**] for cardiac catheterization on [**8-29**] which showed 80% distal left main, LAD: Total Occlusion LCx: 80% ostial, 80% OM 2 RCA: PDA w serial 80% lesions. He was referred for cardiac surgery evaluation. Past Medical History: Hypertension Diabetes Mellitus CAD s/p PTCA LAD and LCX in [**2167**], LAD PCI in [**2184**] Atrial Fibrillation -on coumadin Hyperkalemia [**2-9**] ACE-I Stage II CKD (creatinin 1.6-1.2) chronic systolic CHF - EF 40% Bilateral knee replacement Prostate Ca, s/p prostatectomy Osteoarthritis s/p PPM Pulmonary HTN chronic thrombocytopenia Past Surgical History Bilateral total knee replacement Prostatectomy Herniorrhaphy Past Cardiac Procedures Pacemaker [**2179**], [**Company 1543**] Social History: -Tobacco history: None -ETOH: Rare, but none in [**5-13**] months -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse: 60 paced Resp: 15 O2 sat: 97%RA B/P Right: Left: 129/58 Height: Weight: 88kg Five Meter Walk Test - bedrest General: NAD, supine following cath Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _trace__ Varicosities: early venous stasis changes- no gross varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left: 1+ DP Right: 2+ Left:1+ PT [**Name (NI) 167**]: Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: Pertinent Results: Conclusions No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). 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. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. 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. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Compared with the prior study (images reviewed), the overall findings are similar. [**2185-9-8**] 04:39AM BLOOD WBC-7.9 RBC-2.96* Hgb-9.9* Hct-28.9* MCV-98 MCH-33.4* MCHC-34.2 RDW-14.6 Plt Ct-130* [**2185-9-8**] 04:39AM BLOOD Plt Ct-130* [**2185-9-8**] 04:39AM BLOOD Glucose-161* UreaN-41* Creat-1.6* Na-138 K-4.0 Cl-102 HCO3-28 AnGap-12 [**2185-9-5**] 12:50AM BLOOD ALT-12 AST-30 AlkPhos-55 Amylase-34 TotBili-0.9 [**2185-9-8**] 04:39AM BLOOD Mg-2.2 [**2185-8-30**] 03:51AM BLOOD %HbA1c-6.4* eAG-137* [**2185-8-30**] 03:51AM BLOOD Triglyc-51 HDL-46 CHOL/HD-2.8 LDLcalc-73 [**2185-8-30**] 03:51AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE [**2185-8-30**] 03:51AM BLOOD HCV Ab-NEGATIVE [**2185-9-13**] 10:54AM BLOOD WBC-6.6 RBC-2.88* Hgb-9.5* Hct-27.7* MCV-96 MCH-33.2* MCHC-34.4 RDW-14.1 Plt Ct-202 [**2185-9-10**] 05:03AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.5* Hct-28.2* MCV-97 MCH-32.9* MCHC-33.8 RDW-14.3 Plt Ct-172 [**2185-9-13**] 05:20AM BLOOD PT-23.5* INR(PT)-2.2* [**2185-9-12**] 05:27AM BLOOD PT-28.3* INR(PT)-2.7* [**2185-9-11**] 05:06AM BLOOD PT-25.4* INR(PT)-2.4* [**2185-9-13**] 10:54AM BLOOD UreaN-26* Creat-1.4* Na-133 K-4.1 Cl-96 [**2185-9-12**] 05:27AM BLOOD UreaN-24* Creat-1.4* Na-136 K-3.7 Cl-98 [**2185-9-11**] 05:06AM BLOOD UreaN-25* Creat-1.3* Na-137 K-4.2 Cl-100 [**2185-9-14**] 05:57AM BLOOD WBC-7.9 RBC-2.78* Hgb-9.1* Hct-26.7* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.9 Plt Ct-235 [**2185-9-14**] 05:57AM BLOOD PT-21.4* PTT-31.8 INR(PT)-2.0* [**2185-9-13**] 05:20AM BLOOD PT-23.5* INR(PT)-2.2* [**2185-9-12**] 05:27AM BLOOD PT-28.3* INR(PT)-2.7* [**2185-9-11**] 05:06AM BLOOD PT-25.4* INR(PT)-2.4* [**2185-9-10**] 05:03AM BLOOD PT-23.8* INR(PT)-2.2* Brief Hospital Course: 80 year old Male with Congestive Heart Failure (LVEF 40%), Coronary Artery Disease status post Percutaneous angioplasty of the Left Circumflex and Left Anterior Descending arteries in [**2167**], Drug Eluding Stent x3 to the Left Anterior Descending in [**5-/2184**], dyslipidemia, Diabetes Mellitus, Hypertension, Atrial Fibrillation on coumadin, s/p pacemaker [**2179**] presented to outside hospital with unstable angina and positive stress test. He was transferred to [**Hospital1 18**] for catherization which showed 3 vessel CAD. Preop work up was completed and on [**9-2**] he underwent Coronary bypass grafting x4(Left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the posterior descending artery, and reverse saphenous vein graft to the second obtuse marginal artery with a Y-graft to the diagonal artery) with Dr.[**Last Name (STitle) **]. Cross Clamp time:94 minutes. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in stable condition. He awoke neurologically intact and was extubated the following day. His respiratory status remained somewhat concerning with bronchospasm evident. He was placed on inhalers and nebulizer treatments. Inotropes were weaned off and then ultimately restarted for support. He was gently diuresed toward his preop weight. When inotropes were weaned off, Beta blockade/statin/Aspirin were initiated. All lines and drains were discontinued per protocol. He was transferred to the stepdown unit on POD #5 to begin increasing his activity level. Physical Therapy was consulted for evaluation of strength and mobility. PICC placed for access. Coumadin restarted for his chronic A Fib. The remainder of his postoperative course was essentially uneventful. He developed a right leg cellulitis at his vein harvest site and was started on Vancomycin for this reason. He remained afebrile and WBC was 6.6 at discharge. His left PICC was removed with some erythema at the insertion site and a new right sided PICC was placed on [**9-13**]. His respiratory status slowly improved and he was weaned off supplemental oxygen. On POD 12 he was discharged to home with VNA. All follow up appointments were advised. Dr. [**Last Name (STitle) 5686**] will continue to follow the patient's INR and manage coumadin. Medications on Admission: Ativan 1 mg tid prn Imdur 30 mg daily Paxil 20 mg daily ASA 325 mg daily Zocor 20 mg daily Proair prn Glipizide XL 2.5 mg daily Metoprolol 50 mg twice daily Plavix 75 mg daily** Warfarin 4 mg daily** Bumex 3 mg [**Hospital1 **] ??Norvasc 10 mg daily Discharge Medications: 1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. 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* 5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*2* 8. bumetanide 1 mg Tablet Sig: Three (3) Tablet PO twice a day. 9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. cephalexin 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. Disp:*42 Tablet(s)* Refills:*0* 14. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 15. hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*2* 16. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: dose to change daily for goal INR 2-2.5. Disp:*60 Tablet(s)* Refills:*2* 17. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/insomnia. Disp:*20 Tablet(s)* Refills:*0* 19. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [**2185-9-15**] Results to Dr. [**Last Name (STitle) 5686**] [**Telephone/Fax (1) 11554**] 20. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation four times a day. Disp:*qs * Refills:*2* 21. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: s/p CABG x4 HTN,NIDDM,CAD s/p PTCA LAD/cx [**2167**],LAD PCI in [**2184**],Chr. AF,Stage II CKD(1.6),chronic systolic CHF - EF 40%,B TKR,Prostate Ca, s/p prostatectomy,Osteoarthritis,s/p PPM,Pulmonary HTN,chronic thrombocytopenia,s/p herniorrhaphy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg -Right with erythema, no drainage Edema 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on Thursday, [**10-13**] @ 1:15 pm in the [**Hospital **] medical office building [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 5686**] [**Telephone/Fax (1) 11554**] on [**9-21**] @ 9:45 AM Wound Check, [**Hospital Unit Name 4081**], [**Telephone/Fax (1) 170**] Date/Time:[**2185-9-29**] 10:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 39374**] [**Name (STitle) 39375**] [**0-0-**] in [**4-12**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [**2185-9-15**] Results to Dr. [**Last Name (STitle) 5686**] [**Telephone/Fax (1) 11554**] Completed by:[**2185-9-14**]

[ "414.2", "V45.82", "998.59", "412", "411.1", "790.4", "427.31", "414.01", "250.00", "V58.61", "416.8", "459.81", "428.0", "519.11", "E942.2", "428.22", "682.6", "585.2", "E849.8", "403.90", "V43.65", "287.5", "300.00", "V45.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10343, 10373

5206, 7600

292, 373

10665, 10876

2702, 5183

11717, 12664

1798, 1913

7901, 10320

10394, 10644

7626, 7878

10900, 11694

1928, 2683

242, 254

401, 1168

1190, 1678

1694, 1782

76,174

194,164

49589

Discharge summary

report

Admission Date: [**2118-5-12**] Discharge Date: [**2118-5-13**] Date of Birth: [**2037-8-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: abdominal pain since this morning Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 80 year old male with past medical history significant for two vessel coronary artery disease s/p PCI to RCA and LCX in [**2110**], peripheral vascular disease s/p stenting of bilateral CIA in [**2112**], hypertension, diabetes, dysplipidemia and chronic kidney disease. . He was instructed to stop his aspirin and plavix on [**2118-5-4**] in anticipation of spinal stenosis surgery by his cardiologist. He reports doing well until being woken up from sleep last night at 1 am with acute onset of band like abdominal pain which was not associated with nausea/vomiting/presyncope/syncope/diaphoresis/nonradiating. Tumas and gasex did not relieve the abdominal pain. He reports having no symptoms with prior interventions. He reported on chest pain/palpatation/shortness of breath. . He presented to his primary care physician's office at 8 am since the pain was persistent. She gave him aspirin and called ambulance to transfer to [**Hospital1 18**] ED. He reports his abdominal pain resolved during his ambulance ride and has not returned since. . . In the ED, initial vitals were 99.0 65 124/49 18 97%RA. Code STEMI was called for ST elevation in inferolateral leads (I,II, V5 and V6) compared to EKG 2 weeks ago. He was loaded with plavix 600 mg x 1 and started on heparin gtt. . Cardiac catheterization showed probably LCx stent thrombosis which had resolved with antithrombotic treatment. He was placed on integrillin gtt for 12 hours and restarted on aspirin 325 mg po qdaily/plavix 75 mg po qdaily and transferred to CCU for monitoring. . In the CCU, he reported no complaints.. Past Medical History: CAD s/p RCA and LCx PCI [**2110**] h/o exercise induced SVT CRI (baseline 1.7-2.3) PVD ([**2113-5-4**], revascularization of B/L iliacs) [**7-9**] 60% lesion REIA 70% lesion [**Female First Name (un) 7195**] s/p stents (5) LCIA s/p stent RCIA DJD GERD T2DM HTN Hyperlipidemia s/p excision of melanoma Gout Ulcerative Colitis (not active) Social History: Married with children and is a CPA. Occasional EtOH use. No current tobacco use. No IVDU. Family History: Father had rheumatic fever. Physical Exam: GENERAL: Well-appearing man in NAD, comfortable, appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no JVD. HEART: RRR, faint 1/6 systolic murmur at LUSB, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: slightly firm and distended, mildly TTP throughout no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. No groin hematoma or bruits SKIN: No rashes or lesions. LYMPH: No cervical LAD. NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: EKG: ST elevation in I/II/V5/V6 compared to EKG 2 weeks ago . 2D-ECHOCARDIOGRAM [**2118-5-12**] IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and preserved global left ventricular systolic function. Mildly dilated aortic root. No clinically significant valvular regurgitation or stenosis. Very small pericardial effusion. . CARDIAC CATH ([**2118-5-12**]) 1. Probable CX stent thrombosis resolved with anti-thrombotic Rx . Cardiac Cath ([**5-/2113**]) The distal portion of the RCA contained a discrete 40% lesion with no impact on flow. An acute marginal branch demonstrated a 70% ostial lesion. The left anterior descending artery demonstrated mild luminal irregularities throughout with a 50% mid vessel lesion. A large septal branch demonstrated a 40-50% lesion. The LAD gave rise to three large OM's with a 50-60% lesion in the 2nd OM. The left circumflex demonstrated widely patent stents with only 30% in-stent restenosis in the distal portion of the vessel. A small ramus demonstrated a 70% proximal lesion. 2. LV ventriculography was deferred. 3. Limited hemodynamics demonstrated normal left and right filling pressures. Cardiac output / index were normal (6.7 L/min / 3.2 L/min/m2). There was no significant gradient across the aortic valve upon pullback from the left ventricle to the aorta. . LABORATORY DATA: See below. . CARDIAC ENZYMES [**2118-5-12**] 12:07PM BLOOD CK-MB-3 cTropnT-0.01 [**2118-5-12**] 03:58PM BLOOD CK-MB-3 cTropnT-<0.01 [**2118-5-13**] 03:00AM BLOOD CK-MB-3 cTropnT-0.02* [**2118-5-12**] 12:07PM BLOOD CK(CPK)-32* [**2118-5-12**] 03:58PM BLOOD CK(CPK)-29* [**2118-5-13**] 03:00AM BLOOD CK(CPK)-45* ADMISSION [**2118-5-12**] 12:07PM BLOOD Glucose-176* UreaN-51* Creat-1.4* Na-136 K-4.4 Cl-109* HCO3-17* AnGap-14 [**2118-5-12**] 12:07PM BLOOD WBC-15.6*# RBC-3.81* Hgb-10.9* Hct-33.6* MCV-88 MCH-28.5 MCHC-32.3 RDW-15.5 Plt Ct-156 DISCHARGE [**2118-5-13**] 03:00AM BLOOD WBC-8.5 RBC-4.03* Hgb-11.3* Hct-36.5* MCV-91 MCH-27.9 MCHC-30.8* RDW-15.4 Plt Ct-130* [**2118-5-13**] 03:00AM BLOOD Glucose-149* UreaN-44* Creat-1.5* Na-137 K-4.6 Cl-105 HCO3-22 AnGap-15 Brief Hospital Course: 80 M with DM, HTN, DL and distant history of PCI with multiple stents placed who recently stopped aspirin and plavix in anticipation of a back surgery. Presented with atypical bandlike thoracoabdominal pain and ST elevations in I,II and lateral precordial leads. Received aspirin, heparin, integrillin. Cath was unchanged suggesting probable circumflex in-stent thrombosis with medical therapy induced resolution. Patient was intermittently in slow 4:1 Aflutter and discharged on KOH with cardiology f/u # CAD - s/p multiple PCI - Dyslipidemia - Hypertension - T2DM Chest pain was highly atypical with the DDx being abdominal complaints and MI. Given the ST elevations and the timecourse after aspirin cessation, despite the unchanged coronary evaluation and negative cardiac enzymes, his working diagnosis was a probable circumflex in-stent thrombosis which resolved with anti-thrombotic treatment. His lipids were off target, so he was switched from Simva to Atorvastatin. He was cautioned clearly and repeatedly to continue aspirin 325 mg po qdaily indefinitely. He was asked to continue plavix for atleast 30 days. He was asked to consider restarting betablockade outpatient. Continued ACE and CCB. TTE was w/o WMA and consistent with cardiac risk factors (LVH) FOLLOW UP: 1. Consider re-initiating betablockade 2. Consider dc plavix after 4-6 weeks 3. Lifelong aspirin # Sinus rhythm with occasional slow (4:1) atrial flutter. Asymptomatic aflutter captured on tele. CHADS2 of 3. Coumadin deferred to cardiology evaluation outpatient given upcoming surgery and that he is currently on dual anti-platelet. Sent home with KOH to identify burden of dysrythmia. Follow up with new cardiologist (Dr. [**Last Name (STitle) **] FOLLOW UP 1. Consider coumadin 2. KOH results pending # Chronic Kidney Disease Stage 3: Baseline creatinine of 1.4 - 1.7. Likely due to diabetes/HTN. Creatinine at baseline today. Renoprotective measures taken periprocedure #. Leukocystosis on admission: Likely due to stress response. He has been afebrile. CXR with questionable infiltrate. WBC resolved on following day # Normocytic Anemia: HCT at baseline in the setting of CKD # Spinal stenosis Patient will f/u outpatient with surgeons. Has been asked to continue plavix x 30 days minimum and aspirin lifelong. Timing of surgery may impact coumadin intiation. # GERD: Continue omeprazole 20 mg po qdaily. # Gout: allopurinol SUMMARY OF FOLLOW UPS 1. Consider re-initiating betablockade 2. Consider dc plavix after 4-6 weeks 3. Lifelong aspirin 4. Consider coumadin for flutter 5. KOH results pending for flutter Medications on Admission: ALLOPURINOL - 100 mg Tablet qd AMLODIPINE -5 mg Tablet qd ATENOLOL - 50 mg Tablet qd CLOPIDOGREL [PLAVIX] - 75 mg qd (stopped [**5-4**]) GLIPIZIDE - 5 mg Tablet XR qd LISINOPRIL - 10mg qd NITROGLYCERIN - 0.3 mg Tablet qd OMEPRAZOLE - 20 mg Capsule qd SIMVASTATIN [ZOCOR] 80 mg qd VITAMINS ASPIRIN - 325 or 81mg (stopped [**5-4**]) Immodium Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4-6 weeks. 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain. 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: Please hold until you follow up with your cardiologist as your heart rate has been slow. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: In-stent rethrombosis with resolution Atrial Flutter Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 18134**], It was a pleasure participating in your care. You were admitted for chest pain and found to have a clot in the stent in your heart vessel that resolved with medical management. You underwent a cardiac catheterization which confirmed that the clot had resolved. You also were found to occasionally have an abnormal heart rhythm called atrial flutter. You will be given a heart monitor to use for the next 48h and will follow-up with a cardiologist to discuss the results. Please call or return to the hospital if you develop increasing shortness of breath, chest pain, lightheadedness, dizziness, increased ankle swelling or any other problems that concern you. Do NOT stop taking aspirin. You should be taking this medication every day for the rest of your life. . Please START the following medications: - Atorvastatin 80mg daily Please STOP the following medications: - Simvastatin Please HOLD the following medications: - do not take Atenolol until you see your cardiologist as your heart rate has been low. Discuss with him when it will be appropriate to restart. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 507**] [**Doctor First Name 508**] Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**] Appointment: Friday [**5-20**] at 10:45AM Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP When: TUESDAY [**2118-5-24**] at 2:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**] Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: GASTROENTEROLOGY When: MONDAY [**2118-5-16**] at 2:30 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2143-5-3**] Discharge Date: [**2143-5-20**] Date of Birth: [**2071-12-13**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: CODE STROKE Major Surgical or Invasive Procedure: Intubation Endoscopic placement of a PEG tube History of Present Illness: The pt. is a 71 year-old right-handed woman who presented with acute onset left-sided weakness and slurred speech. . The history is mostly obtained per EMS who transported the pt, who took from husband. Pt herself supplemented history. Pt was in USOH yesterday. Awoke needing to use the bathroom with headache at 245am. Pt got up and went to use the bathroom without difficulty. Minutes later, the husband heard a loud noise from the bathroom and found the pt on the floor, unable to move her left side. Apparently, he repeatedly attempted to lift the pt back to bed until calling EMS roughly 60 to 90 minutes later. She was brought to the ED for further evaluation. . She offered no complaints at the time of my encounter. . This examiner was paged for Code Stroke at 0414, I was at bedside by 0416. Pt arrived via EMS also at 0416. NIHSS was completed by 0425. CT scan was performed and reviewed by me at 0440. There was no ICH. Discussion with stroke fellow occurred at 0445. As NIHSS was 19, CT negative for ICH, and husband denied all contraindications, decision was made to proceed with tPA. tPA bolus was started at 0456 based on estimated 60kg body weight. Past Medical History: -hypertension -CAD with h/o MIs, s/p CABG and valve replacement 3 years ago per pt- was on warfarin 6 months post-op but not in last 2.5 years -history of strokes per husband, pt denies -hyperlipidemia Social History: Lives with husband. Denied tobacco, alcohol, illicit drugs. Family History: Unknown at present. Physical Exam: Vitals: T: 96.5F P: 120 R: 16 BP: 157/69 SaO2: 100% on 100%NRB General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple, no carotid bruits Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: tachycardic, irregularly irregular rhythm, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. . Neurologic (NIHSS): 1a. LOC: alert, responsive (0) 1b. LOC questions: knew age and name of month (0) 1c. LOC commands: closed eyes and gripped with right hand (0) 2. Partial gaze palsy, would not follow finger across midline to left, but was overcome by oculocephalic maneuver (1) 3. Visual: complete left hemianopia to threat (2) 4. Left near total lower facial palsy (2) 5a. Left arm: No movement (4) 5b. Right arm: no drift (0) 6a. Left leg: No movement (4) 6b. Right leg: no drift (0) 7. No limb ataxia on right, left not testable (0) 8. Sensory: no sensory loss bilaterally (0) 9. Language: mild loss of fluency (did not use propositions on stroke cards, speech seemed telegraphic) but comprehends (1) 10. Dysarthria: mild to moderate (1) 11. Extinction/inattention: Neglects left side, extinguishes to DSS on left (2) Pertinent Results: [**2143-5-3**] 12:51PM GLUCOSE-188* UREA N-19 CREAT-0.9 SODIUM-142 POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-20* ANION GAP-21* [**2143-5-3**] 12:51PM CK(CPK)-89 [**2143-5-3**] 12:51PM CK-MB-NotDone cTropnT-0.01 [**2143-5-3**] 12:51PM WBC-10.8 RBC-4.62 HGB-15.1 HCT-45.4 MCV-98 MCH-32.7* MCHC-33.3 RDW-13.5 [**2143-5-3**] 12:51PM NEUTS-75.0* LYMPHS-20.1 MONOS-4.1 EOS-0.1 BASOS-0.8 [**2143-5-3**] 12:51PM MACROCYT-1+ [**2143-5-3**] 12:51PM PLT COUNT-237 [**2143-5-3**] 12:51PM PT-14.7* PTT-31.6 INR(PT)-1.3* [**2143-5-3**] 07:37AM K+-4.5 [**2143-5-3**] 04:18AM GLUCOSE-148* UREA N-16 CREAT-0.9 SODIUM-138 POTASSIUM-6.3* CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 [**2143-5-3**] 04:18AM CK(CPK)-94 [**2143-5-3**] 04:18AM CK-MB-2 cTropnT-<0.01 [**2143-5-3**] 04:18AM WBC-10.4 RBC-4.86 HGB-15.8 HCT-46.9 MCV-97 MCH-32.5* MCHC-33.7 RDW-13.5 [**2143-5-3**] 04:18AM PLT COUNT-275 . . Radiologic Data CHEST (PORTABLE AP) [**2143-5-3**] 12:21 PM IMPRESSION: Cardiomegaly and pulmonary edema. Left lower lobe effusion and atelectasis. . CT HEAD W/O CONTRAST [**2143-5-3**] 12:21 PM FINDINGS: There is no effacement of the cerebral sulci with loss of [**Doctor Last Name 352**]-white matter differentiation at the supply territory of the right middle cerebral artery, compatible with an evolving subacute infarct (series 2, image 16). However, no hyperdense foci, or fluid collections can be identified to suggest hemorrhagic transformation, or intracranial hematoma. Again, there is no hydrocephalus, displacement of the normally midline structures, or effacement of the basal cisterns. Review of bone windows demonstrates CT features of prior bilateral mastoidectomy. The remainder of the paranasal sinuses is normally aerated. CONCLUSION: CT features of an evolving subacute infarct involving the right middle cerebral artery supply territory, with no evidence of hemorrhagic transformation at present. . MR HEAD W/O CONTRAST [**2143-5-3**] 10:39 AM FINDINGS: This is a limited study, with only diffusion-weighted images and sagittal T1 images performed. The sagittal T1 series is severely limited by motion artifact, of limited diagnostic value. Diffusion-weighted images demonstrate a wedge-shaped area of slow diffusion confined within the supply territory of the right middle cerebral artery, distal to the lenticular striate arteries. CONCLUSION: Limited study, with only DWI and T1 images performed. MR features of acute infarct confined to the right middle cerebral artery supply territory. . CAROTID SERIES COMPLETE PORT [**2143-5-3**] 3:57 PM FINDINGS: Duplex evaluation was performed of both carotid arteries, somewhat difficult study due to patient. This is a portable study in emergency room with the patient agitated and unstable. On the right, peak systolic velocities are 77, 58, 77 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 100, 31, 147 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 3. This is consistent with less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Somewhat difficult to perform study due to details listed above. There does not appear to be any significant carotid stenosis. Based on velocities, there is less than 40% carotid stenosis bilaterally. If more information is required, a repeat study under better circumstances or an MRI may be warranted. . CT HEAD W/O CONTRAST [**2143-5-3**] 4:23 AM FINDINGS: There is no evidence of hemorrhage, mass effect, shift of the normally midline structures, or infarction. The [**Doctor Last Name 352**]-white matter differentiation appears preserved. Mild periventricular white matter hypodensities are consistent with chronic microvascular ischemia. There is no hydrocephalus. The osseous structures are unremarkable. There is mild mucosal thickening of the left maxillary sinus. IMPRESSION: 1. No evidence of hemorrhage or infarction. MRI with diffusion-weighted images should be performed for further evaluation. . ECG [**2143-5-3**] 4:17:16 AM Atrial fibrillation with a moderate ventricular response. Possible anterior and inferior wall myocardial infarction. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. . ECG [**2143-5-3**] 1:36:42 PM Atrial fibrillation with rapid ventricular response. Premature ventricular contractions or aberrant ventricular conduction. Left axis deviation Intraventricular conduction defect Old inferior infarct Lateral ST-T changes may be due to myocardial ischemia Repolarization changes may be partly due to rhythm Low QRS voltages in limb leads Since previous tracing of [**2143-5-3**], Ventricular rate is increased . CT HEAD W/O CONTRAST [**2143-5-4**] 4:03 AM FINDINGS: There has been interval evolvement of focal sulcal effacement and edema in a right MCA distribution. There are no areas of increased attenuation to suggest hemorrhagic transformation. There is mild mass effect on the right lateral ventricle. There is no hydrocephalus. Osseous windows demonstrate prior bilateral mastoidectomy. The paranasal sinuses are well aerated. IMPRESSION: 1. Evolving right middle cerebral infarct with increased focal effacement and edema. No evidence of hemorrhagic transformation. . CHEST (PORTABLE AP) [**2143-5-6**] 9:18 AM IMPRESSION: 1. Resolving interstitial edema. 2. Increased left retrocardiac opacity, likely due to a combination of atelectasis and effusion, but as aspiration or infectious pneumonia are also possible in the appropriate setting. 3. Carotid artery calcifications. . EEG [**2143-5-6**] IMPRESSION: This is an abnormal routine EEG due to the presence of a slow and disorganized background rhythm over the entire left hemisphere with intermittent delta frequency slowing over the left fronto-temporal regions. Additionally, there is a lack of background of the entire right hemisphere with superimposed fast activity. These findings suggests deep subcortical dysfunction and is consistent with a mild encephalopathy. Intermittent delta frequency slowing over the left temporal region suggests additional subcortical dysfunction in this region. An irregular heartbeat with frequency pauses are seen. . ECHO Study Date of [**2143-5-6**] Conclusions: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal severe hypokinesis of the basal half of the inferior and inferolateral wall. The remaining segments contract well. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets appear structurally normal. No mitral valve prolapse is seen. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD. Moderate mitral regurgitation most likely due to papillary muscle dysfunction. Pulmonary artery systolic hypertension. Based on [**2133**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . CT HEAD W/O CONTRAST [**2143-5-7**] 2:26 PM FINDINGS: There is a continued evolution of large right MCA infarct with further increases in hypodensity of the territorial infarction. There is now marked effacement of the right cerebral sulci with compression of the right lateral ventricle and a small subfalcine herniation that has evolved from [**2143-5-4**]. Slight deformity of the suprasellar cistern is relatively unchanged without significant uncal herniation. IMPRESSION: Continued evolution of large right MCA infarct with increasing edema and mass effect . EEG [**2143-5-7**] IMPRESSION: This record indicates a marked diffuse structural or disruptive process involving the left hemisphere as well as lesser involvement of subcortical and deeper midline structures with an irritative process. In addition, there is a diffuse encephalopathy with some moderate slowing from the right occipute in contrast to the marked left hemispheric slowing. No spike discharges were, however, seen. . CT HEAD W/O CONTRAST [**2143-5-8**] 3:51 PM FINDINGS: Again seen is a large right MCA territory hypodensity consistent with infarct. There has been no significant change in shift of normally midline structures, 5 mm leftward. There has been no significant change in size of previously seen left moderate-sized hypodensity consistent with infarct of the MCA territory. No additional infarcts or hemorrhage are noted. Osseous and soft tissue structures are unchanged. IMPRESSION: No significant interval change in bilateral MCA territory infarcts with no change in mild subfalcine herniation leftward. Brief Hospital Course: 1. Stroke: The pt initially improved in the emergency department in that within 45 minutes after the tPA infusion was started, she began to move the left arm and leg. However, later that day, the pt became diaphoretic, agitated and combative. She went into atrial fibrillation with rapid ventricular rate into the 160's. She vomited and was intubated for airway protection and admitted to the intensive care unit. She was started on a propofol gtt for sedation while intubated, but her SBP transiently dropped into the 70's. She was aggressively bolused with normal saline and started on a neosynephrine gtt to keep her SBP > 140mmHg. It was also noted that the pt's left-sided weakness worsened and repeat head CT demonstrated evolution of stroke in the right MCA territory. She was placed on a heparin gtt as her stroke was felt to represent a cardioembolic event given new-onset atrial fibrillation and/or mural thrombus due to inferior cardiac wall hypokinesis noted on echocardiography. With regard to atrial fibrillation and RVR, the pt was started on beta blockade and was transiently on a diltiazem gtt for rate-control. When sedation was weaned and the pt was extubated, she remained aphasic but also profoundly encephalopathic. EEG was performed and ruled out nonconvulsive status epilepticus (but did demonstrate slowing consistent with encephalopathy). On hospital day five when she was noted to be moving the left side less. A CT of the head was ordered and demonstrated an infarct in the territory of the left MCA. Throughout the remainder of the hospital stay, the pt's neurologic examination was most notable for aphasia, abulia, neglect of left half of environment and left greater than right limb weakness. As above, she was maintained on a heparin gtt and after placement of a PEG tube, she was started on warfarin with the plan for chronic anticoagulation given cardioembolic stroke. She will need to be maintained on a heparin gtt with goal PTT 40-60 until her INR is [**1-18**] on warfarin. 2. History of alcohol use: The pt was placed on thiamine, folate, and a multivitamin. 3. UTI: Early in the course of the hospital stay, the pt was found to have a urinary tract infection with Moraxella. She completed a 7 day course of levofloxacin. 4. Aspiration pneumonia: The pt had low-grade fever early in the hospital course and was found to have a retrocardiac opacity on CXR after intubation. This was thought to represent an aspiration pneumonia. She was completed a 7 day course of levofloxacin and metronidazole. 5. FEN: The pt had a PEG tube placed under endoscopic guidance by the gastroenterology service on hospital day 15. Note was made of an ulcer in the body of the stomach and daily PPI therapy was continued and should be post-discharge. She did have a slight increase in WBC count after placement of the PEG tube, but the gastroenterology service felt that the PEG was functioning fine and there was no evidence of localized infection. The pt should be maintained on tube feeds after discharge. 6. CAD: The pt was continued on ASA 81mg daily, beta blockade and a statin. Medications on Admission: -metoprolol 50mg po bid -quinapril 10mg po qday -lipitor 20mg po daily -ASA 81mg po daily Discharge Medications: 1. Acetaminophen 650 mg Suppository [**Month/Day (3) **]: [**12-17**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Therapeutic Multivitamin Liquid [**Month/Day (2) **]: One (1) Cap PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 9. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). 11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Benzoyl Peroxide 10 % Gel [**Last Name (STitle) **]: One (1) Appl Topical DAILY (Daily) for 7 days: Apply to PEG site daily for one week. Apply one gauze on external bumper. . 13. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 14. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 15. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution [**Last Name (STitle) **]: titrate gtt for PTT 40-60 until INR therapeutic ([**1-18**]) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: -bilateral MCA territory ischemic strokes -atrial fibrillation -hypertension -hyperlipidemia -coronary artery disease -UTI -aspiration pneumonia Discharge Condition: Stable. Neurologic examination on discharge notable for aphasia, abulia, neglect of left half of environment and left greater than right limb weakness in an UMN pattern. Discharge Instructions: Please continue all medications as prescribed. Please attend all follow-up appointments. If the pt experiences fever, worsening neurologic examination, call the pt's PCP or have her brought to the emergency department for evaluation. Followup Instructions: Please call [**Telephone/Fax (1) 35826**] to arrange follow-up with the pt's PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2026**]. Neurology: Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] within the next 4 weeks. The family will have to call to update the pt's demographic information so that the appointment can be made. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "434.11", "401.9", "599.0", "518.81", "V45.81", "428.0", "438.20", "272.4", "427.31", "507.0", "V43.3" ]

icd9cm

[ [ [] ] ]

[ "99.10", "96.04", "96.6", "43.11", "96.71" ]

icd9pcs

[ [ [] ] ]

17480, 17550

12440, 15563

328, 376

17738, 17909

3289, 12417

18191, 18786

1893, 1914

15703, 17457

17571, 17717

15589, 15680

17933, 18168

1929, 3270

277, 290

404, 1575

1597, 1800

1816, 1877

8,895

187,995

49977

Discharge summary

report

Admission Date: [**2133-4-19**] Discharge Date: [**2133-4-23**] Date of Birth: [**2067-12-4**] Sex: F Service: MEDICINE Allergies: Macrodantin / Amoxicillin / Bactrim / Codeine / Demerol / Cephalosporins Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: fever Major Surgical or Invasive Procedure: EGD s/p dilation of Schatzki's ring Bronchoscopy History of Present Illness: 65 y/o F w/NHL s/p nonmyeloablative allo-BMT [**2125**], with recurrence currently getting abd radiation (# 15/17), who presented to the ED on [**4-19**] c/o fevers. For details of pt's presentation, please see [**Hospital Unit Name 153**] admission note. In brief, the pt was evaluated on [**3-23**] for fever and was diagnosed with a CAP for which she was tx'd with levaquin with improvement in sxs. Several days after stopping the abxs, her fevers recurred and was placed on another 10 day course of levaquin. Last Saturday, the pt had sudden onset of fevers, chills, and rigors with fever up 103.4. In the ED, she had a T 101.8, was tachycardic, and was sating 96% on 5L NC. A CXR and CTA were significant for a multi-focal PNA without evidence of PE. . Currently, the pt denies fevers, chills, night sweats, cough, shortness of breath. ROS is also negative for abd pain, n/v/d, headache, stiff neck. The pt does c/o dysphagia with solids that occurs at least once a week. Feels that food "gets stuck" in the middle of her chest. Past Medical History: # NHL: Diagnosed [**12/2121**]. s/p nonmyeloablative peripheral stem cell transplant in [**7-/2126**] with multiple therapies since that time for recurrent disease. Her more recent chemotherapy was with six cycles of oral CEPP chemotherapy completed in 10/[**2129**]. Her last donor lymphocyte infusion was on [**2130-9-19**]. In summer [**2131**] noted increasing uptake in R uterus and adnexal area with vaginal wall mass, biopsy c/w lymphoma. Received 2 weeks of Rituxan [**7-13**], then underwent radiation to area of uptake completed [**8-13**]. F/u PET showed resolution of uterus uptake, but new uptake near inferior IVC so she is s/p 4 weeks Rituxan completed [**2132-12-24**]. # HTN # Hyperlipidemia # GERD # Osteoporosis # Left upper extremity deep vein thrombosis secondary to catheter. # Status post bilateral kidney stents. # History of liver graft versus host disease. Past [**Doctor First Name **] Hx: # Colostomy [**11/2125**] for obstruction [**1-9**] lymphoma, subsequently had colostomy reversed # [**12-11**] had SBO with part of small bowel resected, pathology + for lymphoma Social History: Married, 5 children. Retired finance advisor at [**Hospital3 60734**]. Smoked briefly in her teens, none since them. No regular EtOH use. Family History: 2 sisters with lung cancer, 1 with kidney cancer (all 3 were heavy smokers), brother with DM Physical Exam: T 98.6 BP 114/70 HR 96 RR 20 O2 sat 96% RA Wt 166.4 (75.4 kg) Gen: pleasant female, NAD, speaking in full sentences HEENT: NC, AT, anicteric, clear sclera, clear OP, MMM Neck: no LAD, no JVD, no carotid bruits Lungs: coarse crackles over R middle lung field, decresaed breath sounds b/l with crackles at R base, no egophony CV: RRR, nl s1, s2, no m/r/g Abd: + BS, SNT/ND, no hsm Ext: no edema, no cyanosis, L leg marginally chronically more swollen than R. No rashes Neuro: full ROM of all 4 extremities, CN II-XII intact, [**4-11**] motor strength b/l, nl tone, sensation grossly intact to light touch, gait not tested Pertinent Results: LABS ON ADMISSION: [**2133-4-18**] 09:00PM WBC-4.7# RBC-3.95* HGB-13.2 HCT-39.1 MCV-99* MCH-33.3* MCHC-33.7 RDW-14.9 [**2133-4-18**] 09:00PM NEUTS-93.1* BANDS-0 LYMPHS-3.8* MONOS-2.2 EOS-0.5 BASOS-0.3 [**2133-4-18**] 09:00PM PLT SMR-NORMAL PLT COUNT-163 [**2133-4-18**] 09:00PM ALT(SGPT)-9 AST(SGOT)-15 LD(LDH)-123 ALK PHOS-59 TOT BILI-0.3 [**2133-4-18**] 09:00PM ALBUMIN-3.9 [**2133-4-18**] 09:00PM GLUCOSE-145* UREA N-18 CREAT-0.8 SODIUM-139 POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-23 ANION GAP-16 [**2133-4-18**] 09:21PM LACTATE-2.9* [**2133-4-18**] 10:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2133-4-18**] 10:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2133-4-18**] 10:20PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-[**2-9**] [**2133-4-19**] 05:39PM IgG-102* . IMAGING: CXR [**4-18**] - Since the prior study, there has been development of a vague opacity in the right mid lung. The contour of the cardiac and mediastinal structures is unchanged. Pulmonary vascularity is within normal limits. There are no pleural effusions. Osseous structures again demonstrate mild degenerative changes of the spine. IMPRESSION: New hazy opacity in the right mid lung is concerning for pneumonia. . CTA chest [**4-18**] - The right thyroid lobe is largely replaced by multiple nodules, the largest of which measures 18 x 18 mm, unchanged from [**2130-10-17**]. There are no filling defects within the pulmonary artery, proximal, or distal branches to suggest the presence of a pulmonary embolism. There is no significant mediastinal, axillary, or hilar lymphadenopathy. A subcarinal lymph node measures 7 mm in short axis. The heart, pericardium, and great vessels are normal in appearance. There is no pericardial effusion. There is a tiny left pleural effusion with left lower lobe compressive atelectasis. Scatterd areas of air space consolidation in the posterior right upper lobe, right middle lobe, left lung base and, most prominently, right lower lobe are consistent with multifocal pneumonia. Ground glass opacity in the right middle and anterior right upper lobes support an underlying infectious etiology. Global bronchial wall thickening is unchanged. The airways are patent to the subsegmental level bilaterally. Imaging of the upper abdomen is not sufficient for diagnosis. A small hiatal hernia is again noted. Multiple low attenuation lesions within the liver parenchyma are unchanged since [**2129**] and likely represent simple cysts. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous abnormalities. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Multifocal pneumonia or aspiration. 3. Stable right thyroid nodules. 4. Liver cysts. 5. Small hiatal hernia. . Bronchial wash [**4-20**] - NEGATIVE FOR MALIGNANT CELLS. Numerous neutrophils and macrophages. . Barium swallow study [**4-22**] - 1. Small hiatal hernia, unchanged compared to prior study, with narrowing at the level of gastroesophageal junction with holdup of 13-mm barium tablet. Endoscopy is recommended for further assessment of the stricture at the GE junction. 2. Infiltrate is seen at the left lower lobe. No aspiration was noted at the time of exam. . EGD [**4-23**] - Small hiatal hernia, Schatzki's ring (dilation),Erythema and granularity in the antrum compatible with chronic gastritis. Otherwise normal EGD to second part of the duodenum . CULTURE DATA: CMV VL [**4-19**] not detectable Legionella Ag [**4-19**] - neg Urine Cx [**4-21**] - no growth Bld Cx [**4-21**] - NGTD BAL [**4-20**] - GRAM STAIN (Final [**2133-4-20**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2133-4-22**]): ~8OOO/ML OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2133-4-21**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2133-4-21**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): VIRAL CULTURE (Preliminary): No Virus isolated so far. . LABS ON DISCHARGE: [**2133-4-23**] 06:55AM BLOOD WBC-2.2* RBC-3.34* Hgb-11.4* Hct-32.5* MCV-97 MCH-34.0* MCHC-35.0 RDW-14.0 Plt Ct-182 [**2133-4-23**] 06:55AM BLOOD Plt Ct-182 [**2133-4-23**] 06:55AM BLOOD Glucose-106* UreaN-7 Creat-0.5 Na-142 K-4.2 Cl-109* HCO3-27 AnGap-10 [**2133-4-23**] 06:55AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.4 Brief Hospital Course: 65 y/o F with NHL currently receiving abd radiation to lymph node, p/w persistent fevers despite 2 courses of levofloxacin and found to have multi-focal PNA. . 1) Fevers: Due to multifocal PNA seen on imaging on admission. Given her prior failed treatment courses with levaquin, this was concerning for resistant organisms, atypical or fungal organism, or possible recurrent aspiration. Furthermore, an IVIG level was checked, which was low. Thus, the pt may have been unable to effectively clear the pneumonic process. She was admitted to the [**Hospital Unit Name 153**] intially given concern for hypoxia given her 5L NC oxygen requirement was placed on ceftriaxone and azithromycin. The following day, a blanching maculopapular rash was noted over the torso and upper thighs, which was concerning for a drug rash. Ceftriaxone was discontinued and meropenem started. Sputum cxs were negative for fungus, PCP, [**Name10 (NameIs) **] AFB smear negative. Urine legionella negative. The pt underwent a bronch for BAL that showed 1+ GPC in pairs, GNRs, no fungus, neg. legionella. There was a question of TE fistula on the admission CT scan after further review with the MICU attending, but there no evidence of TE fistula was seen on bronch. A speech and swallow consult was negative for OP aspiration. The pt was weaned off her O2 requirement and transferred to the BMT service for further care. 500 mg/kg of IVIG was given. ID was consulted who recommended treatment with a 14 day course of ertapenem and azithromycin. She was discharged in good condition and will complete the course of azithromycin at home and will come into the 7[**Hospital 1826**] clinic daily to receive an infusion of ertapenem to finish a 14 day course. . 2) Lymphoma: With recurrence of disease. Was scheduled to undergo 2 more session of radiation with Dr. [**Last Name (STitle) 776**] as an outpatient, which the pt completed (cycles 16 and 17 out of 17) as an inpatient. During the hospital course, the pt did not require any blood product transfusions to keep her hct > 25, plts > 10K. She will follow-up with Dr. [**First Name (STitle) **] as an outpatient. . 3) Dysphagia: The pt reported worsening dysphagia over the past year with solids. Had an EGD in [**2130**] that showed a widely patent Schatzki's ring without other abnormalities. GI was consulted who recommended a barium swallow study which showed distal obstruction at the GE junction. She underwent an EGD the following day in which a Schatski's ring was dilated. Findings in the antrum suggestive of chronic gastritis were also seen. She will follow-up with Dr. [**Last Name (STitle) 10689**] as an outpatient. . 4) HTN: HCTZ held on admission and was restarted by the time of discharge. . 5) GERD: PPI continued. . FULL CODE Medications on Admission: boniva 150 mg po q month (every 26th) hydrochlorothiazide 12.5 mg daily vitamin b 12 q month (every 24th) Prilosec 30 mg QD Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*1 bottle* Refills:*0* 2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for Itching. Disp:*30 Capsule(s)* Refills:*0* 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 9 days. Disp:*9 Capsule(s)* Refills:*0* 4. Ertapenem 1 g Recon Soln Sig: One (1) Recon Soln Injection qdaily () for 9 days: You will need to go to the 7Feldberg outpatient clinic for this infusion daily for a total of 9 more days. Disp:*9 Recon Soln(s)* Refills:*0* 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Multi-focal pneumonia Dysphagia s/p dilation of Schatzski's ring . Secondary Diagnosis: recurrent NHL HTN Hyperlipidemia GERD Discharge Condition: Good, ambulating, breathing well on room air, eating well. Discharge Instructions: You were admitted for treatment of a multi-focal pneumonia and were treated with antibiotics. You will need to continue a 14 day course of antibiotics while you are at home and will come into the 7 [**Hospital Ward Name 1826**] outpatient clinic daily to receive an IV antibiotic infusion. You also had an EGD to evaluate difficulty swallowing and had a dilation of your lower esophagus, where a stricture was found. Please take all medications as prescribed. You will need to take an antibiotic called Azithromycin every day and will need to come into clinic daily to receive an IV antibiotic called Ertapenem. Call your doctor or go to the emergency room if you experience any of the following: fever > 101, chills, night sweats, shortness of breath, increasing cough, chest pain, diarrhea. Followup Instructions: Please follow-up with your primary care doctor within 1 week. Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks time. Call ([**Telephone/Fax (1) 12625**] to make an appointment. Please follow-up with your gastroenterologist, Dr. [**Last Name (STitle) 10689**], in 1 month. Call (617) ([**Telephone/Fax (1) 8622**] to make an appointment. Completed by:[**2133-4-24**]

[ "V42.82", "272.4", "202.83", "530.3", "V13.01", "530.81", "401.9", "787.2", "782.1", "486", "458.9", "V12.51", "733.00" ]

icd9cm

[ [ [] ] ]

[ "45.13", "42.92", "92.29", "33.22" ]

icd9pcs

[ [ [] ] ]

12039, 12045

8280, 11054

347, 398

12234, 12295

3507, 3512

13139, 13524

2753, 2847

11228, 12016

12066, 12066

11080, 11205

12319, 13116

2862, 3488

7707, 7829

7861, 7921

302, 309

7941, 8257

426, 1462

12173, 12213

12085, 12152

3527, 7674

1484, 2582

2598, 2737

30,417

130,724

32670

Discharge summary

report

Unit No: [**Numeric Identifier 76125**] Admission Date: [**2152-12-12**] Discharge Date: [**2153-4-2**] Date of Birth: [**2152-12-12**] Sex: F Service: NB HISTORY: This infant was born at 24 and 5/7 weeks gestation to a 27-year-old G1, P0, now 1 mother with prenatal screen. Mom's prenatal screen was blood type A negative, antibody negative, GBS unknown, HBsAg negative, RPR nonreactive. Past medical history for the mother was remarkable for asthma which was treated with albuterol. Mother was diagnosed with cervical incompetence during this pregnancy. She presented to [**Hospital 1474**] Hospital with vaginal bleeding on [**2152-12-7**] and found to be in preterm labor with cervical dilatation. She was transferred to [**Hospital1 18**] at that time and given betamethasone. She was treated with magnesium sulfate for the preterm labor and her dilatation progressed and a decision was made to proceed to vaginal delivery at that time. Mother received intrapartum antibiotics for unknown GBS status while she was in labor. Rupture of membranes occurred at delivery. There was no maternal fever. The infant was born by normal vaginal delivery with Apgar's of 4, 7 and 8 at 1, 5 and 10 minutes. The infant was intubated in the delivery room after positive pressure ventilation was given with bag and mask and then transported to the NICU without incident. Measures at birth was a weight of 765 grams, length of 31 cm and head circumference of 23 cm. PHYSICAL EXAM AT DISCHARGE: Discharge weight of 3725 grams. A head circumference of 35.5 cm. Length of 48.5 cm. Active and alert, well-appearing female infant on nasal cannula oxygen. HEENT: Anterior fontanelle soft and flat. Sutures approximated. Intact palate. Normal red reflexes bilaterally. Neck: Supple. Normal facies. Breath sounds clear and equal to auscultation with comfortable respiratory effort. Cardiovascular: Normal rate and rhythm with no murmur, normal pulses, pink and well-perfused. GI: Abdomen soft and round with active bowel sounds. No palpable masses. GU: Normal female genitalia with mild edema. Musculoskeletal: Good tone. Straight spine, intact hips, moves all extremities well. Neuro: Normal reflexes, tracks and follows. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory - Infant had respiratory distress syndrome on admission to the NICU and received 2 doses of surfactant therapy on the newborn day. The infant was started on caffeine citrate on day 4 of life and extubated to CPAP also later that day. The infant was then reintubated on day of life 12 for worsening respiratory distress. She had a presumed pneumonia on [**2153-1-7**] which is day of life 26 due to x-ray findings and was treated with antibiotics at that time. On [**2153-1-17**], she was started on diuretic therapy of Lasix 3 times a week for chronic lung disease. She was also started on a 7 day course of dexamethasone on [**2153-1-23**] for chronic lung disease in the hope of extubation. She did extubate to CPAP on [**2153-1-24**] which is day of life 43. Her caffeine citrate was discontinued on [**2153-1-31**] due to tachycardia at that time. She transitioned from CPAP to nasal cannula on [**2153-2-28**]. Initially she was on high flow nasal cannula and weaned over time to the present nasal cannula setting of 250 mL/min flow of 100% FiO2 oxygen. She continues on Lasix therapy with supplemental KCL replacement. She was without any apnea of prematurity or desaturations > 5 days prior to discharge. Her last arterial blood gas was on [**3-19**] which revealed: pH 7.41; PaCO2 53; PaO2 95; Base Excess 6. 2. Cardiovascular - She had hypotension on admission to the NICU and received 2 normal saline boluses and also was started on dopamine. She received dopamine at 5 mcg/kg/min for 2 days and since that time has not had problems with her blood pressure. She has had 3 echocardiograms. Initial echocardiogram was done on [**2152-12-15**] which showed no PDA, but noted was a right coronary artery that came off leftward and higher than usual, but from the right sinus and the left coronary artery was not seen well. Follow-up echocardiogram was done on [**2152-12-22**] which showed again no PDA, but there is a comment on echocardiogram that there was a prominent venous structure bringing blood towards the left side of the innominate vein and there were 2 left sided pulmonary veins going to the left atrium. An echocardiogram done on [**2153-3-15**], was found to be within normal limits and there was no comment regarding abnormal venous and coronary structures, but cardiology does recommend follow up after discharge at 1 month of age at [**Hospital1 **] Cardiac Clinic. At that time, a repeat echocardiogram is recommended. At the present time of discharge, the infant is hemodynamically stable with no murmur and normal blood pressures, heart rate, and pulses. 3. Fluids, electrolytes and nutrition - The infant was made n.p.o. on admission to the NICU and IV fluids were via umbilical arterial and venous catheters. The infant had significant electrolyte instability within the first few days of life which required total fluid to a maximum of 280 mL/kg/day. The infant also developed hyperglycemia and was treated with an insulin drip for the first couple of days. The electrolytes were unstable initially and slowly stabilized over the first few days of life. The UAC was discontinued on day of life 5, [**2152-12-17**]. The UVC was discontinued on [**2152-12-18**] at which time a noncentral PICC line was placed for PN enteral lipid therapy. Enteral feedings were initiated on [**2152-12-18**] and slowly advanced. The infant achieved full enteral feedings by [**2152-12-28**] which is day of life 16. PICC line was discontinued on [**2152-12-29**]. Calories were further concentrated to a maximum caloric density of 32 cal/ounce feedings of breast milk or premature Enfamil formula. She has been growing well and her calories have subsequently been decreased. She is presently at discharge ad lib p.o. feeding of Enfamil 26 cal/ounce and taking approximate 150 mL/kg/day. She is voiding and stooling normally and she has showed steady weight gain. Her most recent set of electrolytes on [**4-2**] were Na 137; K 5.1; Cl 100; tCO2 35. At the time of discharge she is on potassium chloride supplementation due to chronic Lasix therapy. 4. Gastrointestinal - She was treated for hyperbilirubinemia for a total of 6 days and had a peak bilirubin level of 3.4/0.4. She has had no other GI issues. 5. Hematology - Her blood type is A positive, DAT negative. She had an initial hematocrit at birth of 48 with a platelet count of 340,000. She has received numerous red blood cell transfusions with the most recent transfusion being on [**2153-2-28**], for a hematocrit of 23 at that time. Her most recent hematocrit was 28 with a retic count of 2.5 and that was done on [**2153-3-19**]. She was started on supplemental iron on [**2153-1-1**] and she remains on iron at the time of discharge for anemia of prematurity. 6. Infectious Diseases - A CBC and blood culture were screened on admission due to preterm labor and prematurity. The CBC at that time was not left shifted, but the infant did receive 7 days of ampicillin and gentamicin for presumed chorioamnionitis and preterm labor. Blood cultures were negative at that time. No lumbar puncture was done at that time. She had a CBC and blood culture screened due to spells and reintubation on [**2152-12-24**]. At that time the blood culture was again negative. No antibiotics were given at that time. On [**2153-1-7**], a CBC and blood culture was screened due to worsening respiratory status and a chest x-ray consistent with patchy infiltrates. The CBC was benign at that time, but she was treated with 7 days for presumed pneumonia. A viral tracheal aspirate culture and rapid viral cultures were done on her sputum and both were found to be negative. No lumbar puncture was done during that time. She has been screened for sepsis 2 other times most recently being [**2153-1-31**] with benign CBCs and no antibiotics given. She did develop a monilial rash on her neck and was treated with 5 days of Miconazole cream to her neck from [**2153-3-7**] to [**2153-3-11**]. 7. Neurology. She has had head ultrasounds done on [**2152-12-15**], [**2152-12-20**], [**2153-1-10**] and [**2153-3-15**], all within normal limits. She has had no neurologic issues. 8. Audiology. A hearing screen was performed with automated auditory brainstem responses and she passed in both ears on [**2153-3-24**]. 9. Ophthalmology. She has had numerous ophthalmologic exams for retinopathy of prematurity and her most recent exam was done on [**2153-3-27**] which showed immature retina, stage 3 with recommended follow up in 3 weeks. 10.Endocrine. Numerous state screens have been done. The initial state screen was done on [**2152-12-14**] which showed an elevated 17OH at that time. Follow up state screen was done on [**2152-12-26**], which showed a normal 17-OH level but a low thyroxine level. Repeat state screen was done on [**2153-1-6**] which also showed a low thyroxine level. Endocrinology at [**Hospital3 1810**] was consulted on [**2153-1-6**]. On [**2153-1-23**], the state screen came back as normal and on [**2153-2-20**] the state screen was also within normal limits. The thyroid level pattern and spontaneous resolution is consistent with Transient Hypothyroxinemia of Prematurity. There are no further issues at this time. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7662**], MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) 1474**] Pediatrics. Telephone number [**Telephone/Fax (1) 43014**]. CARE RECOMMENDATIONS: Ad lib p.o. feedings of Enfamil 26 cal/ounce. MEDICATIONS: 1. Ferrous Sulfate (concentration 25mg/mL) 0.6 mL PO daily 2. KCL 1.5 meq po BID. 3. Lasix 7 mg PO Mon, Weds, Fri 4. Iron and vitamin D supplementation. a. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. b. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as multiple vitamin preparation daily until 12 months corrected age. 5. The infant was screened in a car seat in an upright position and the infant passed the car seat screening test. 6. State newborn screens as previously mentioned. 7. Immunizations received. The infant has received numerous immunizations. She received the hepatitis B vaccine on [**2153-1-18**]. She received Pediarix on [**2153-2-19**], HIB on [**2153-2-19**]. On [**2153-2-20**], the pneumococcal vaccine. On [**2153-3-24**], Synagis. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any of the following full criteria: 1. Born less than 32 weeks gestation. 2. Born between 32 and 35 weeks with 2 of the following - either daycare during RSV season, smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart defect. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not received the Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOW UP APPOINTMENTS RECOMMENDED: 1. Pediatrician within two days of discharge. 2. Early intervention referral has been made with [**Location (un) 14221**] Early Intervention Program, telephone number [**Telephone/Fax (1) 76126**]. Initial contact was made on [**2153-3-22**]. 3. Visiting nurse referral was made with Centrus Home Care, telephone number 1-[**Telephone/Fax (1) 45165**] and they were contact[**Name (NI) **] on [**2153-3-22**]. 4. Follow up with ophthalmologist, Dr. [**Last Name (STitle) 36137**] at [**Hospital3 1810**], telephone number [**Telephone/Fax (1) 43283**]. 5. Follow up with pediatric pulmonology, Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], at [**Hospital3 1810**]. 6. Referral made to Infant Follow Up Program at [**Hospital1 18**] with the criteria for the infant being born less than 28 weeks gestation. DISCHARGE DIAGNOSES: 1. Prematurity, extremely low birth weight infant. 2. Respiratory distress syndrome, resolved. 3. Chronic lung disease. 4. Apnea of prematurity, resolved. 5. Presumed pneumonia, treated. 6. Hypotension, resolved. 7. Questionable abnormal coronary vessels seen with echocardiograms. 8. Presumed sepsis, treated. 9. Hyperbilirubinemia, resolved. 10.Anemia of prematurity. 11.Retinopathy of prematurity. 12.Transient Hypothyroxinemia of prematurity, resolved. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Name8 (MD) 75423**] MEDQUIST36 D: [**2153-3-25**] 19:45:23 T: [**2153-3-25**] 21:40:07 Job#: [**Job Number 76127**]

[ "743.65", "458.8", "V05.3", "774.2", "762.7", "V30.00", "794.5", "746.85", "771.81", "790.29", "770.7", "276.2", "486", "782.1", "765.22", "776.6", "779.89", "276.0", "769", "765.03", "362.21", "775.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "99.55", "93.90", "96.04", "38.92", "31.42", "99.83", "99.15", "03.31", "38.93" ]

icd9pcs

[ [ [] ] ]

10039, 10296

13326, 14024

10319, 11359

2260, 9993

10008, 10015

11387, 13305

21,138

114,060

8896

Discharge summary

report

Admission Date: [**2195-4-29**] Discharge Date: [**2195-5-14**] Date of Birth: [**2117-1-19**] Sex: M Service: MEDICINE Allergies: Penicillins / Ancef / Prilosec / Procainamide / Vancomycin Attending:[**First Name3 (LF) 4309**] Chief Complaint: Cough and dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 78 year-old male with history of COPD with 3L baseline oxygen requirement, bioprostetic mitral valve replacement, coronary artery disease status post CABG, left ventricular psuedoaneurysm, left carotid stent, who was admitted for worsening dyspnea and productive cough. At baseline, his activities are limited by dyspnea. He does not climb stairs in home and has stair chair. He requires assistance with his ADLs. Over the past few months, he has had worsening dyspnea on exertion to the point of becoming dyspneic after about 20 steps. Over the past week, he describes not feeling well with subjective weakness. The morning of admission, he developed a productive cough. He denies fevers and chills. He has been intermittently compliant with his home lasix regimen. He states that he has to urinate about 20-25 times a day and has missed several doses last week. He stopped taking his lasix 3 days prior to admission. Review of systems is negative for chest pain, palpitations, light-headedness, nausea, or vomiting. Past Medical History: 1. Coronary artery disease status post myocardial infarction and 4 vessel coronary bypass in [**State 108**] in [**2189**]. 2. Large ventricular pseudoaneurysm with thrombus diagnosed by transesophageal echocardiogram in [**2193**] 3. Mitral valve replacement with porcine bioprosthetic valve in [**2189**] 4. History of Paroxysmal Atrial fibrillation. 5. Chronic obstructive pulmonary disease on 3 liters of home oxygen with baseline carbon dioxide in the 48 to 52 range. Pulmonary function tests in [**11/2189**] revealed an FVC of 1.84 (41 percent), FEV1 0.94 (32 percent), FEV/FVC 51 (77%) 6. Peripheral vascular disease. 7. Bilateral carotid stenosis status post left carotid stent in 8/[**2192**]. 8. History of large gastrointestinal bleed in [**4-/2191**] while on [**Year (4 digits) 4532**]. 9. Pulmonary hypertension. 10. Chronic renal insufficiency with a baseline creatinine of 1.3 to 1.5. 11. Anemia 12. Skin cancers 13. Status post cholecystectomy. Social History: The patient was widowed in [**2194**]. He now lives with one of his three daughters. [**Name (NI) **] has a remote 40 pack year smoking history. He doesn't drink alcohol. He is a retired firefighter with possible past asbestos exposure. Family History: Non-contributory Physical Exam: Vitals: Temperature:98.1 Pulse:73 Blood Pressure:132/58 Respiratory Rate:18 Oxygen Saturation:94% on 4L nasal canula General: Comfortable in no acute distress HEENT: Pupils equal and reactive, extraoccular movements intact, oropharynx clear, moist mucous membranes Cardiac: Regular rate and rhythm with normal s1 s2 with 3/6 systolic murmur Pulmonary: Poor air movement with coarse breath sounds throughout, no wheezes Abdomen: Normoactive bowel sounds, soft, nontender, nondistended Extremities: 2+ bilateral pitting edema Neuro: Grossly non-focal Pertinent Results: Hematology: WBC-5.7 HGB-8.5 HCT-28.0 PLT COUNT-118 . Chemistries: SODIUM-143 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-30 UREA N-41 CREAT-1.6 GLUCOSE-106 CALCIUM-9.1 PHOSPHATE-2.9 MAGNESIUM-2.2 . Liver Function Tests: ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-74 TOT BILI-0.5 ALBUMIN-4.0 . Lipid Panel: CHOLEST-95 TRIGLYCER-62 HDL CHOL-45 CHOL/HDL-2.1 LDL(CALC)-38 . TSH-3.1 %HbA1c-6.5 . Imaging: 1. Chest x-ray: Mild pulmonary edema, bibasilar atelectasis. Brief Hospital Course: 1) Dyspnea / hypoxia - The etiology of patient's dyspnea and hypoxia was thought to be multifactorial. The patient has known severe COPD, necessitating chronic home supplemental oxygen therapy. Given his one week history of malaise and weakness, along with his new productive cough, there was likely an element of an acute COPD exacerbation. However, the patient's family had also reported a history of noncompliance with his diuretics, and he appeared grossly volume overloaded on exam at admission. He was started on high dose intravenous steroids, nebulizer treatments, and a course of antibiotics for a COPD exacerbation. He was also agressively diuresed with IV lasix a CHF flare. He improved dramatic with these interventions, and was symptomatically back to baseline by hospital day 5. His oxygen requirement also improved to his baseline of 3L by nasal canula. Despite this improvement, however, the patient continued to have transient hypoxic episodes to the 70s but recovered quickly with supplemental oxygen therapy via facemask. These episodes were thought to be secondary to mucous plugging. Given the increased frequency of his hypoxic episodes with increased work of breathing, he was transfered to the intensive care unit for further monitoring. He did not require intubation. An echocardiogram showed severe pulmonary hypertension. Given the severity and irreverisble nature of his disease, the family decided to make him DNR/DNI with the goal of [**Name (NI) **] care. His respiratory status was supported with nebulizer treatments and supplemental oxygen. . 2) Cardiac - He has a substantial coronary artery disease history including a 4 vessle CABG. He ruled out for MI by serial enzymes on admission. He was continued on an aspirin and statin. A repeat transthoracic echocardiogram showed hypokinesis of the right ventrible with a PA pressure of ~100. . 3) Atrial Fibrillation: During the later part of his admission, he had several episodes of atrial fibrillation with rapid ventricular rate. At baseline, he was rate controlled with digoxin. However, he required diltazam to control his rate. At the end of the admission, his rate was unable to be controlled without dropping his pressure. . 4) ?Endocarditis - An incidental finding on his echocardiogram showed that his prosthetic mitral valve had a small echodensity on it consistent with endocarditis verse a fibrinous cord. He remained afebrile while he was monitored with serial blood cultures. One set came back positive for MRSA, and he was started on daptomycin. At that time, his white count began to rise to 30. Another blood culture while on antibiotics also grew out MRSA. At that point, the patient's condition began to deteriorate. The family decided to take him home with [**Name (NI) **] so the antibiotics were discontinued. . 5) Renal insufficiency - He has known chronic renal insufficiency with a baseline creatinine between 1.5-1.6. He had some worsened renal failure with intravenous lasix administration. This improved when his diuresis was halted and he has remained relatively euvolemic without supplemental lasix. . 6) Anemia - He has known chronic anemia secondary to blood loss. On previous upper and lower endoscopies, he has been noted to have angiectasias, diverticuli, and internal hemorrhoids. His iron studies on a previous admission in [**2195-2-8**] showed a normal serum iron. His hematocrit since that time has been stable 25-28. His hematocrit remained stable. Anticoagulation for his hypokinesis was considered but deferred after discussion with his PCP who felt that his bleeding risk outweighed any benefit from anticoagulaion. . 7) Thrombocytopenia - HE has chronic thrombocytopenia of unclear etiology. Electronic allergy records list an allergyy to Prilosec as causing thrombocytopenia. However, review of discharge summaries from the time when the allergy was recorded revealed that the culprit was thought to be more likely linezolid. The patient had tolerated Nexium at that time, and had been taking it as an outpatient prior to this admission. A DIC panel and HIT antibody during this hospitalization were negative. His platelet count has remained relatively stable around 100. . 8) Hyperglycemia - He carries a diagnosis of postprandial hyperglycemia. A recent Hb a1c on [**2195-4-28**] was 6.5. His blood sugars were monitored while on steroids, and he was covered with a humalog insulin sliding scale. Towards the end of his admission, his sugars became more uncontrolled despite a steroid taper. This was attributed to a worsenin infection, likely MRSA endocarditis. . 9) Agitation - During times of hypoxia, the patient would become agitated and confused. These episodes corrected with oxygen. Once the family decided on [**Date Range **] level care, his agitation was controlled with small amounts of zyprexa. . 10) Prophylaxis - He received a PPI for GI prophylaxis, and a bowel regimen while hospitalized. Pneumoboots were used in lieu of SQ heparin given his thrombocytopenia. . 11) Code - He was confirmed a full code on admission, but his code status was changed to DNR/DNI after discussion a family meeting outlining his overall prognosis. Numerous additional family meetings with the medical team, palliative care team, and social work were held to discuss goals of care. As the patient's condition worsened with increased hypoxia, increased atrial fibrillation with rapid ventricular rate, and MRSA positive blood cultures on antibiotics, the family decided to pursue full [**Date Range **] care. Given his wishes to go home and the families desire to not have him die in the hospital, he was transfered home with [**Date Range **]. Medications on Admission: ADVAIR DISKUS 250/50 1 spray [**Hospital1 **] ALDACTONE 25 mg QD Multivitamin 1 tablet QD ASPIRIN 81 mg QD DIGOXIN 125 mcg QD LASIX 20 mg QD NEXIUM 40 mg QD VITAMIN C 500 mg [**Hospital1 **] ZOCOR 40 mg QD TYLENOL PRN Discharge Medications: Morphine concentrate Ativan Nebulizer treatments Supplemental oxygen Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Congestive heart failure Chronic obstructive pulmonary disease Atrial fibrillation Anemia Thrombocytopenia Hyperglycemia Discharge Condition: His oxygenation decline and his family opted to take him home with [**Location (un) **] so that he could die at home. Discharge Instructions: Continue to use nebulizer treatments, morphine, ativan, and oxygen for comfort. Call you primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] nurses as needed. Followup Instructions: NA Completed by:[**2195-5-14**]

[ "E930.8", "433.10", "585.9", "V45.81", "428.0", "421.0", "491.21", "280.0", "V42.2", "427.31", "416.8", "287.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9817, 9868

3748, 9455

337, 344

10033, 10153

3278, 3725

10382, 10416

2674, 2692

9724, 9794

9889, 10012

9481, 9701

10177, 10359

2707, 3259

280, 299

372, 1414

1436, 2401

2417, 2658

82,655

195,706

34302+57913

Discharge summary

report+addendum

Admission Date: [**2192-7-31**] Discharge Date: [**2192-8-4**] Date of Birth: [**2121-12-29**] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Sulfamethoxazole / Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Progressive SOB Major Surgical or Invasive Procedure: [**2192-7-31**] AVR(19mm St. [**Male First Name (un) 923**] Epic Supra Porcine) History of Present Illness: This 70WF has a h/o aortic stenosis and has been experiencing progressive SOB. She had an echo which revealed [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.6cm with a peak gradient of 116 mmHg. She underwent cardiac cath which revealed clean coronary arteries. She is now admitted for elective AVR. Past Medical History: Aortic stenosis CREST/Raynaud's/scleroderma PUD, s/p UGIB esophageal strictures, s/p multiple dilations Dyslipidemia s/p excision of facial melanoma s/p hiatal hernia repair s/p TAH Social History: Retired Activities Director. Denies tobacco and ETOH. Currently lives with her daughter and son-in-law. Family History: No family history of premature valvular or coronary artery disease. Physical Exam: Preop Exam: Vitals: 90/48, 78, 18 Elderly female in no acute distress Significant erythema and swelling of hands Oropharynx benign, upper and lower dentures noted Neck supple, no JVD. Transmitted murmurs noted over carotid region. Lungs clear bilaterally Heart regular rate and rhythm, 3/6 systolic ejection murmur noted Abdomen soft, nontender, nondistended with normoactive bowel sounds Extremities warm, no edema Alert and oriented, CN 2-12 grossly intact, no focal deficits noted Distal pulses 2+ Pertinent Results: [**2192-7-31**] 01:49PM BLOOD WBC-14.6*# RBC-2.52*# Hgb-7.5*# Hct-22.2*# MCV-88 MCH-29.8 MCHC-33.9 RDW-13.7 Plt Ct-131* [**2192-8-2**] 05:35AM BLOOD WBC-16.1* RBC-3.61* Hgb-10.7* Hct-32.5* MCV-90 MCH-29.8 MCHC-33.0 RDW-13.8 Plt Ct-101* [**2192-7-31**] 01:49PM BLOOD PT-16.6* PTT-68.5* INR(PT)-1.5* [**2192-8-1**] 02:42AM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-136 K-4.7 Cl-109* HCO3-23 AnGap-9 [**2192-8-2**] 05:35AM BLOOD Glucose-122* UreaN-10 Creat-0.7 Na-134 K-4.0 Cl-100 HCO3-23 AnGap-15 [**2192-8-1**] 01:42AM BLOOD Type-ART pO2-93 pCO2-35 pH-7.38 calTCO2-22 Base XS--3 Brief Hospital Course: Mrs. [**Known lastname **] was admitted and underwent aortic valve replacement by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and transferred to the SDU on postoperative day one. She went on to experience paroxsymal atrial fibrillation which was initially treated with Amiodarone and beta blockade. She converted back to a normal sinus rhythm on POD 2 and remained in normal sinus rhythm throughout the hospital course. The patient made good progress with physical therapy and was discharged in good condition to home on POD 4. Medications on Admission: Lipitor 20 qd, Trental 400 qd, Verapamil 120 qd, Iron 325 qd, Prilosec 20 [**Hospital1 **], HCTZ 25 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*30 * Refills:*0* 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). Disp:*qs 1 month Disk with Device(s)* Refills:*0* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs 1 month * Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*1* 8. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). Disp:*90 Tablet Sustained Release(s)* Refills:*0* 9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: 400 [**Hospital1 **] x 5 days, then 200 [**Hospital1 **] x 7days then 200 daily x 7 days. Disp:*41 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 12. Prilosec OTC Oral 13. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for nausea. Disp:*10 Tablet(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic Stenosis - s/p AVR Postoperative Atrial Fibrillation Chronic Diastolic Congestive Heart Failure CREST/scleroderma/Raynaud's PUD, s/p UGI bleed ^chol. esophageal strictures, s/p multiple dilations s/p excision of facial melanoma s/p hiatal repair s/p TAH Discharge Condition: Good. Discharge Instructions: Take all medications as prescribed. Do not drive for 6 weeks. Do not lift more than 10 lbs. for 6 weeks Keep wound clean and dry. OK to shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office with sternal drainage, temp>101.5 Followup Instructions: [**Hospital 409**] clinic in 2 weeks Make an appointment with Dr. [**Last Name (STitle) 8446**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1016**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2192-8-4**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 12713**] Admission Date: [**2192-7-31**] Discharge Date: [**2192-8-4**] Date of Birth: [**2121-12-29**] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Sulfamethoxazole / Codeine Attending:[**First Name3 (LF) 741**] Addendum: Mrs. [**Known lastname **] was discharged to home, not to ECF. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2192-8-4**]

[ "710.1", "997.1", "443.0", "E878.1", "427.31", "428.32", "533.90", "424.1", "272.4", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

6666, 6846

2295, 3078

319, 400

5573, 5581

1695, 2272

5929, 6643

1090, 1159

3231, 5187

5289, 5552

3104, 3208

5605, 5906

1174, 1676

264, 281

428, 748

770, 953

969, 1074

945

148,525

4407

Discharge summary

report

Admission Date: [**2157-2-23**] Discharge Date: [**2157-2-24**] Date of Birth: [**2095-5-7**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Percocet / Dilantin Attending:[**First Name3 (LF) 1835**] Chief Complaint: New right occipital lesion on MRI Major Surgical or Invasive Procedure: Right occipital steriotactic biopsy. History of Present Illness: [**Known firstname **] [**Known lastname 5239**] is a 61 year-old right-handed woman with a multifocal left temporal glioblastoma multiforme. She is here with her husband, brother and son after a head MRI. Her walking is now normal without any imbalance and she no longer is using the cane. Her Decadron had been lowered one month ago but she developed severe headaches so this was increased back up to the 2 mg daily. The headaches are less intense but occur most often on awakening in the left fronto-parietal region but are not daily. She still gets floaters in the left eye and feels that her vision is "off" at times. There is tingling of the right 4th and 5th digits. Her neurologic history began on [**2156-6-30**] with word finding difficulty, memory loss, confusion and holocranial dull headache. She came to our emergency room and a head MRI revealed a left temporal mass. Only 80% of the tumor could safely be resected. Pathology revealed glioblastoma. This was followed by involved-field radiation with Temodar 75 mg/m2. Cyberknife radiation was given to the right occipital nodule on [**2156-9-10**]. MRI on the [**2157-2-4**] showed right occipital enhancing lesion, therefore Dr [**Last Name (STitle) **] decided to do steriotactic brain bx to differenciate tumor growth versus radiation necrosis. Past Medical History: 1. Subtotal resection on [**2156-7-2**] by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD 2. Involved-field cranial irradiation + Temodar ([**Date range (1) 18951**]) to 6000 cGy 3. Cyberknife radiation to right occipital lesion on [**2156-9-10**] 4. Hospitalized [**Date range (1) 18952**]/05 for fever, neutropenia and left elbow abscess 5. Monthly Temodar started [**2156-10-18**] 6.Glioblastoma multiforme of left temporoparietal lobe [**6-/2156**] 7.Anxiety Social History: Never smoked, drinks alcohol on rare occasions. Lives with husband. Worked as secretary. Family History: Father had lung cancer. Mother had [**Name (NI) 2481**] disease. Her siblings are all healthy. She has 1 son and 1 daughter, and both of them are healthy. Physical Exam: VS: 97.5 HR:95 RR:16 BP:141/83 O2sat:97 RA GEN: Alert, awake, NAD CVS: RRR, normal S1 S2. ABD: soft, nt, nd, bowel sounds presernt. EXTR: No c/c/e. SKIN:Intact. NEURO: She is alert and oriented to time, person, and place. Language is clear and fluent with good comprehension. Pupils are 4 mm and equally reactive. Visual fields and EOM's are full without nystagmus. Hearing is intact to finger rub. Face is symmetric and sensation is intact. Tongue is midline. Palate rises symmetrically. Shoulder shrug is strong. There is no drift. Strength is [**4-15**]. Sensation is intact to light touch. Reflexes are 2- in the upper extremities and 2+ in the lower. Romberg is negative. Unable to tandem. Gait is normal based and steady. Pertinent Results: MR HEAD W & W/O CONTRAST [**2157-2-23**] 6:51 AM MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN Reason: ASL/Wand protocol for stereotactic brain biopsy [**2157-2-23**]. Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 61 year old woman with glioblastoma. REASON FOR THIS EXAMINATION: ASL/Wand protocol for stereotactic brain biopsy [**2157-2-23**]. INDICATION: Glioblastoma. WAND protocol for stereotactic brain biopsy. TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained, with diffusion-weighted images. Post-contrast T1-weighted images were also obtained. FINDINGS: Again demonstrated are multiple areas of abnormal enhancement within the brain, unchanged. The right medial inferior parietal lobe rounded enhancing lesion and the lesion of the left posterior corpus callosum are unchanged in size and appearance. Associated increased T2 signal associated with these lesions is unchanged as well. The left temporal lobe tumor resection site is unaltered, with blood products and mild irregular enhancement. No new sites of abnormal enhancement are detected. IMPRESSION: No significant change compared to the [**2-4**] exam. Brief Hospital Course: [**Known firstname **] [**Known lastname 5239**], is a 61 year old woman who brought in electively in [**2157-2-23**] who underwent Right occipital stereotactic biopsy under MAC. She had preoperative a MRI WAND protocol study. Patient tolerated procedure well, no intraoperative complications occurred, with minimal blood loss. Patient transferred to PACU for close monitoring after 6 hours of stay in [**Hospital 13042**] transferred to floor. Her neurologic exam is same as preoperative state, she still has word finding difficulty, full strength. She has been ambulating, tolerating her diet without difficulty, voiding freely. Her headache has been under good control. She has been afebrile and vital signs has been stable throughout her hospital stay. She discharged home with follow up discharge instructions. Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) 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. Decadron 4 mg Tablet Sig: 1/2 tablets(2mg) Tablet PO once a day: discuss further continuation at the follow up with Dr [**Last Name (STitle) 724**]. Disp:*14 Tablet(s)* Refills:*0* 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Discharge Disposition: Home Discharge Diagnosis: Right occipital lesion Discharge Condition: Neurologically stable. Discharge Instructions: Keep your inscion site dry and clean. Do not wet until sture removed.Monitor for redness, swelling, or drainage. Report fever greater than 101.5, chills or any other neurologic symptoms that may be concerning. Followup Instructions: Follow up in Brain [**Hospital 341**] Clinic([**Telephone/Fax (1) 1844**]) on [**2157-3-14**] at 1pm. Sture will be removed at the time of follow up. Completed by:[**2157-2-24**]

[ "E849.8", "349.89", "E879.2", "191.2", "300.00" ]

icd9cm

[ [ [] ] ]

[ "01.13" ]

icd9pcs

[ [ [] ] ]

5766, 5772

4455, 5274

340, 379

5839, 5864

3266, 3458

6122, 6303

2340, 2500

5297, 5743

3495, 3532

5793, 5818

5888, 6099

2515, 3247

267, 302

3561, 4432

407, 1721

1743, 2217

2233, 2324

14,230

172,385

28249+57584

Discharge summary

report+addendum

Admission Date: [**2155-12-12**] Discharge Date: [**2155-12-27**] Date of Birth: [**2096-3-28**] Sex: F Service: CARDIOTHORACIC Allergies: Amiodarone / Oxycodone Hcl/Acetaminophen / Lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: Known CAD, abnormal stress test-referred for cardaic catheterization which showed native 3VD w/occlude svg-OM and LAD. Patent Lima-Diag. Then referred to cardiac surgery Major Surgical or Invasive Procedure: Redo sternotomy/MVR-[**First Name3 (LF) **]/CABGx3/Lft CEA [**12-16**] Cardiac catheterization [**12-12**] History of Present Illness: Ms. [**Known lastname 68603**] is a very nice 59 year-old woman with prior MI, CABG+MVrepair [**2152**], CHF with EF 38% history of lung cancer, s/p RULobectomy [**2152**] who had an abnormal outpatient stress test for recurrent angina and occasional rest chest pain. Cardaic catheterization which showed native 3VD w/occlude svg-OM and LAD. Patent Lima-Diag. Then referred for CABG. Past Medical History: Lung cancer s/p RUL lobectomy [**12-6**] CHF Mitral regurgitation LV thrombus NSTEMI Hypertension Hyperlipidemia Prior tobacco use: 2ppd x 40 years s/p mechanical fall 6 weeks ago with compression fracture in back and injury to left heel- wearing support boot. Atrial fibrillation post operatively Social History: Social history is significant for the absence of current tobacco use. She quit 3 years ago and has history of 80 pack-year. There is no history of alcohol abuse, but has 1 drink on saturdays. Married,lives with husband. Retired. Family History: There is no family history of premature coronary artery disease or sudden death. Mother had cervical cancer and died at age 69. Physical Exam: Admission: VS- T [**Age over 90 **] F, HR 74, BP 123/71, RR 18, SpO2 98% on RA. Height 5'5" Wt 104lbs Gen: WDWN middle aged woman in NAD. Neuro:Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 9 cm. [**3-6**] bruit in neck in both sides. CV: RRR. No m/r/g. Chest: CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Rt: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge: VS 98.2, 97.9, 134/84, 94SR, 18, 100% 2LNC Gen NAD, cachectic white female Neuro grossly intact Pulm scatterred rhonchi- clears with cough, otherwise clear CV RRR, audible mechanical valve click, no murmur Abd NABS, soft, non-tender, non-distended Ext no edema Incisions: sternal- c/d/i without erythema or drainage, R EVH- c/d/i Pertinent Results: [**2155-12-13**] 05:40AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.1* Hct-29.5* MCV-87 MCH-29.9 MCHC-34.4 RDW-14.2 Plt Ct-240 [**2155-12-13**] 05:40AM BLOOD PT-13.3 INR(PT)-1.1 [**2155-12-13**] 05:40AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-139 K-3.9 Cl-105 HCO3-27 AnGap-11 [**2155-12-15**] 01:00PM BLOOD ALT-13 AST-16 LD(LDH)-180 CK(CPK)-48 AlkPhos-182* TotBili-0.4 [**2155-12-13**] 05:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 [**2155-12-15**] 01:00PM BLOOD Albumin-4.1 [**2155-12-15**] 01:00PM BLOOD %HbA1c-6.1* [**2155-12-26**] 06:00AM BLOOD WBC-10.7 RBC-2.83* Hgb-8.8* Hct-25.0* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.0 Plt Ct-611* [**2155-12-26**] 06:00AM BLOOD PT-26.6* INR(PT)-2.7* [**Known lastname **],[**Known firstname 3996**] E. [**Age over 90 68604**] F 59 [**2096-3-28**] Radiology Report CHEST (PA & LAT) Study Date of [**2155-12-25**] 7:23 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA5 [**2155-12-25**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 68605**] Reason: f/u atx [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with s/p redo, MVR, CABG, Left CEA REASON FOR THIS EXAMINATION: f/u atx Wet Read: [**First Name9 (NamePattern2) 68606**] [**Doctor First Name **] [**2155-12-25**] 8:22 PM Bilateral basilar atelectasis is unchanged. [**Doctor Last Name **] 8:20 pm [**2155-12-25**]. Final Report INDICATION: 59-year-old woman status post redo of mitral valve replacement, CABG, and left carotid endarterectomy. Follow up atelectasis. COMPARISON: Multiple chest radiographs, most recent of [**12-23**], [**2154**]. TECHNIQUE: PA and lateral views of the chest. FINDINGS: Bibasilar atelectasis has not significantly changed since prior study. Bilateral pleural effusions remain, left greater than right, with perhaps small decrease in the size of both. Suture material is seen in the right upper lung, most likely corresponding with the prior history of right upper lobectomy. The heart size remains enlarged, unchanged. IMPRESSION: No significant changes in bibasilar atelectasis. Bilateral pleural effusions, right greater than left, slightly decreased since prior study. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: FRI [**2155-12-26**] 1:53 PM Imaging Lab [**2155-12-26**] 06:00AM BLOOD WBC-10.7 RBC-2.83* Hgb-8.8* Hct-25.0* MCV-89 MCH-31.0 MCHC-35.0 RDW-14.0 Plt Ct-611* [**2155-12-27**] 05:50AM BLOOD PT-29.8* INR(PT)-3.0* [**2155-12-27**] 05:50AM BLOOD Glucose-92 UreaN-16 Creat-0.9 Na-135 K-3.9 Cl-98 HCO3-28 AnGap-13 [**2155-12-27**] 05:50AM BLOOD Mg-2.2 Brief Hospital Course: Ms. [**Known lastname 68603**] is a very nice 59 YO woman with extensive vascular history including CAD s/p CABG multiple PCI attempts, and carotid artery disease with persistent chest pain referred for cardiac catheterization. Catheterization revealed native 3VD and occluded OM-LAD grafts. She was then referred to cardiac surgery. On [**12-16**] she was brought to the operating room, please see OR report for details. In summary she had Mitral valve replacement(mechanical)Coronary bypass grafting x3 with saphenous vein graft to left anterior descending with jump obtuse marginal and saphenous vein graft to posterior descending artery and a concomitant left carotid endarterectomy. He tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition. The patient was hemodynamically stable in the immediate post-op peroid however several attemts to wake and wean sedation were met with increasing hypertension and agitation, she was therefore resedated and ventilated throughout the operative night. Early on POD1 she was weaned from the ventilator and extubated. Once extubated she had an uneventful post-operative course however she stayed in the ICU for several additional days for hemodynamic, neurologic and pulmonary monitoring. On POD4 she was transferred to the floor for further post-operative care and rehabilitation. Her activity level was advanced and medications titrated. Physical therapy evaluated and continued to work with Mrs.[**Known lastname 68603**] throughout her admission. Her pulmonary status remained tenuous requiring nasal cannula oxygen 2-4 Liters with desaturations during ambulation. Diuresis along with chest physiotherapy TID and inhalers were continued with improvement evident. Supplemental oxygen was arranged for home use, as she required it at home preoperatively in the past as well. POD# 11 continued to progress and was discharged to home. All follow up appointments were advised. Medications on Admission: Lipitor 80mg daily Plavix 75mg daily Fluoxetine 20mg daily Protonix 40mg daily Metoprolol Xl 25mg daily Dilaudid 4mg tablet daily at night and PRN Imdur 30mg daily (started [**12-11**]) Xanax 0.5mg qhs Aspirin 81mg daily Advair disk 1 puff [**Hospital1 **] Spiriva 2puffs at night Ntg prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-6**] hours as needed. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q 3-4 hrs as needed. Disp:*50 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: DOSE WILL CHANGE FOR GOAL INR 2.5-3.5, DR. [**Last Name (STitle) **] [**Last Name (STitle) **] manage. Disp:*30 Tablet(s)* Refills:*2* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. 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:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: s/p redo sternotomy MVR(#23 [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **])CABG x3(SVG-LAD, SVG-OM, SVG-PDA) Lft CEA. [**12-16**] Cardiac catheterization [**12-12**] PMH: HTN ^lipids lung CA s/p RULobectomy CHF LV thrombus CABG/MVR- post-op Afib compression Fx back Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet 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 wounds Followup Instructions: Cardiac Surgery: [**Hospital 409**] clinic([**Wardname 5010**])in 2 weeks Dr [**Last Name (STitle) 7772**] in 4 weeks, call ([**Telephone/Fax (1) 11763**] to schedule appointment Orthopedic: Provider: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2156-1-5**] 10:00 Cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2156-2-5**] 3:20 PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17321**] [**Telephone/Fax (1) 68607**], 2 weeks Dr. [**Last Name (STitle) **] (cardiology) ([**Telephone/Fax (1) 18658**] for coumadin follow up- have INR drawn on monday, [**12-29**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2155-12-27**] Name: [**Known lastname 11756**],[**Known firstname 1116**] E. Unit No: [**Numeric Identifier 11757**] Admission Date: [**2155-12-12**] Discharge Date: [**2155-12-27**] Date of Birth: [**2096-3-28**] Sex: F Service: CARDIOTHORACIC Allergies: Amiodarone / Oxycodone Hcl/Acetaminophen / Lisinopril Attending:[**First Name3 (LF) 265**] Addendum: Spoke with Dr [**Last Name (STitle) **] [**Last Name (STitle) 4682**] [**12-29**] in relation to managing coumadin, INR and coumadin dosing faxed to office. Discharge Disposition: Home With Service Facility: [**Hospital1 328**] VNA [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2155-12-29**]

[ "414.01", "E885.9", "424.0", "401.9", "805.2", "V15.88", "996.02", "V10.11", "492.8", "414.02", "272.4", "733.00", "E878.1", "433.10", "V15.82", "428.32", "411.1", "428.0", "414.2", "412" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.24", "37.22", "36.13", "88.72", "88.56", "38.12", "88.42", "00.40", "38.91" ]

icd9pcs

[ [ [] ] ]

11901, 12076

5564, 7524

491, 600

10076, 10082

2800, 3811

10384, 11878

1598, 1727

7863, 9632

3851, 3904

9731, 10055

7550, 7840

10106, 10361

1742, 2781

282, 453

3936, 5541

628, 1014

1036, 1335

1351, 1582

17,521

163,602

47762

Discharge summary

report

Admission Date: [**2157-8-16**] Discharge Date: [**2157-8-19**] Service: ICU HISTORY OF PRESENT ILLNESS: This is an 81 year old female originally admitted to [**Hospital1 69**] [**Hospital3 628**] late on [**2157-8-15**], with sudden onset of epigastric pain, nausea and vomiting, and found to have elevated lipase, elevated liver function tests and elevated total bilirubin. Abdominal CT showed dilated common bile and pancreatic duct. The patient also complained of left sided chest pain, arm and shoulder pain and was ruled out for myocardial infarction with serial enzymes. On the afternoon of [**2157-8-16**], the patient spiked a fever to 102.2 degrees Fahrenheit. She became hypotensive to 90 systolic which responded to intravenous fluid boluses up to 110 systolic. She is being treated with intravenous fluids, Demerol and Vistaril for pain control, Zofran for nausea. She was also given 10 mg of oral as well as 10 mg subcutaneous Vitamin K to reverse her INR since she was taking Coumadin for her atrial fibrillation. This was done in anticipation of an elective endoscopic retrograde cholangiopancreatography. However, given her fever and low blood pressure, the patient was transferred to the [**Hospital1 69**] Intensive Care Unit. The patient needed an emergent endoscopic retrograde cholangiopancreatography. The patient got a total of two liters of normal saline as well as one dose of Zosyn before transfer. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, right lower lobe lobectomy for mycobacterium xenopi infection. 2. Atrial fibrillation, status post two failed cardioversions. 3. Hypertension. 4. Hypercholesterolemia. 5. Diverticulosis. 6. Status post cholecystectomy. 7, Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. 8. Arthritis. 9. Gastroesophageal reflux disease. ALLERGIES: The patient is allergic to Codeine and Ultram. MEDICATIONS ON ADMISSION: 1. Cardizem CD 180 mg p.o. twice a day.. 2, Coumadin 5 mg p.o. q.h.s. 3. Prozac. 4. Hydrochlorothiazide 25 mg p.o. once daily. 5. Flonase. 6. Lipitor 10 mg p.o. once daily. MEDICATIONS ON TRANSFER: 1. Zosyn 4.5 mg three times a day. 2. Diltiazem 180 mg once daily. 3. Prozac 20 mg once daily. 4. Protonix 40 mg once daily. 5. Maalox. 6. Flovent. 7. Sublingual Nitroglycerin p.r.n. 8. Lipitor 10 mg once daily. 9. Demerol 75 mg intravenously q3hours. SOCIAL HISTORY: The patient lives alone on [**Hospital3 **] and visits her daughter who lives in [**Name (NI) 620**]. Former tobacco use, quit thirty years ago. No alcohol use. PHYSICAL EXAMINATION: On arrival, temperature was 101, heart rate 91, atrial fibrillation, blood pressure 105/51, respiratory rate 16, oxygen saturation 97% on two liters nasal cannula. In general, the patient was alert, oriented times three in mild distress secondary to abdominal pain. Head, eyes, ears, nose and throat examination - Her oropharynx was dry. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cardiovascular is irregularly irregular, no murmurs. The lungs are clear to auscultation bilaterally. The abdomen was soft with moderate distention, diffuse pain to palpation, however, worse pain over her epigastrium with voluntary guarding, but no rebound, hypoactive bowel sounds. Extremities with no edema. LABORATORY DATA: Elevated white blood cell count at 16.9. INR 2.4. ALT 1702, AST 475, LDH 268, alkaline phosphatase 167, amylase and lipase normal, total bilirubin 4.4. CK was normal. Arterial blood gases [**Location (un) **] 7.36/43/97 on two liters nasal cannula. Chest x-ray was negative. KUB was negative. HOSPITAL COURSE: 1. Ascending cholangitis - The patient was started on Ampicillin, Levofloxacin and Flagyl and overnight was kept NPO and went for endoscopic retrograde cholangiopancreatography the following morning. She underwent sphincterotomy with release of bile sludge without complications. The patient's diet was advanced and she was switched to oral antibiotics, Augmentin and Levofloxacin. She was to complete a total two week course of these antibiotics through [**2157-8-30**]. 2. Infectious disease - fever and elevated white blood cell count from cholangitis - The patient's blood and urine cultures remained negative through her hospital stay. The patient was having loose stools which were close to the patient's baseline upon discharge. She also did spike a temperature in the evening prior to discharge. The patient was unable to give a stool sample to check for Clostridium difficile before leaving the hospital. 3. Atrial fibrillation on Coumadin - The patient was given Vitamin K at the outside hospital as well as four units of fresh frozen plasma prior to her procedure to reverse her INR for the endoscopic retrograde cholangiopancreatography. The patient'a anticoagulation was started two days later on the date of discharge with 5 mg of Coumadin once daily. The patient is to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14887**], on [**Location (un) **] for INR checks. 4. Hypotension likely secondary to cholangitis. The patient's blood pressure remained stable after intravenous fluid hydration. 5. Atrial fibrillation - The patient was restarted on her outpatient Diltiazem for rate control. 6. Chronic obstructive pulmonary disease - The patient received Albuterol and Atrovent nebulizers while in the hospital. The patient had a right atrial line placed for closer blood pressure monitoring as well as an endoscopic retrograde cholangiopancreatography. FOLLOW-UP: The patient is to continue two weeks of antibiotics as described above. The patient is to follow-up her INR with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14887**]. The patient is also to follow-up with her cardiologist, Dr. [**First Name (STitle) **], to reschedule cardioversion now she has been off anticoagulation. The patient was seen by physical therapy and cleared to be safe to go home. DISCHARGE DIAGNOSES: 1. Ascending cholangitis. 2. Status post endoscopic retrograde cholangiopancreatography with sphincterotomy. 3. Atrial fibrillation. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Status post reversal of anticoagulation. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg p.o. once daily until [**2157-8-30**]. 2. Augmentin 500 mg p.o. three times a day until [**2157-8-28**]. 3. Coumadin 5 mg p.o. q.h.s. to be adjusted by her primary care physician. 4. Lipitor 10 mg p.o. once daily. 5. Diltiazem 100 mg p.o. once daily. 6. Flonase. 7. Hydrochlorothiazide 25 mg p.o. once daily. 8. Prozac. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Name8 (MD) 7112**] MEDQUIST36 D: [**2157-8-19**] 16:20 T: [**2157-8-27**] 11:12 JOB#: [**Job Number 100832**]

[ "577.0", "429.3", "401.9", "496", "427.31", "716.90", "562.10", "576.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "51.85" ]

icd9pcs

[ [ [] ] ]

6126, 6369

6395, 7023

1953, 2133

3716, 6105

2624, 3699

116, 1446

2158, 2420

1468, 1927

2437, 2601

7,809

184,994

48894

Discharge summary

report

Admission Date: [**2137-5-28**] Discharge Date: [**2137-6-4**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3705**] Chief Complaint: DKA Major Surgical or Invasive Procedure: femoral line History of Present Illness: Ms. [**Known lastname 18741**] is a 58 year old female with history of poorly controlled type 1 diabetes, gastroparesis, CVA, HTN, Hep C, and multiple prior admissions for DKA presenting with DKA. The patient is lethargic and unable to provide much history. However of further questioning patient reports n/v x3 over the last day as well as overall malaise. She reported poor po intake due to her "gastroparesis acting up" and did not take her [**Known lastname 31217**] last evening or this morning. She reported feeling more thirsty however drinking fluids made her feel nauseated. She noted her FS were very high this morning and also felt weak and dizzy per report. Her daugter called EMS. In the ED, initial VS were: HR 140s, BP 99/64. She was altered and had Kussmaul breathing. She was oriented to person and was able to refuse a central line in her neck. A femoral CVL was placed. CXR was unrevealing for frank consolidation, UA was negative. CT head showed no acute process. VBG showed 7.10/13/98/4. Labs showed anion gap of 39, Na 124, K 6.2, HCO3 < 5, Cr of 2.5, WBC 15.3, lactate 5.5, Trop < 0.01. Repeat VBG 7.02/13/108/4 with lactate down to 4.8. She was given 2L NS, levofloxacin 750mg IV, [**Known lastname 31217**] bolus and gtt of 8U. Repeat Chem 7 showed gap of 35, K of 5.1. On arrival to the MICU, patient's VS 96.4 131/77 109 20 99% RA. Patient c/o mild abdominal pain and some overall weakness. Reported feeling thirsty with polyuria at home. Also reports dry cough x 2 years. Denies fevers, chills, nausea, constipation, diarrhea, dysuria. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath,dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: --Type I DM: diagnosed at age 5, multiple hospitalizations for DKA and hyperglycemia. Complicated by retinopathy, severe peripheral neuropathy, and gastroparesis with marked constipation. --CVA --Diabetic polyneuropathy --Hypertension --Grave's disease, on MMI --Seronegative arthritis, followed in rheumatology --Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, not on antiviral therapy; acquired from a blood transfusion in [**2110**]. Had previous liver biopsy without significant fibrosis. Never been treated with antivirals. --GERD --Status post bilateral knee arthroscopies --Migraine headaches --Asthma --s/p TAH --Mouth surgery for removal of tumors --Bilateral foot drop requiring wheelchair use Social History: Patient lives in an apt building with her daughter and 2 grandchildren(who are in their 20s). She has a home health aid. She has not worked for many years. She uses a wheelchair at baseline. She is a never smoker and does not use alcohol or drugs. Family History: Mother died of colon cancer. There are multiple family members with DM. Physical Exam: admission exam Vitals: 96.4 131/77 109 20 99% RA General: Alert, oriented, no acute distress [**Year (4 digits) 4459**]: Sclera anicteric, dry MM, oropharynx clear, EOMI, [**Year (4 digits) 2994**] Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, minimally tender throughout, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3. CNII-XII intact, 5/5 strength upper extremities, lower extremities weak and exam limited by patient effort. gait deferred. Discharge exam Afebrile, VSS Abdomen: mild suprapubic tenderness Exam otherwise unchanged since admission Pertinent Results: ADMISSION EXAM: [**2137-5-28**] 01:05PM BLOOD WBC-15.3*# RBC-3.67* Hgb-10.9* Hct-36.9 MCV-101* MCH-29.8 MCHC-29.6* RDW-13.4 Plt Ct-366 [**2137-5-28**] 01:05PM BLOOD Neuts-83.2* Lymphs-13.9* Monos-2.4 Eos-0.2 Baso-0.4 [**2137-5-28**] 01:05PM BLOOD PT-11.6 PTT-38.5* INR(PT)-1.1 [**2137-5-28**] 01:05PM BLOOD Glucose-769* UreaN-47* Creat-2.5*# Na-124* K-6.2* Cl-80* HCO3-LESS THAN [**2137-5-28**] 02:35PM BLOOD Glucose-727* Na-128* K-5.1 Cl-88* HCO3-LESS THAN [**2137-5-28**] 04:43PM BLOOD Glucose-651* UreaN-44* Creat-2.0* Na-132* K-4.1 Cl-97 HCO3-5* AnGap-34* [**2137-5-28**] 06:07PM BLOOD Glucose-586* Na-134 K-4.2 Cl-100 [**2137-5-28**] 07:10PM BLOOD Glucose-525* Na-132* K-4.1 Cl-101 HCO3-10* AnGap-25* [**2137-5-28**] 01:05PM BLOOD ALT-29 AST-43* AlkPhos-100 TotBili-0.4 [**2137-5-28**] 01:05PM BLOOD Lipase-23 [**2137-5-28**] 01:05PM BLOOD cTropnT-<0.01 [**2137-5-28**] 07:10PM BLOOD cTropnT-<0.01 [**2137-5-28**] 01:05PM BLOOD Albumin-4.0 Calcium-8.9 Phos-9.7*# Mg-2.1 [**2137-5-28**] 04:43PM BLOOD Calcium-7.1* Phos-6.3*# Mg-1.8 [**2137-5-28**] 07:10PM BLOOD Calcium-7.2* Phos-4.1# Mg-1.6 [**2137-5-28**] 02:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2137-5-28**] 01:24PM BLOOD Type-[**Last Name (un) **] pO2-98 pCO2-13* pH-7.10* calTCO2-4* Base XS--23 [**2137-5-28**] 02:46PM BLOOD Type-[**Last Name (un) **] pO2-108* pCO2-13* pH-7.02* calTCO2-4* Base XS--26 Intubat-NOT INTUBA [**2137-5-28**] 12:20PM BLOOD Glucose-GREATER TH Lactate-5.5* K-6.7* [**2137-5-28**] 01:24PM BLOOD Lactate-5.6* [**2137-5-28**] 02:46PM BLOOD Lactate-4.8* Admission ECG: Sinus tachycardia. rate 135. NA/NI. nonspecific ST changes in inferior and lateral leads CXR: FINDINGS: Single AP portable view of the chest is compared to previous exam from [**2137-4-24**]. Given the limitations of the portable film with respiratory motion, the lungs are grossly clear. Cardiomediastinal silhouette is normal. Osseous and soft tissue structures are unremarkable. IMPRESSION: No definite acute cardiopulmonary process. CT head w/o contrast: No definite acute intracranial process, although the exam is severely limited by motion artifact. DISCHARGE LABS: [**2137-6-4**] 06:29AM BLOOD WBC-7.2 RBC-2.86* Hgb-8.4* Hct-27.9* MCV-97 MCH-29.2 MCHC-29.9* RDW-15.3 Plt Ct-314 [**2137-6-4**] 06:29AM BLOOD Glucose-429* UreaN-22* Creat-1.3* Na-131* K-5.0 Cl-95* HCO3-30 AnGap-11 [**2137-6-4**] 06:29AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 Brief Hospital Course: Ms. [**Known lastname 18741**] is a 58 year old female with history of poorly controlled type 1 diabetes, gastroparesis, CVA, HTN, Hep C, and multiple prior admissions for DKA presenting with DKA in the setting of missing [**Known lastname 31217**] doses. # DKA/Type I diabetes - Patient presented with elevated sugars in the 700s, anion gap of 39, ketonuria. Precipitant most likely due to patient not taking her [**Known lastname 31217**] correctly as she admitted to skipping her dose the evening prior and morning of admission. Other possible triggers considered were infection given leukocytosis however patient afebrile and workup unrevealing. Patient r/o MI. Tox screen only positive for benzos (given in the ED). Patient was given 8 units of [**Known lastname 31217**] as bolus then started on [**Known lastname 31217**] drip in the ED prior to transfer to the MICU. Patient was aggressively hydrated and continued on [**Known lastname 31217**] drip until her anion gap closed. [**Known lastname **] drip was stopped and patient was restarted on her home dose of [**Known lastname 31217**]. Her electrolytes were closely monitored and repleted appropriately. Her blood sugars remained difficult to control as patient is sensitive to [**Known lastname 31217**], but does not eat consistent [**Known lastname 16429**] and sometimes has late night snack around 10 or midnight. She is not consistent enough to teach carb counting. While on the floor, blood sugars fluctuated between 50 and 400s. Patient tolerating [**Known lastname 16429**] (no nausea, [**Known lastname **]). She can feel when she is hyperglycemic or hypoglycemic, feeling tired and at times dizzy but never had confusion, altered mental status or increased anion gap. [**Last Name (un) **] was consulted to help with management of her diabetes and recommended uptitration of her glargine and sliding scale and 3AM blood glucose given late night snack. Patient discharged home with new sliding scale and arranged close follow up with [**Last Name (un) **] and PCP. # Abdominal pain - Patient reported diffuse mild abdominal pain on admission. Likely related to DKA and her gastroparesis. Abdominal labs including LFTs and lipase were unremarkable. She was restarted on her home regimen of reglan, hyocyamine sulfate. Her pain improved to baseline and she was able to tolerate po. # Acute kidney injury - Cr elevated to 2.5 on arrival from baseline normal creatinine. This was likely related to volume depletion from n/v and poor po intake. Her losartan was initially held and medications were renally dosed. She was volume recuscitated and Cr improved to 1.1 and losartan was restarted. Cr. was 1.3 on the day of discharge and patient encouraged to increase PO fluid intake. Please follow up as outpatient. # UTI - On the day of discharge, patient developing suprapubic tenderness, no dysuria, no fever. U/A showed 13WBC, few bacteria, few yeast, sm leuks. In the setting of suprapubic tenderness, uncontrolled blood glucose, patient was started on cipro x 7 days. Urine culture pending at the time of discharge. # Hypertension - Patient was normotensive on arrival. Losartan was initially held then restarted after kidney function recovered. # Peripheral neuropathy - Continued on gabapentin, amitryptyline, percocet and flexeril. # Grave's disease - Continued methimazole 10 mg Tablet TID. # Asthma - Continued home fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **], montelukast 10 mg po daily, and albuterol prn. # GERD - Continued pantoprazole 40 mg po qd # Hyperlipidemia - Continued simvastatin 10 mg po qhs # Arthritis - Continued sulfasalazine 1000mg po BID # Hepatitis C - genotype 1A, acquired from a blood transfusion in [**2110**]. Untreated, never been on antiviral therapy Transitional issues: - Code status: DNR/DNI - Follow up: [**Hospital **] clinic - Pending studies: urine culture from [**6-4**] Addendum: [**6-10**] urine culture contaminated Medications on Admission: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before [**Month/Year (2) 16429**] and at bedtime)). 5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: Three (3) Tablet, Sublingual Sublingual [**Hospital1 **] (2 times a day). 7. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 14. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three times a day. 15. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. methimazole 10 mg Tablet Sig: One (1) Tablet PO twice a day. 17. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 18. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 19. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 20. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 22. Lantus 100 unit/mL Solution Sig: One (1) 10 Subcutaneous qam. 23. Lantus 100 unit/mL Solution Sig: One (1) 8 Subcutaneous qpm. 25. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 26. [**Hospital1 31217**] lispro 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: per sliding scale. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before [**Hospital1 16429**] and at bedtime)). 5. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. hyoscyamine sulfate 0.375 mg Capsule,Extended Release 12 hr Sig: One (1) Capsule,Extended Release 12 hr PO BID (2 times a day). 7. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 13. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 14. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three times a day. 15. amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. methimazole 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 18. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. 19. zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 20. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 21. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 22. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 23. [**Hospital1 31217**] sliding scale Lantus 12 units every morning; 17 units every evening Humalog: see attached sliding scale 24. sliding scale humalog qAM: 81-120 11 U 121-170 12 U 171-220 13U 221-270 14 U 271-320 15U 321-370 17 U 371-420 19 U 421-440 21 U lunch: 81-120 5 U 121-170 6 U 171-220 7 U 221-270 8 U 271-320 9 U 321-370 10 U 371-420 11 U 421-440 13 U dinner: 81-120 3 U 121-170 4 U 171-220 5 U 221-270 6 U 271-320 7 U 321-370 9 U 371-420 11 U 421-440 13 U 10pm: 221-270 2 U 271-320 6 U 321-370 7 U 371-420 8 U 421-440 10 U 3am: 221-270 2 U 271-320 6 U 321-370 7 U 371-420 8 U 421-440 10 U 25. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: PRIMARY Diabetic ketoacidosis Diabetes Mellitus type 1 Gastroparesis SECONDARY: h/o stroke diabetic neuropathy 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: Ms. [**Known lastname 18741**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted after you had high blood sugar from missing [**Hospital1 31217**] doses. We treated you with [**Hospital1 31217**] drip in the intensive care unit and made changes to your [**Hospital1 31217**] regimen. You had discomfort with urination. We are treating your UTI with antibiotics. We made the following changes to your medications: CHANGED Humalog sliding scale CHANGED Lantus dose STOPPED Compazine as needed for nausea STARTED Zofran as needed for nausea STARTED ciprofloxacin (last day [**6-10**]) Followup Instructions: PCP [**Name Initial (PRE) **]: [**Name Initial (PRE) 766**] [**6-10**] at 3:00pm With:[**Name6 (MD) **] [**Last Name (NamePattern4) 102678**],MD Location: UPHAMS CORNER HEALTH CENTER Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**] Phone: [**Telephone/Fax (1) 7538**] Endocrinology Appointment: Wednesday, [**6-5**] at 4pm With [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP Location:One [**Last Name (un) **] Place [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Completed by:[**2137-6-5**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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809

Discharge summary

report

Admission Date: [**2196-4-13**] Discharge Date: [**2196-4-19**] Date of Birth: [**2127-10-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: [**4-13**] CABG x 3 History of Present Illness: 68 yo male with abnormal stress test as part of routine physical, referred for cardiac catheterization which showed 2 vessel disease and he was referred for surgery. Past Medical History: PMH/PSH: Diabetes, diagnosed in [**2187**], Hyperlipidemia, Renal calculi, costochondritis, S/P torsion testicle with repair, Tonsillectomy Social History: quit tobacco 40 years ago occasional etoh lives with wife Family History: NC Physical Exam: HR 71 RR 17 BP 140/77 NAD Lungs CTAB anteriorly Heart RRR, no M/R/G Abdomen soft/NT/ND Extrem warm, no edema Pertinent Results: CHEST (PORTABLE AP) [**2196-4-16**] 7:29 AM CHEST (PORTABLE AP) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 68 year old man with s/p POD 3 CABG now RAF REASON FOR THIS EXAMINATION: interval change PORTABLE CHEST ON [**2196-4-16**] AT 08:30 INDICATION: Post-op CABG. COMPARISON: [**2196-4-15**]. FINDINGS: The right CVL has been removed and there is no pneumothorax. A previously visualized left PTX is not seen on the current study. Left basilar atelectasis and small effusion remain. No new airspace disease is seen. IMPRESSION: No PTX after right CVL removal and no new airspace disease. [**2196-4-19**] 05:30AM BLOOD Hct-25.9* [**2196-4-18**] 05:20AM BLOOD WBC-12.6* RBC-3.14* Hgb-9.5* Hct-28.2* MCV-90 MCH-30.3 MCHC-33.7 RDW-14.5 Plt Ct-240 [**2196-4-19**] 05:30AM BLOOD PT-21.7* INR(PT)-2.1* [**2196-4-18**] 05:20AM BLOOD PT-14.3* PTT-24.8 INR(PT)-1.2* [**2196-4-15**] 02:03AM BLOOD PT-12.8 PTT-25.4 INR(PT)-1.1 [**2196-4-19**] 05:30AM BLOOD UreaN-30* Creat-1.0 K-4.2 [**2196-4-18**] 05:20AM BLOOD Glucose-102 UreaN-37* Creat-1.2 Na-140 K-4.4 Cl-103 HCO3-28 AnGap-13 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 5738**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 5739**] (Complete) Done [**2196-4-13**] at 2:33:55 PM 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: [**2127-10-25**] Age (years): 68 M Hgt (in): 67 BP (mm Hg): 140/70 Wgt (lb): 176 HR (bpm): 65 BSA (m2): 1.92 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 786.05, 786.51, 440.0, 413.9 Test Information Date/Time: [**2196-4-13**] at 14:33 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: [**Pager number 5741**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 1.2 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 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. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium and right atrium are normal in cavity size. 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 aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve appears structurally normal with mild mitral regurgitation. POST-BYPASS: Biventricular systolic function is normal. Mitral regurgitation may be slightly improved. Thoracic aorta appears intact. Brief Hospital Course: He was taken to the operating room on [**2196-4-13**] where he underwent a CABG x 3. She was transferred to the ICU in stable condition. He was extubated post op. He was tranfused. He was weaned from his neo and transferred to the floor on POD #2. He has rapid atrial fibrillation for which he was started on amiodarone and his lopressor was increased, and he was started on coumadin. His chest tubes and wires were discontinued with out incident. He then remained in sinus rhythm and was ready for discharge home on POD #6. Spoke with [**Doctor Last Name 2048**] at Dr. [**Last Name (STitle) 5742**] office who confirmed that Dr. [**Last Name (STitle) **] will assume coumadin management. Medications on Admission: Atenolol 25', Byetta 10 mg injected'', Zetia 10', Metformin 500 mg 1 tab qAM and 2 tabs qPM, Crestor 40', Diovan 80', ASA 81', MVI' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. 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* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). Disp:*60 Tablet(s)* Refills:*0* 8. Coumadin 2 mg Tablet Sig: 1.5 Tablets PO at bedtime for 1 days: Check INR [**4-20**] with results to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5743**]/([**Telephone/Fax (1) 5744**]. Disp:*60 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: then 200 mg daily. Disp:*50 Tablet(s)* Refills:*0* 13. Byetta Subcutaneous 14. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD now s/p CABG Post-op Atrial fibrillation PMH/PSH: Diabetes, diagnosed in [**2187**], Hyperlipidemia, Renal calculi, costochondritis, S/P torsion testicle with repair, Tonsillectomy Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Have INR checked [**4-20**] with results to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5743**]/([**Telephone/Fax (1) 5744**]. Followup Instructions: Dr. [**Last Name (STitle) **] 2 weeks - Appointment has been scheduled for you for [**5-3**] at 3pm. Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2196-4-19**]

[ "997.1", "413.9", "999.2", "427.31", "250.00", "458.29", "414.01", "451.84" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8785, 8834

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7031, 8762

1084, 1128

8855, 9042

6875, 7008

9095, 9496

825, 936

283, 297

1157, 6135

385, 552

574, 715

731, 790

2,905

160,220

11961

Discharge summary

report

Admission Date: [**2141-2-10**] Discharge Date: [**2141-3-2**] Date of Birth: [**2064-10-30**] Sex: M Service: MEDICINE Allergies: Keflex Attending:[**First Name3 (LF) 1973**] Chief Complaint: found down Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 77 year old man who was found down at his rooming house. Date of birth [**2064-10-30**], most likely [**Known firstname 789**] [**Known lastname **]. It is not known when he was last seen. Staff of the rooming house checked out his appartment this am as it smelled of urine. He was found in bed, only responsive to pain, with urine on the bed, floor and in buckets. Alcohol was found at the site as well. No evidence of vomiting or diarrhea. BP at the scene was 90/60. HR 110, resp 8. FS 150. A pile of medical records was taken with him to the hospital and most of the background info is from those records. Pt is not able to provide any information. ADDITIONAL INFO: This is additional information about [**Known firstname 789**] [**Known lastname **] DOB [**2064-10-30**]. Since there are no OMR notes on [**Known firstname 789**] [**Known lastname **], I will summarize his OSH and outpatient records for the purpose of continued care. Only [**Hospital1 18**] computerized record of [**Known firstname 789**] [**Known lastname **] shows that he had an EKG and head CT in [**2135-11-16**] which showed left axis deviation and no evidence of acute intracranial pathologic process, respectively. Based on outpatient records, Mr. [**Known lastname **] followed at [**Location (un) 37619**] Family Medicine, P.A. between the dates of [**2135-8-17**]. His vitals show that he had hypertension with blood pressure range 124-218/62-84. Weight had been relatively stable in the 151-154 in [**2138**]. His most recent vitals were from [**2140-2-18**] 98.6 192/83 64 20 wt 162. Repeat BP 182/88. At that visit, he was started on Caduet [**4-30**] and continued on Benicar 40/25. Diovan/HCTZ was changed to Benicar on [**2139-10-19**]. Most recent outpatient visits, patient complained of fatigue, blurred vision-visual changes, and nausea secondary to vytorin. Past Medical History: -Hypertension -hypercholesterolemia -disc bulge L4-5 w/o herniation -hx of osteomyelitis T12-11 [**2136**] -screening carotid study '[**37**]: bilateral mild to moderate carotid stenosis -s/p laminectomy thoracic spine Social History: Lives in rooming house. Denies tobacco, history of heavy alcohol use (2 pint/day) but has been less recently. Retired biochemist. In hospital contact with Sister [**Name (NI) 37620**] [**Name (NI) **] and brother. . PCP office in [**Name9 (PRE) 37619**], SC: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]. [**Telephone/Fax (1) 37621**] Emergency contact person: [**Name (NI) **] [**Name (NI) 2450**] [**Telephone/Fax (1) 37621**] Has an address in [**Doctor First Name 26692**]: [**Street Address(2) 37622**], [**Location (un) 37619**], [**Numeric Identifier 37623**] Phone [**Telephone/Fax (1) 37624**] as of [**2139-9-17**]. Family History: Non contributory Physical Exam: Admission: VITALS: T100 HR95 BP135/97 RR8-->38 sO288--> 98 with NRB, [**Last Name (un) 6055**] [**Doctor Last Name **] GEN: dry, NRB, opens eyes to name HEENT: dry, no rash NECK: no LAD; no carotid bruits LUNGS: weak breathing sounds, no distinct rhonchi anteriorly; [**Last Name (un) 6055**] [**Doctor Last Name **] HEART: Regular rate and rhythm, normal S1 and S2, no murmurs ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: pressure sore at the L-heel MENTAL STATUS: Opens eyes to voice and to pain, able to grimace; unable to speak or follow commands CRANIAL NERVES: II: No blink to threat. Pupils 1.5mm, minimally reactive; unable to discern discs. III, IV, VI: dolls intact V: corneal present on the R, not on the L VII: grimace symmetrical in upper face; L-facial droop lower face VIII: responds to voice IX: - XII: - [**Doctor First Name 81**]: - MOTOR SYSTEM/SENSORY SYSTEM: Diffuse wasting; rigidity in RUE; low tone in LUE and in both legs. No adventitious movements, no tremor, no asterixis. Withdrawal and grimace to noxious in RUE, not in LUE. Withdrawal in both LE with grimace. REFLEXES: B T Br Pa Pl Right 3 3 3 2 - Left 3 3 3 2 - In upper extremities, spread of reflexes. Toes: up on the L; equivocal on the R. COORDINATION: unable. GAIT: deferred . Discharge: HR 92, BP 100/60, Temp 97.9, R 18, 100% RA Gen: opens eyes to name, alert and oriented X 3, appropriately answers questions, speech improved during course, perseverates--but improved. Car: RRR no murmur Resp: coarse BS bilaterally, ronchi R improved but present, [**Month (only) **]. BS right base, no wheezing, no crackles Abd: s/nt/nd/nabs Ext: in protective equipment, trace edema bilaterally, nonpitting Neuro: alert and oriented, follows simple commands. L no blink to threat, L facial droop, R gaze preference, less attentive to left, left arm/leg weakness/hemiplegia, toe upgoing on left. Pertinent Results: CT HEAD [**2141-2-10**]: FINDINGS: Again seen is a large acute to subacute infarct involving the distribution of the right MCA with edema and effacement of the sulci in the right frontal, parietal and temporal lobes, not significantly changed from the earlier study. No areas of intracranial hemorrhage is identified. Density indicating thrombus is again seen within the sylvian fissure. There is no shift of midline structures or effacement of the basal cisterns. There is age- appropriate diffuse atrophy. Osseous and soft tissue structures are unremarkable. Mild opacification of the mastoid air cells. IMPRESSION: 1. Stable short interval appearance of acute to subacute right MCA infarct without significant mass effect or areas of hemorrhage identified. CT HEAD with Contrast [**2141-2-10**]: There is an acute-to-subacute infarct affecting the distribution of the right MCA with edema and effacement of the sulci/gyri within the right frontal, parietal and temporal lobes. Additionally there is a area of dense clot identified within the sylvian fissure, corresponding to the hemispheric/cortical branch distribution of this infarct. No significant shift of midline structures, hemorrhage, or mass effect on the lateral ventricles is identified. There is age inappropriate diffuse atrophy and dense calcifications within the intracranial carotid vessels. Osseous and soft tissue structures are unremarkable. There is mild opacification of the mastoid air cells with remaining paranasal sinuses well aerated. IMPRESSION: 1. Acute-to-subacute right cortical distribution MCA infarct with no significant mass effect/shift of midline structures or areas of hemorrhage identified. These findings were discussed with caring physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on date of exam at approximately 10:20 a.m. 2. Age inappropriate atrophy. 3. Dense atherosclerotic disease with area of thrombus identified within the right sylvian fissure. OUTSIDE IMAGING--Studies from PCP from prior to admission: [**2139-9-16**] Amb BP monitoring CTA renal arteries [**2139-7-20**]: abdominal aorta no evidence of aneurysm or dissection. Scattered calcifications and mural wall thrombus, particularly within infrarenal portion, [**Female First Name (un) 899**], SMA and celiac artery widely patent at origins. This is area of mild narrowing in proximal portion of SMA. . Heavy calcifications in the common iliac arteries which extends into the proximal iliac arteries and hypogastric arteries though no flow limiting lesions. Moderate stenosis involving the right common femoral artery. Likely cysts 1.4 cm and 8 mm in diameter in left lobe of liver. Kidneys symmetric enhancement without hydronephrosis or stones. Two rounded low density areas 3-4 mm in upper pole of left kidney likely cyst. Diverticulosis of colon. Osteoarthritic changes. IMPRESSION: No evidence of sign arterial occlusive disease invovling renal arteries and no evidence of fibromuscular dyplasia. . [**2138-11-17**] Carotid artery: Bilateral mild/mod stenosis: fairly low to mod amount of plaque buildup not affecting blood flow velocities which were <110cm/s. . MRI L-spine [**2136-12-28**]: Collapse T10-T11 as described with significant focal kyphotic angulation. No epidural component. Subtle increased paraspinal enhancement on the R likely due to progression of the vertebral body collapse. No evidence of further progression of osteomyelitis. No extension into paravertebral soft tissues or other vertebral levels. . Holter [**2137-8-7**]: occassional APCs and occassional PVCs (predominately uniform with rare couplets and no runs). AV block greater than 1st degree NOT noted. ST segment deviation present and seemed secondary to underlying bundle branch block. Asymptomatic. Admission labs: Lactate:2.1 Trop-T: Pnd 161 121 110 AGap=21 -------------< 130 5.6 25 3.9 CK: 45 MB: not done Ca: 9.1 Mg: 3.7 P: 6.8 ALT: 20 AP: 63 AST: 18 [**Doctor First Name **]: 84 Lip: Pnd Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc negative . WBC P11.9 PLT335 Hct31.0 N:82 PT: 16.3 PTT: 27.7 INR: 1.5 . URINE (Admission) Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-[**2-13**] CastGr-0-2 CastHy-0-2 Mucous-OCC bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG. CT head ([**2141-2-10**]): R-MCA infarct, Acute to subacute, involving cortical branches with extensive carotid calcification, and "dot sign" within Sylvian fissure MCA; involvement PCA; hemorrhagic focus in between MCA and PCA territories; effacement of sulci; no midline shift . Carotid series ([**2141-2-10**]): Findings indicating patency of both common carotid and internal carotid arteries. However, velocities are quite low and should be correlated with the patient's cardiac status. . EEG ([**2141-2-11**]): This is an abnormal EEG in the waking and drowsy state due to the right hemisphere lower voltage and frequency of the posterior predominant rhythm. This suggests widespread right hemisphere subcortical dysfunction. No epileptiform features were noted. . Repeat EEG [**2141-2-19**]: This is an abnormal EEG due to the low voltage slower right more than left hemisphere background rhythm, and bursts of generalized theta slowing. The lower voltage and slower activity over the right hemisphere suggests a right hemisphere subcortical dysfunction. The disorganized and slow background rhythms, with bursts of generalized slowing, suggest an encephalopathic pattern. This may be seen with infections, ischemia, medication effect and toxic metabolic abnormalities. . Echo ([**2141-2-13**]): Conclusions: The left atrium is elongated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is >20 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Tissue synchronization imaging demonstrates no significant left ventricular dyssynchrony. There is no significant delay in peak systolic contraction between opposing walls. The right ventricular cavity is moderately dilated. There is moderate global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. EF 10-15%. . Repeat echo [**2141-2-24**]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed. Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There is mild global right ventricular free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. EF 10-15%. . Compared with the prior study (images reviewed) of [**2141-2-13**], estimated pulmonary artery pressure is now minimally higher. . pCXR ([**2141-2-14**]): Persistent right basilar opacity that is likely an effusion. Resolved retrocardiac opacification. . pCXR ([**2141-2-17**]): 1. Progressive airspace process involving the right lung base, likely representing right lower lobe consolidation with collapse, and accompanying pleural effusion. 2. No interval development of CHF. . pCXR ([**2141-2-18**]): Increasing multifocal consolidation in right middle and both lower lobes, concerning for evolving multifocal pneumonia. Cardiomegaly but no evidence of CHF. . pCXR ([**2141-2-24**]): Extensive consolidation in the right lung has progressed accompanied by increasing moderate right pleural effusion and new mild pulmonary edema in the left lung. Moderate to severe enlargement of the cardiac silhouette is unchanged. Nasogastric tube ends in the region of the pylorus, and right subclavian line tip projects over the mid SVC. No pneumothorax. Dr. [**Last Name (STitle) 10351**] was paged to report these findings at the time of dictation.. AXR ([**2141-2-16**]): No ileus or small bowel obstruction is noted. . pCXR ([**2141-2-28**]): Improving large right pleural effusion with persistent underlying consolidation or atelectasis. Near complete resolution of left effusion. . Renal ultrasound ([**2141-2-17**]): No hydronephrosis on either side. Slightly increased echogenicity of the kidneys raising the possibility of parenchymal renal disease. . Abdominal Ultrasound [**2141-2-21**]: 1. No acute hepatobiliary abnormalities identified. 2. Equivocal findings in the pancreas including possible small cysts and/or pancreatic ductal dilatation. This could be followed by ultrasound. If clinically indicated, further evaluation could be obtained by MRI or CT. . CT Chest ([**2141-2-25**]): CT OF THE CHEST: There is a large consolidation within the right lower lobe with adjacent moderate/large sized pleural effusion. Small pleural effusion is seen on the left with adjacent compressive atelectasis. The heart is enlarged. Coronary calcifications are seen within the left main, LAD and circumflex. There is a small pericardial effusion. Right subclavian central venous catheter and NG tube are in standard position. Small mediastinal lymph nodes are seen which not meet CT criteria for pathologically enlargement. Atherosclerotic calcification is seen within the aorta. The visualized upper abdomen demonstrates a 1.6 x 1.3 cm hypodensity within the left lobe of the liver, incompletely characterized. BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. Degenerative changes are seen within the thoracic vertebrae. Laminectomies have been performed on T9, T10 and T11. . Lab tests at discharge: Brief Hospital Course: Impression: 77yo man with a history of HTN and hypercholesterolemia, found down at his rooming house, with examination notable for poor responsiveness, left hemiplegia, and left sensory loss, and fever, and labs showing hypernatremia, renal failure, and hypovolemia. CT head showed subacute R-MCA and R-PCA stroke, with some blood present in between MCA and PCA territories; and the deep territories of MCA spared. Hospital course is reviewed below by problem: 1. Stroke: He was admitted to the neurology ICU. Repeat head CT was stable. Carotid ultrasound was limited but did not reveal an etiology for the stroke. A1C was normal and lipid panel revealed elevated lipids, for which he was treated with a statin. He went into atrial fibrillation while in the ICU, which was likely the source of his stroke. ECHO did not reveal any thrombus. Coumadin was not started in the setting of a large acute stroke involving >50% of a hemisphere per the stroke team, and could not be started as the patient developed a GI bleed as well. He will require anticoagulation as an outpatient once GI bleeding resolves (see below). He is on a lipid-lowering [**Doctor Last Name 360**] and was followed on sliding scale insulin. Antihypertensives were initially held (with prn medications given) to maintain perfusion pressure, but then he was started on beta blockers for arrhythmias (see below) and a low dose ace-inhibitor for cardiomyopathy. He should have a repeat Head CT 1 week after discharge. If there is no evidence of hemorrhage, coumadin can be started with a goal INR [**1-14**]. 2. Arrhythmia: He had intermittent atrial fibrillation when in the ICU, the likely source of his stroke. In addition, once in the stepdown unit, he had multiple PVCs and eventually a 2.5 minute run of stable ventricular tachycardia (no change clinically, normal blood pressure). Cardiac enzymes were negative. Cardiology/Electrophysiology were consulted. He was treated with metoprolol for rate control. TTE showed that he had thickened AV leaflets, trace AR, mild thickened tricuspid valve, 2+ TR, and only 10-15% LVEF. High risk of re-stroke given paroxysmal atrial fibrillation. Plan to start coumadin if repeat head CT negative for bleed (see #1) post discharge. . 3. Systolic Heart Failure with NSTEMI: in evaluation for his atrial fibrillation and stroke, the patient had a TTE which demonstrated severely depressed global ventricular function with an ejection fraction of [**9-25**]%. He was started on a low dose beta blocker for arrythmias, which will also help his cardiomyopathy. It was unclear if this is a permanent problem for the patient or if this is myocardial stunning in the setting of an acute stroke (more often seen in Right MCA strokes). He was also noted with initally positive low troponins, possibly consistent with an NSTEMI, however this has been described in the literature as a side effect of a Right MCA stroke, although in truth there is clearly mycardial damage, so NSTEMI is probably the appropriate term regardless of the etiology. CHF team was consulted who felt that this was a nonischemic cardiomyopathy and therefore would not start anti-platelett therapy for this condition, especially in light of his gasrtic bleeding. At discharge, he was on a low dose beta blocker and low-dose ace inhibitor. He will need a repeat echo in 1 month to evaluate for improvement. His fluid status was monitored closely and he required daily Lasix to keep his I/O even. He was discharged on 80 mg of Lasix daily. Please follow daily weights on the patient. Please send the results of the repeat echo and weights with the patient when he comes to see Dr. [**First Name (STitle) 437**] in the [**Hospital 1902**] clinic for follow up. . 4. Acute renal failure: at admission, creatinine markedly elevated from expected prerenal azotemia. He responded to fluid, and ultimately stabilized around 1.8 which was his expected baseline. The renal team followed the patient through the hospitalization. He initially received large volumes of IV fluids for hypernatremia and then required aggressive diuresis. At discharge, his creatinine had been stable for one week and he was started on a low dose ace-inhibitor. His Vitamin D level was <4 and he was started on Vitamin D replacement at discharge. He will take 50,000 units weekly for 8 weeks followed by 800 units daily indefinitely. His PTH was 303. He will have renal follow up. . 5. Aspiration Pneumonia: at admission, the patient had a temperature to 100.0. Blood cultures in the ED grew [**3-15**] positive coagulase negative staphylococcus with several different morphologies. He was initially treated with vancomycin. He underwent TTE to evaluate his valves (see above) which was negative for endocarditis (but he did have valvular disease). ID was consulted who felt that his initial cultures were contaminants given the multiple different morphologies and negative subsequent cultures, therefore the antibiotics were discontinued. Later in his course the patient began to complain of shortness of breath (stable O2 saturations) and he had an xray which demonstrated a RLL pneumonia with effusion. He was treated for nosocomial pneumonia with levoquin, flagl and vancomycin. He was discharged on this regimen to complete a 14 day course. He had a CT scan to better delineate his pulmonary disease which showed consolidation of most of his RLL with a large pleural effusion. After 4 days of antibiotics, he had a repeat xray which demonstrated improvement in his infiltrate and effusion. He remained afebrile for most of his hospitalization and had no leukocytosis or worsening oxygen requirement. He felt subjectively better at discharge. Aspiration likely played a large role in this pneumonia (see below). He was maintained on standing nebs-albuterol/atrovent/normal saline. He requires his vancomycin to be dosed per level given his renal insufficiency. He should be dosed 1 gram daily for random level <15. . 6. Acute Blood Loss Anemia due to Gastric Hemorage: The patient was found to have coffee ground secretions from his NGT in the setting of a dropping hematocrit. His hematocrit dropped from 31.0 at admission to 21.1 over several days, and he ultimately began to have melena. GI was consulted who did not feel that the patient was a clinically stable for endoscopy because he could not tolerate the moderate sedation for the procedure due to his CHF. Helicobacter Pylori serologies were obtained, which were positive. He was medically managed with transfusion support, IV fluids, IV PPI, sucralfate and ultimately treatment for Helicobacter pylori. It is likely that the etiology of his GI bleed was gastritis or a stress ulcer in the setting of acute CVA, but this was unable to be confirmed. He is to complete 14 days of triple therapy for Helicobacter pylori infection. He continued to intermittently require blood transfusions during the hospitalization, the most recent transfusion was [**2141-2-28**]. . 7. Abnormal red cells: He was found to have nucleated RBCs and target cells on peripheral smear concerning for possible thalassemia. Per heme path, other cell lines did not appear to be abnormal, making malignancy lower suspicion. Hemoglobin electrophoresis was sent and was found to have sickle cell trait. He was iron deficient but given that oral iron can upset his stomach, the decision was made to hold off of iron supplementation until his hematocrit stabilized and he finished therapy for Helicobacter pylori. He will likely need iron supplementation. . 8. Hypernatremia: at admission, had a sodium of 161 and peaked at 164. He responded to free water repletion. At discharge his sodium was being managed by adjusting the fluid and NaCl content of his TPN. Goal sodium is 138-142 per renal consult. . 9. Skin: the patient developed several areas of skin breakdown during the hospitalization despite preventative measures including a coccygeal ulcer, an ulcer on his left heel, left elbow and left shoulder blade area. He was followed by the wound care team and aggressive pressure relief was reinforced. . 10. Aspiration: The patient was ultimately fed by TPN. He had several speech and swallow evaluations during this hospitalization, the most recent on [**2141-2-27**]. On this evaluation, the patient demonstrated overt signs of aspiration with both the most and least restrictive po textures as well as a significant oropharyngeal dysphagia. It also appears he may be aspirating his own secretions. He was therefore kept strictly NPO except medications and had frequent mouth care. His electrolytes were followed daily and his TPN was adjusted accordingly. . 11. Disposition: the patient was transferred to a stroke rehabilitation facility. He will complete his courses of antibiotics and his electrolytes will be monitored. The patient will continue on TPN for several weeks and will need follow up swallow evaluations as he continues rehabilitation from his stroke. Ultimately, he will likely need a G-J tube, but it is unsafe to give tube feeds at this point given his high aspiration risk and known aspiration pneumonia. Code status was addressed several times during the hospitalization, usually with his sister present, and the patient was full code at discharge. This will likely need to be an ongoing discussion. Communication was with his sister [**Name (NI) 37620**] [**Name (NI) **] and his brother. The patient's alertness and appropriateness improved during the course of the hospitalization and at discharge was alert and oriented and answered questions appropriately. Medications on Admission: Unclear at admission, per records: ** new since last PCP [**Name Initial (PRE) **] [**2-14**]. ** -benicar 40/25 (olmesartan medoxomil-hydrochlorothiazide) ** -caduet [**4-30**] (AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM) stopped HCTZ and diovan -ASA 81mg PO daily -clonidine 0.1mg PO BID -zocor 40mg Po daily -dynacirc CR (isradipine) 10mg PO daily (Ca channel blocker) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days: last dose [**2141-3-7**] . Disp:*qs Tablet(s)* Refills:*0* 8. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily): to coccygeal ulcer. 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: last dose [**2141-3-9**]. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days: last dose [**2141-3-9**]. 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for sbp <100, hr <60. 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for sbp <100. alternate times with metoprolol. 14. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp <100. 15. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours). 17. Insulin Regular Human 100 unit/mL Solution Sig: 1-10 units Injection ASDIR (AS DIRECTED). 18. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 8 days: dose only for random vancomycin level <15. Last dose should be [**2141-3-9**]. 19. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 8 weeks. 20. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a day: to start after 8 weeks of 50,000 units once a week. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: MCA cerebrovascular accident Nonischemic cardiomyopathy GI bleed Acute renal failure on chronic renal insufficiency Aspiration pneumonia Paroxysmal atrial fibrillation TPN dependent Coccygeal ulcer Discharge Condition: Stable, on room air, afebrile, to rehabilitation. Discharge Instructions: you develop chest pain, shortness of breath, nausea, vomiting, diarrhea, bloody stool, vomiting blood, fevers or new/worsening neurologic symptoms. . The patient is to complete 14 days of antibiotics for nosocomial/aspiration pneumonia--last day is [**2141-3-9**]. He will need vancomycin dosing per level. Dose 1 gram for random Vancomycin level <15. . The patient is to complete 14 days of antibiotics for Helicobacter pylori--last day is [**2141-3-7**]. . The patient will need to have daily electrolyte checks and adjustment in his TPN as needed. . Please monitor his I/O daily and adjust his lasix as needed. Please follow his potassium. . The patient will need to have daily hematocrit checks and may require intermittent transfusions. Given his poor cardiac status, goal hematocrit should be 30.0. . Please repeat Head CT in one week. If no evidence of hemorrhage, please start coumadin. Goal INR [**1-14**]. . Please repeat TTE 3 weeks from discharge. Please check the patient's weight daily. Please send the results of the TTE and weights to the [**Hospital 1902**] clinic follow up appointment. Followup Instructions: -Please make a follow up appointment with your PCP once you have completed rehabilitation. . -Neurology/Stroke: Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 33346**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2141-3-21**] 11:00 . -Nephrology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-3**] 9:00. . [**Hospital 37625**] clinic: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2141-4-17**] 10:00

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icd9cm

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126,767

21415

Discharge summary

report

Admission Date: [**2192-5-2**] Discharge Date: [**2192-5-10**] Date of Birth: [**2119-9-25**] Sex: M Service: NME DIAGNOSIS: Intracerebral bleed. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **], who is a 72 year-old man with history of hypertension and hypercholesterolemia and a recent cerebrovascular stroke of ischemic nature eight months ago that left him with left arm and leg weakness, was found to have distal right hand weakness with an episode of fall and a facial droop on the right side on [**5-1**]. He was seen in [**Location (un) 3844**] local hospital and his internal carotids were reported as 100 percent stenotic and occluded on the left. He was, therefore, referred to the vascular surgery service at our hospital, the [**Hospital1 190**]. Upon admission to the vascular service, carotid examination revealed left sided stenosis only less than 69 percent. A CAT scan and MRI as well as MRV were performed and a left sided hemorrhagic stroke was documented. Our service was consulted for the evaluation of his stroke. He was transferred to our care and was admitted to the Intensive Care Unit for overnight observation because the patient exhibited episodes of respiratory arrest during the catheterization study. The patient improved in the Intensive Care Unit and was transferred to our general neurology floor for the continuation of care. During his stay, his motor examination had revealed right sided weakness, as well as a right sided facial droop. These neurologic deficits improved during his stay and he was evaluated by the physical therapy to be safe to depart for home. During his admission, the patient underwent the following studies: Chest examination revealed no evidence of pneumonia on initial examination but mild evidence of congestive heart failure on the second and near resolution of all the cardiopulmonary findings on the third scan performed on [**5-8**]. Magnetic resonance imaging of brain, as noted above, revealed a left external capsule putamen hemorrhage with mild old lacunar infarct. His right vertebral artery from the level of the foramen magnum to the basilar artery had loss of signal. Left internal carotid artery had severe narrowing which was studied by ultrasound to be less than 69 percent stenotic. The patient also had a MR venous angiogram on [**5-3**] which revealed no abnormality. A video swallow study was performed several times, the last one of which was the day prior to discharge, revealed frank aspiration and a po diet consistency of nectar thick liquids with soft solids and crushed pills was recommended by the swallow team. LABORATORY DATA: Mild elevation of white count in the range of 12 to 13 on the last date of his admission. Thrombocytopenia which drifted down from 150 on admission to the range of 126 on the day of discharge. Normal INR. Normal urinalysis. Abnormal high creatinine which ranged between 1.4 to 1.9, with 1.7 on the day of discharge. Abnormally high glucose. Normal cardiac enzymes. Lipid panel: Triglycerides 132; cholesterol 138; HDL 34; LDL 78. HOSPITAL COURSE: As mentioned, the patient had MICU stay and was intubated because of episodes of respiratory arrest during the study of brain with CT. His stay on the general floor was uneventful and revealed major improvements. He received physical therapy evaluations and treatment on a daily basis. He continued on medical treatment with his blood pressure medications, including Metoprolol 50 mg twice a day. He received a full dose of Levaquin for four days for the findings of lower lobe opacity in his chest. He continued on aspirin 81 mg daily and, due to the presence of hemorrhage inside his brain, we discontinued his Plavix. He will, however, continue taking his Plavix on [**5-17**]. He had an episode of agitation and confusional spell in the Intensive Care Unit, for which he received Seroquel 2.5 mg twice a day with good effect. FOLLOW UP: 1. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Internal [**Last Name (LF) **], [**2192-5-16**] at 1:30 p.m. 2. Neurology follow up with Dr. [**Last Name (STitle) **] on [**2192-6-5**] at 1:00 p.m. 3. Speech and swallow follow up on a daily basis from home. As mentioned, the patient was at risk for frank aspiration and was instructed to take only soft diet with nectar thick fluids without any straws. Swallow and speech team arranged a follow up for this patient in his residence in [**Location (un) 3844**]. MEDICATIONS ON DISCHARGE: 1. Lipitor 10 mg po q day. 2. Levofloxacin 250 mg po q 24 hours for two more days. 3. Aspirin 81 mg po q day. 4. Plavix 75 mg po q day; hold until [**5-17**]. 5. Atenolol 50 mg po q day. DISCHARGE DIAGNOSIS: Left basal ganglionic ICH Asymptomatic left ICA stenosis CONDITION ON DISCHARGE: The patient was discharged home. His condition was good. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56549**] Dictated By:[**Last Name (NamePattern1) 55438**] MEDQUIST36 D: [**2192-5-11**] 15:02:19 T: [**2192-5-11**] 17:24:23 Job#: [**Job Number 56550**]

[ "287.5", "518.81", "433.10", "276.5", "401.9", "507.0", "482.41", "272.0", "431" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.71", "38.91", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

4765, 4823

4555, 4744

3119, 3956

3967, 4529

198, 3101

4848, 5158

12,152

165,049

5670

Discharge summary

report

Admission Date: [**2104-2-19**] Discharge Date: [**2104-3-3**] Date of Birth: [**2028-5-15**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 6114**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: s/p right hip ORIF s/p intubation History of Present Illness: 75yo F with CAD s/p MI x4 (s/p LAD stent '[**96**] and RCA stentx2 in '[**98**] and '[**02**]), CHF with EF 55%, PAF, Inducible Vtach s/p AICD placement, sick sinus syndrome s/p pacer and COPD with restrictive lung disease. Per daughter, pt was in her USOH until two days prior to admission when she was noted to have a superficial ulcerations on her foot with erythema. Pt was taken to [**Location (un) 511**] [**Hospital 11461**] Hospital and started on unasyn IV. Pt awoke later that night and felt unsteady on her feet and sustained a mechanical fall. Per daughter, pt did not note chest pain, tachycardia, had a good PO intake and no noted seizure activity. Pt was in severe "back pain" as per daughter which was treated with dilaudid. CT of the neck revealed a possible C1 fracture and the X-ray at the OSH revealed intratrochanteric fracture of the right femur. Pt was subsequently transferred to [**Hospital1 18**] for orthopaedic evaluation. In ED at [**Hospital1 18**], pt was seen by the Trauma service where a CT of the neck revealed no fracture (however, the c-collar was maintained secondary to pain). The orthopaedic service recommended emergent repair of the intratrochanteric fracture secondary to instability. The ED stay was complicated by runs of afib to 133 requiring IV lopressor. . ROS: Pt is very SOB at baseline, not on home ox, no CP at rest, no LE edema, no PND, stable orthopnea (2 pillows). Pt ambulates 10 feet with significant fatigue as per daughter. (?[**Month (only) **] in exercise tolerance). Med change include discontinuation of coumadin secondary to inc risk of upper GI bleed. Digoxin, Norvasc and Imdur was also discontinued. . HPI: 75 yoF with CAD s/p stenting, VT, SSS s/p pacer, COPD, presented to OSH [**2104-2-18**] with foot ulceration. Started on unasyn, in hospital suffered mech. fall with hip fx. Transferred to [**Hospital1 18**] [**2-19**]. Medically eval not high risk surgery, preop beta blocker given. . ORIF with repair of neck fracture [**2104-2-20**]. Expected prolonged extubation course given COPD history, as with colon CA resection surgery. In PM extubated, transferred to floor [**2104-2-20**]. . Late [**2-20**] found with afib and RVR, given beta blocker with min. response, started dilt. drip. Received 2 mg dilaudid for pain o/n. . This AM with respiratory failure, continued tachycardia on dilt. gtt. Transferred to unit and urgently intubated (labs below.) . Of note, a NGT by Xray was not in correct position ?lungs -> possibly used for medication administration this AM. Past Medical History: 1. CAD s/p LAD stent in '[**96**] +RCA stet in '[**98**] with repeat RCA stent in '[**02**]. Last cath in [**8-31**] 2. PAF 3. DM 4. Sick sinus syndrome s/p pacer placement in '[**96**] 5. Depression 6. COPD (no PFT available) 7. Chronic restrictive lung disease (no PFT available) 8. HTN 9. Hyperlipidemia 10. Obesity 11. s/p TAH 12. s/p colonic resection secondary to perforation s/p polypectomy 13. Inducible Vtach on EP study with AICD placement [**9-30**] 14. CHF 15. Upper GI bleed Physical Exam: VS: HR: 133 BP: 110/80 Gen: sedated but A+O x3 HEENT: cervical collar in place CV: tachycardia Chest: CTA bilaterally Abd: + BS, soft, NT, ND, BS+ Ext: no peripheral edema, R leg shortened and rotated, + cellulitis Pertinent Results: [**2104-2-19**] 02:45AM WBC-12.7* RBC-4.32 HGB-10.5* HCT-33.2* MCV-77* MCH-24.2* MCHC-31.5 RDW-15.4 [**2104-2-19**] 02:45AM NEUTS-90.5* LYMPHS-5.1* MONOS-3.7 EOS-0.6 BASOS-0.2 [**2104-2-19**] 02:45AM HYPOCHROM-3+ POIKILOCY-1+ MICROCYT-2+ [**2104-2-19**] 02:45AM PLT COUNT-324 [**2104-2-19**] 02:45AM PT-13.6 PTT-25.2 INR(PT)-1.2 [**2104-2-19**] 02:45AM GLUCOSE-191* UREA N-14 CREAT-0.6 SODIUM-141 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16 [**2104-2-19**] 02:45AM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.9 [**2104-2-19**] 11:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2104-2-19**] 11:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2104-2-19**] 11:25AM URINE RBC-0-2 WBC-[**3-1**] BACTERIA-OCC YEAST-NONE EPI-0 [**2104-2-19**] 11:25AM URINE HYALINE-3* [**2104-2-19**] 11:25AM CK(CPK)-178* [**2104-2-19**] 11:25AM CK-MB-7 [**2104-2-19**] 04:45PM D-DIMER-1748* [**2104-2-19**] 04:45PM CK(CPK)-153* [**2104-2-19**] 04:45PM CK-MB-5 cTropnT-<0.01 . . '[**98**] TTE: EF 50-55%; mild to moderate MR, left atrium is moderately dilated, trace AR . . [**8-31**]: Cardiac catheterization: inferior, posterobasilar hypokinesis, 1+MR, EF 48%, mid RCA 50%, distal RCA 40%, mid LAD 50%, OM3 diffusely diseased s/p stenting of RCA with drug eluting stent with 10% residual flow. . . [**2104-2-19**] CXR: moderate cardiomegaly without CHF, no effusions, left retrocardiac opacity consistent with atelectasis vs. consolidation . . [**2104-2-19**] CT c-spine: 1) No evidence of fracture of the cervical spine. No definite fracture of C1 is identified to correlate with the history of questioned C1 fracture from outside hospital. 2) Extensive degenerative change of the cervical spine." . . [**2104-2-19**] Femur & R knee X-ray: 1) Comminuted intertrochanteric fracture of the right femur, with avulsion of the lesser trochanter, displacement and angulation. 2) No other definite fractures identified. degenerative changes of the lumbosacral spine." . . [**2104-2-29**] Flexion extension xrays of cervical spine: Mild degree of instability at level C3-C4 as described. Possibility of arch element in this region cannot be excluded. Brief Hospital Course: A/P: 75yo F s/p MIx4, numerous cath, PAF, Inducible VTach s/p AICD and pacer with severe COPD/restrictive lung disease s/p fall with intertrochanteric fracture. As per ortho, pt requires emergent repair of intertrochanteric fracture to preserve neurovascular function. Pt is a moderate risk for a needed emergent non-cardiac procedure. Pt is medically cleared for procedure , likely has some mile rate related ischemia. . 1. Cards: ---Pre-op B-blocker with goal HR <70 ---No real utility in MIBI/cath prior to procedure gien previous caths with no significant lesions to be intervened on. ---V-Tach: pt has AICD in place, however b-blocker should contorl Vtach for now. ---B-blocker IV, Dilt PRN for PAF ---Hold coumadin for afib given hx of upper GIB and surgery in AM ---Continue ASA, plavix ---ROMI, check AM ECG . 2. COPD/Restrictive lung disease: ---Nebs/MDI PRN ---no need for steroids now ---expect prolonged wean given previous history of prolonged wean s/p colonic resection ---incentive spirometry for atelectasis . 3. Hip fracture: ---pain control with diluadid, tylenol ---lovenox tonight x1, hold AM dose per ortho ---Pt to OR in early AM . 4. Anemia: ---iron studies ---TSH ---no need fortransfusion currently, keep Hct >30 . 5. Hypokalemia: ---60IV K now ---continue PO K ---check lytes in PM . 6. Cellulitis: ---continue unasyn ---hold off on X-rays for now . 7. DM: ---RISS - tight glucose control pre-op . 8. [**Month/Day/Year 5**]: ---Protonix, Lovenox, R boot as per ortho . 9. Diet: NPO . 10. Code: Full --> DNR/DNI . MICU course: ORIF with repair of neck fracture [**2104-2-20**]. Had expected prolonged post-op extubation in PACU given COPD history, as with colon CA resection surgery. In PM extubated, transferred to floor [**2104-2-20**]. . Late [**2-20**] found with afib and RVR, given beta blocker with min. response, started dilt. drip. Received 2 mg dilaudid for pain o/n. . On [**2-21**] AM p/w with respiratory failure, continued tachycardia on dilt. gtt. Transferred to unit and urgently intubated. . Of note, there was a question of misplaced NGT. When NGT tube was pulled out, it was noted to have respiratory-like secretions. Concern for aspiration of mediations to lungs. However, evaluation of CXR revealed NGT coiled in esophagus. . Pt's respiratory distress is most likely on setting of aspiration pneumonia vs. pneumonitis in the setting of depressed mental status secondary to post-operative narcotics. Pt was pan-cultured and switched from unasyn (started at OSH for foot ulcer) to zosyn. Vanco was added for possible nosocomial infection. CTA was performed which was negative for PE, but revealed bilateral patchy ground glass opacities c/w aspiration vs. pneumonia vs. edema. Pt was weaned down on ventilator, minimal secretions noted. On [**2-24**], pt was noted to have depressed mental status off all sedating medications; mental status improved over the course of the day. Pt was diuresed. Atrial fibrillation was rate-controlled on dilt drip. Dilt drip was discontinued and metoprolol titrated up. Cardiac enzymes were cycled in setting of rapid AF and were flat. Initially, pt was noted to be dry with low FeNa and given IVF. Then, noted to be volume overloaded and diuresed with lasix. Pt had depressed mental status on transfer to MICU in setting of narcotics. She was then started on propofol while intubated. Head CT was negative for acute bleed, mass effect, or stroke. Mental status improved during times when propofol was held. On [**2-24**], pt was noted to have significantly depressed M.S. off propol improved off sedation. All sedating medications including prn narcotics were held and mental status cleared somewhat. s/p hip fx repair: started on lovenox for anti-coagulation. Given standing NSAID, tylenol for pain control. opiates used very sparingly in setting of MS change On transfer to floor team from MICU active issues and plan included: Resp failure/COPD: Initially got steroids upon intubation. Off for days now. Extubated on [**2-28**]. Still tachypneic and hypoxic on room air. Lung sounds fairly clear. ?COPD vs atelectasis as cause of hypoxia. On [**Last Name (LF) **], [**First Name3 (LF) **] pe less likely - atrovent standing. prn albuterol only given A fib with RVR - inhaled steroids - obtaining pcp set of [**Name9 (PRE) 11149**] . Fever: In the ICU. Had received unasyn, vanc, zosyn during hospital course for cellulitis and other unclear reasons, including possible vent associated pna. No true source found. Afebrile >24 hours off abx. - culture if spikes. No abx unless source found . a.fib with RVR - Has ppm, so can have lot of nodal agents. Now rate controlled on metop 125 tid and dilt. 30 QID. Titrate prn. - continue nodal agents - consider anti coag for cva prevention, but wait until ambulating better . CAD: on asa, b blocker, ace. No statin. need to clear with family . Heme - anemic. Unclear baseline. Possible anemia [**1-30**] operative blood loss. Follow hct daily Goal >28 . Neck: never had c spine cleared by neurosurg. Had fall pta with ?fx on initial CT, neg fx on f/u ct. - flex/ext films done - will clear with neursurg prior to removing hard collar Overnight on pt's first evening on the floor, she had episode of desaturation with inc O2 requirement (4L->6L-> sating 91% on NRB) - CXR with worsening - non responsive to lasix. Family meeting held and pt made clear wishes after extubation that she does not want to be intubated again and made DNR/DNI. No BIPAP. Now pt lethargic and min responsive. All four children in pts room and agree on [**Month/Day (2) 3225**] - want to d/c c-collar and start morphine ggt. Discussed with night float cover Dr. [**First Name (STitle) **] COmmander and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**]. Although Dr. [**Last Name (STitle) **] will be covering pt today, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3646**] spoke with family this morning and has noted that pt is [**Name (NI) 3225**]. EP was called to deactivate pt dual chamber ICD as per family wishes. On exam, pt lethargic, responsive to pain but not voice, with NRB in place; obvious inc wob. IV in R foot for access. Family at bedside. afebrile; BP: 159-161-139-98(after morphine)/69 HR: 148-->88; rr: 28-40 O2: 94% NRB . As above, made [**Name (NI) 3225**] after meeting with NF team and family and reconfirmed with primary medical team on [**3-1**]. Start morphine ggt and titrate to comfort. D/c'ed all lab draws/vitals. Prn nebs for comfort. Family at bedside and aware and in agreement of plan. Morhpine ggt titrated up to 18mg/hr by monday morning and pt expired [**3-3**] at 7:40am. Medications on Admission: MEDICATION: 1. Coumadin 2mg once daily (stopped recently due to risk of GI bleed) 2. Zoloft 100mg once daily 3. Toprol 100mg [**Hospital1 **] 4. Lasix 40mg [**Hospital1 **] 5. AS 81mg once daily 6. Plavix 75mg once daily 7. KCl 40mEq once daily 8. Prandin 0.5mg once daily 9. Unasyn 3gIV Q8hours . ALLERGIES: Morphine -> confusion/delerium. . Discharge Disposition: Expired Discharge Diagnosis: n/a Discharge Condition: n/a Discharge Instructions: n/a Followup Instructions: n/a

[ "E885.9", "707.15", "428.30", "357.2", "998.11", "496", "V53.32", "997.3", "250.60", "428.0", "820.21", "285.1", "272.4", "348.39", "412", "507.0", "427.31", "401.9", "414.01", "681.10", "276.2", "458.29" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "88.43", "96.72", "96.6", "99.04", "38.91", "79.35", "97.01" ]

icd9pcs

[ [ [] ] ]

13043, 13052

5964, 12641

277, 312

13099, 13104

3694, 5941

13156, 13162

13073, 13078

12667, 13020

13128, 13133

3454, 3675

229, 239

343, 2911

2933, 3439

82,006

125,850

54442

Discharge summary

report

Admission Date: [**2142-12-5**] Discharge Date: [**2142-12-7**] Date of Birth: [**2088-4-3**] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 2763**] Chief Complaint: vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 54 year old female with anxiety presenting with diarrhea x1 day and n/v x12 hours. Patient reports [**3-30**] diffuse, intermittent abd cramping and has been unable to tolerate po intake. She denies fevers/chills but does report dizziness. Denies blood in vomit or stool. Denies sick contacts, unusual foods. Patient refused to answer any additional questions despite repeated attempts, and no further history was able to be obtained. . In the ED, initial vs were: T98.8 P116 BP 135/97 R18 PO2 100%. Patient was given Zofran 4mg IV x2, Compazine 10mg IV x1, 5L NS and was tachycardic persistently in the 130's-160's, with an EKG showing sinus tachycardia. Patient continued to have nausea/vomiting and diarrhea, and reportedly had nystagmus with dizziness. She received Valium 5mg IVP. She was found to have K 2.8 and was given 40meq of Potassium. Prior to transfer to floor, vital signs were P142 BP 139/84 sats NL RA. . In the MICU, the patient was lying in bed snoring, and was uncooperative. She denied abdominal pain, reported continued nausea but tolerated fluids and ice chips in the MICU. She was guiac negative in the MICU. Past Medical History: - Hypertension - Hyperlipidemia - GERD - Metabolic syndrome - Colonic polyps - History of hepatitis - Urinary incontinence - Osteopenia - hx of Obstructive sleep apnea--could no tolerate mask - H/o elev liver enzymes Social History: No smoking, minimal alcohol, no drugs. She is a therapist. Family History: No family history of premature heart disease--though her father had cardiac bypass surgery at age 68 followed by a stroke; and her grandfather had an MI at age 60. Physical Exam: GEN: Alert, uncooperative, minimally interactive, NAD. HEENT: PERRL, sclera anicteric, no cervical lymphadenopathy, mmm. CV: Tachycardic, RR, no m/g/r. PULM: CTAB but with poor inspiratory effort, equal BS b/l. ABD: Soft, NT/ND, +BS. LIMBS: No pedal edema, warm, well perfused, 2+ DP/PT/radial pulses b/l. SKIN: No visible rashes, though patient refused to have blankets removed for full skin exam. NEURO: Limited exam [**1-22**] lack of cooperation from patient. CN II-X grossly intact, UE grip strength 5/5 b/l, strength and sensation unable to be assessed [**1-22**] lack of cooperation. Pertinent Results: Admission labs: [**2142-12-5**] 04:45PM BLOOD WBC-14.3*# RBC-4.83 Hgb-12.8 Hct-38.2 MCV-79* MCH-26.6* MCHC-33.5 RDW-14.5 Plt Ct-315 [**2142-12-5**] 04:45PM BLOOD Glucose-123* UreaN-9 Creat-0.7 Na-145 K-2.8* Cl-108 HCO3-24 AnGap-16 [**2142-12-5**] 10:43PM BLOOD Calcium-9.7 Phos-2.1* Mg-0.3* . Discharge labs: [**2142-12-7**] 04:31AM BLOOD WBC-13.4* RBC-4.21 Hgb-11.9* Hct-33.4* MCV-79* MCH-28.1 MCHC-35.5* RDW-14.8 Plt Ct-278 [**2142-12-7**] 04:31AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-144 K-3.4 Cl-112* HCO3-25 AnGap-10 [**2142-12-7**] 04:31AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.2 . Stool and blood cultures negative to date. Brief Hospital Course: 54yoF with history of anxiety presented with n/v, diarrhea, abdominal pain for the past day, tachycardic to the 140's in the ED. Admitted to the MICU for persistent tachycardia. Treated N/V symptomatically. Aggressively repleted electrolytes and fluids. Tachycardia improved, patient felt better, and was discharged directly home from the ICU. . # Nausea/Vomiting/Diarrhea: Most likely viral gastroenteritis given rapid timecourse. Cultures were drawn and were negative after 24 hours. Patient had significant electrolyte imbalances. These were repleted aggressively. She was fluid resusitated as below. Controled symptoms with anti-emetics including compazine, zofran, and ativan. . # Electrolyte imbalances: During the admission the patient was noted to have low phosphate, low potassium, and low magnesium. These were repleted aggressively. While diarrhea and vomiting can cause this, there was concern that it was out of proportion to her acute illness. An email was sent to her PCP with concern for alcohol abuse or eating disorder as an underlying etiology of these deficiencies. She has short term follow up with the [**Hospital **] Clinic and her PCP for these issues. # Tachycardia: Sinus tachycardia by EKG, likely [**1-22**] dehydration in the setting of diarrhea, emesis, abdominal pain, and under-resusitation in the ED. Also may have a component of pain, anxiety. Given lack of risk factors, as well as lack of right heart strain on EKG, less likely to be PE. Improved with fluids. Medications on Admission: ESOMEPRAZOLE MAGNESIUM E.C. 40 mg Capsule po daily FLUTICASONE 50 mcg Spray, 2 sprays each nostril once a day LORAZEPAM 0.5 mg Tablet po bid prn insomnia or anxiety NAPROXEN 500 mg Tablet po bid ROSUVASTATIN 20 mg Tablet po daily TOLTERODINE [DETROL LA] 2 mg Capsule Sust. Release po daily TRAZODONE 100 mg Tablet po qhs VALSARTAN 80 mg Tablet po daily CALCIUM-VITAMIN D3-VITAMIN K 500 mg-200 unit-[**Unit Number **] mcg Tablet, Chewable po bid GLUCOSAMINE 1500 mg Tablets po daily Cymbalta 20mg daily Discharge Medications: 1. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO once a day. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for anxiety/insomnia. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays per nostril Nasal once a day. 9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Glucosamine 500 mg Tablet Sig: Three (3) Tablet PO once a day. 11. Calcium-Vitamin D3-Vitamin K 500-200-40 mg-unit-mcg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Gastroenteritis 2. Sinus tachycardia 3. Hypokalemia 4. Hypophosphatemia Secondary: 1. Hypertension 2. anxiety Discharge Condition: Improved, alert and oriented x 3, conversant, able to ambulate independently. Discharge Instructions: You were admitted to the hospital for vomiting, diarrhea and dehydration. When you were admitted, your heart was beating very rapidly from dehydration, leading to your admission to the MICU. Followup Instructions: You have an appointment scheduled with: MD: Dr.[**First Name (STitle) **] [**Name (STitle) **] Specialty: [**Hospital3 **] Post [**Hospital **] Clinic Date/ Time: Wednesday, [**12-12**]@ 10:10am Location: : [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) **] South, [**Location (un) 830**], [**Location (un) 86**] Phone number: [**Telephone/Fax (1) 250**] Special instructions for patient: This appointment is for follow up to your hospitalization. You will then be connected to your Primary Care provider after this visit. You will need to have your blood electrolytes re-checked at this appointment. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2142-12-7**]

[ "300.00", "008.8", "327.23", "401.9", "276.51", "427.89", "275.2", "276.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6284, 6290

3242, 4741

286, 293

6457, 6537

2590, 2590

6777, 7544

1789, 1954

5294, 6261

6311, 6436

4767, 5271

6561, 6754

2899, 3219

1969, 2571

228, 248

321, 1456

2606, 2883

1478, 1697

1713, 1773

11,901

194,700

46168

Discharge summary

report

Admission Date: [**2177-1-7**] Discharge Date: [**2177-1-10**] Date of Birth: [**2109-11-23**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Hcl / Penicillins / Bactrim / Cephalexin / Nitrofurantoin / Dilantin / Tegretol / Iodine; Iodine Containing Attending:[**First Name3 (LF) 783**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 67yo woman with history of ESRD s/p Cadaveric Renal Transplant in '[**66**], CAD, presented after reportedly having a fall resulting in her lying on the ground for about 4hrs in total. By review of records, she stated that she slipped on carpet around 11pm. No antecedent pre-syncope, CP, SOB, palpitations, n/v/d or decreased po intake. . In ED, she had altered mental status. Rectal temp was 101.8. Otherwise, she was afebrile throughout. BP was in the 90s/50s which trended upward to 115/64 after IVF (of note, she states that her baseline blood pressure is 100/60). In total, she received 2.5L NS in IVF. Regarding possible infection, she had cultures sent, and was empirically covered with vanco/levo/flagyl. She was volume resuscitated with IVF, and was given stress dose steroids with Decadron 8mg IV. . Regarding her fall, she had no acute fractures or hemorrhage on head CT, CT C-spine, or any evidence for RP bleed on Abd CT. . She did, however, have marked CK elevation at 3383, MB of 16, MBI of 0.5, and trop of 0.14. Her creatinine was elevated at 3.0 (from baseline of 2.0). Anion gap of 22. UA had moderate blood with 0-2 RBCs, suggesting myoglobinuria. Creatinine has begun to trend back down from 3.0 to 2.5. . Upon interview in MICU, she is alert and oriented completely. She confirms this history and has an otherwise negative review of systems. She denies any current f/c/n/v/cp/sob/abd pain or other complaints. . Past Medical History: 1. Renal transplant in [**2166**] secondary to chronic reflux nephropathy. 2. Status post craniotomy for an intracranial aneurysm. 3. Osteopenia. 4. Status post cholecystecomy 5. Status post appendectomy 6. Osteonecrosis of feet c/b osteomyelitis now on IV Vanco 7. Hx of c.dif 8. Hx of MRSA 9. NSTEMI - [**6-30**] - Catheterization did not result in intervention. Social History: She is divorced and lives alone. She quit smoking 20 years ago. She occasionally drinks alcohol. Family History: Non-contributory Physical Exam: VS: 97.3, 79, 122/72, 19, 95% on 2l NC . gen: a/o, no acute distress HEENT: NCAT, mmm, anicteric, neck supple COR: RRR, 2+ systolic murmur PULM: clear ABD: +BS, soft, NTND rectal: guaiac neg brown stool (in ED) EXT: larg ecchymoses on LLE NEURO: alert and oriented, CN II-XII in tact, [**3-29**] upper and lower extremity strength Pertinent Results: EKG: NSR, 78bpm, Nl axis, intervals. TWI and 1mm ST depressions from V3-6 compared to prior EKG. chest film: no acute process CT head: IMPRESSION: No evidence of acute intracranial hemorrhage. CT C-spine: IMPRESSION: 1. No evidence of cervical spine fracture or malalignment. 2. Mild-to- moderate degenerative changes as described, particularly at C4/5 and C5/6. At C5/6, a disk osteophyte complex abuts the ventral spinal cord, without prior studies for comparison. If indicated, further imaging could be performed. . CT abd/pelvis: IMPRESSION: 1. No evidence of acute intraabdominal hemorrhage. 2. Unchanged appearance of pneumobilia and diverticulosis. . [**6-30**] cardiac cath: PROCEDURE DATE: [**2176-7-8**] INDICATIONS FOR CATHETERIZATION: Non ST-elevation MI. Severe LV systolic dysfunction (new). Heart failure. FINAL DIAGNOSIS: 1. Single vessel branch coronary artery disease with diffuse atherosclerosis in calcified, tortuous vessels. 2. Intramyocardial segment of the mid-LAD. 3. Mild pulmonary arterial hypertension. 4. Mild systemic arterial systolic hypertension. COMMENTS: 1. Coronary angiography in this right dominant system demonstrated single vessel branch coronary artery disease. The LMCA had mild ostial calcified plaquing. The LAD was moderately calcified with a 40% mid-segment stenosis at a large D1. The D1 itself had a 50-60% stenosis at its origin. There was a long intramyocardial mid-LAD segment with tortuous LAD proximal and distal to this intramyocardial segment. The D2 was tortuous. The LCx was a modest-sized AV groove vessel supplying a distal OM/LPL. The RCA was heavily calcified proximally with tortuous RPL and RPDA. 2. Resting hemodynamics revealed elevated left sided filling pressure with a mean PCWP of 18 mm Hg. There was mild pulmonary arterial hypertension (36/17 mm Hg) and mild systemic arterial systolic hypertension (SBP 142 mm Hg). The cardiac index was normal at 2.5 L/min/m2. There was no transaortic gradient upon pullback of the catheter from the LV to the aorta. [**2177-1-7**] 05:38PM GLUCOSE-191* UREA N-18 CREAT-1.9* SODIUM-131* POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-17* ANION GAP-18 [**2177-1-7**] 05:38PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.7 [**2177-1-7**] 10:09AM ALT(SGPT)-35 AST(SGOT)-107* LD(LDH)-384* CK(CPK)-1744* ALK PHOS-66 TOT BILI-0.4 [**2177-1-7**] 10:09AM CK-MB-9 cTropnT-0.03* [**2177-1-7**] 10:09AM ALBUMIN-3.1* CALCIUM-7.3* PHOSPHATE-4.3# MAGNESIUM-1.7 [**2177-1-7**] 08:04AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004 [**2177-1-7**] 08:04AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2177-1-7**] 08:04AM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0 [**2177-1-7**] 05:30AM URINE OSMOLAL-146 [**2177-1-7**] 02:00AM GLUCOSE-133* UREA N-20 CREAT-2.5* SODIUM-127* POTASSIUM-3.5 CHLORIDE-90* TOTAL CO2-20* ANION GAP-21 [**2177-1-7**] 02:00AM ALT(SGPT)-45* AST(SGOT)-142* LD(LDH)-354* CK(CPK)-2764* ALK PHOS-78 AMYLASE-35 TOT BILI-0.5 [**2177-1-7**] 02:00AM cTropnT-0.07* [**2177-1-7**] 02:00AM CK-MB-13* MB INDX-0.5 [**2177-1-7**] 02:00AM ALBUMIN-3.5 CALCIUM-8.6 PHOSPHATE-4.5# MAGNESIUM-1.8 [**2177-1-6**] 11:31PM LACTATE-1.4 [**2177-1-6**] 08:30PM NEUTS-63.7 LYMPHS-26.0 MONOS-5.4 EOS-3.3 BASOS-1.5 [**2177-1-6**] 08:30PM WBC-7.9 RBC-4.38 HGB-12.8 HCT-38.2 MCV-87 MCH-29.1 MCHC-33.4 RDW-18.5* [**2177-1-6**] 08:30PM CK-MB-16* MB INDX-0.5 [**2177-1-6**] 08:30PM cTropnT-.14* [**2177-1-6**] 08:30PM CK(CPK)-3383* [**2177-1-6**] 08:30PM GLUCOSE-57* UREA N-22* CREAT-3.0* SODIUM-129* POTASSIUM-3.9 CHLORIDE-87* TOTAL CO2-20* ANION GAP-26* [**2177-1-6**] 09:00PM PT-11.1 PTT-26.7 INR(PT)-0.9 [**2177-1-6**] 11:31PM LACTATE-1.4 Brief Hospital Course: A/P: 67yo woman with h/o renal transplant presents after mechanical fall with rhabdomyolysis, elevated creatinine, and troponin elevation. . # Fall: per pt's version of the story the fall seems mechanical. no h/o LOC. CT head neg for bleed. CT spine did not show any fracture. pain was well controlled with percocet. Pt worked with PT to increase ambulation. however she is limited at baseline because of the osteonecrosis of the L hip which causes pain at rest and on ambulation. . # [**Name (NI) 25933**] Pt had a fever of 101 in the ED. she did not have any fever after she was transfered to the ICU and later on on the floors. no localizing symptoms. No clear pulmonary infiltrates. UA equivocal; urine cx not sent in ED. No infectious findings on abdominal/pelvis CT. No meningeal signs/symptoms to warrant LP. . # [**Name (NI) 10271**] pt is ESRD s/p Renal Tx. US [**2177-1-7**] without obstruction and stable transplant kidney function, patent vascular supply. Renal followed te patient through out the admission. prerenal etiology per urine lytes; CT abdomen and U/S kidney show no hydronephrosis and stable kidneys. Cr trended down over the hospital course to 1.2. continued on rapamune and prednisone. # EKG changes w/troponin elevation- .the CK elevation was thought to be secondary tp rhabdomyolysis from the fall. the renal failure might have contributed to elevated trop. cardiac enzymes trended down over hospital course. TTE [**2177-1-7**] w/o wall motion abnormalities. continued ASA, BB . # FEN: renal diet . # ACCESS: peripheral IVs # Code- full . Medications on Admission: ACYCLOVIR 400 mg--1 tablet(s) by mouth twice a day AMBIEN 10 mg--1 tablet(s) by mouth qhs prn sleep AMIODARONE 200 mg--1 tablet(s) by mouth three times a day ASPIRIN 325 mg--1 tablet(s) by mouth once a day Albuterol (Refill) 90 mcg--2 puffs ih four times a day CALCITRIOL 0.25 mcg--1 capsule(s) by mouth twice a day Fluticasone 110 mcg/Actuation--2 puffs ih twice a day KLONOPIN 0.25 mg--1 tablet(s) by mouth twice a day LIPITOR 40 mg--1 tablet(s) by mouth once a day LISINOPRIL 5 mg--1 tablet(s) by mouth once a day METOPROLOL TARTRATE 25 mg--1 tablet(s) by mouth twice a day OXYCONTIN 10 mg--1 tablet(s) by mouth twice a day OXYCONTIN 20 mg--1 tablet(s) by mouth qam in addition to 10mgtab for a total of 30mg q am PERCOCET 5 mg-325 mg--1 tablet(s) by mouth tid prn pain PREDNISONE 10 mg--[**11-28**] tablet(s) by mouth qd as per dr [**Last Name (STitle) **] PREDNISONE 5MG--One by mouth every day PRILOSEC 20 mg--2 capsule(s) by mouth once a day PROCHLORPERAZINE MALEATE 10 mg--1 tablet(s) by mouth qd prn nausea QUININE 260 MG--[**11-26**] by mouth at bedtime as needed for leg cramps RAPAMUNE 1 mg--2 tablet(s) by mouth q m, w, f; 1 tab q sun,tues,thurs,sat 10 pills per week WHEELCHAIR --Dx: foot surgery LEVOXYL 50 mcg--1 tablet(s) by mouth once a day Discharge Medications: 1. Wheelchair Misc [**Month/Day (2) **]: One (1) wheelchair Miscellaneous once a day. Disp:*1 chair* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every six (6) hours as needed for pain for 2 weeks. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levothyroxine 50 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Sirolimus 1 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 8. Sirolimus 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 9. Prednisone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 10. Methyl Salicylate-Menthol 15-15 % Ointment [**Month/Day (2) **]: One (1) Appl Topical PRN (as needed). 11. Acyclovir 200 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO Q12H (every 12 hours). 12. Calcitriol 0.25 mcg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day). 13. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Mechanical fall Secondary diagnosis: 1. Renal transplant in [**2166**] secondary to chronic reflux nephropathy. 2. Status post craniotomy for an intracranial aneurysm. 3. Osteopenia. 4. Status post cholecystecomy 5. Status post appendectomy 6. Osteonecrosis of feet c/b osteomyelitis 7. Hx of c.diff 8. Hx of MRSA 9. NSTEMI [**6-30**] Discharge Condition: At baseline for leg pain and mental status, vital signs stable, feels well. Discharge Instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2g 2. Please take all medications as prescribed. 3. Please followup with all appointments with your physicians as written below. 4. Please come to the emergency room if you experience a fall, dizziness, chest pain, shortness of breath, increasing pain in your leg, or other concerning symptoms. Followup Instructions: 1. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-1-17**] 2:30 PM, for left hip MRI. 2. Orthopedics: Dr. [**First Name (STitle) **], Tuesday [**2177-1-21**] 10:45 AM, [**Hospital Ward Name 23**] building, [**Hospital Ward Name 516**], [**Location (un) **]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2177-1-11**]

[ "733.90", "E888.9", "E878.0", "276.52", "728.88", "996.81", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10801, 10859

6540, 8113

391, 397

11258, 11336

2775, 2902

11804, 12264

2387, 2405

9424, 10778

10880, 10880

8139, 9401

3620, 6517

11360, 11781

2420, 2756

3529, 3603

342, 353

425, 1866

2911, 3496

10937, 11237

10899, 10916

1888, 2254

2270, 2371

24,769

183,532

46381

Discharge summary

report

Admission Date: [**2195-7-23**] Discharge Date: [**2195-7-29**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 76 year old white female with a history of coronary artery disease, status post coronary artery bypass graft in [**2195**], congestive heart failure, hypertension, peripheral vascular disease, atrial fibrillation, Graves' disease, on Coumadin therapy, who presents with a two day history of melena and light-headedness. The patient was in her usual state of health until two days ago when she had her first bout of formed black tarry stools accompanied by light-headedness and fatigue. No nausea, vomiting, diarrhea or abdominal pain. No prior history of gastrointestinal bleeding, peptic ulcer disease, varices or melena. Weakness and fatigue was progressive. Two further episodes of melena yesterday. On the day of admission, the patient was very pale with severe light-headedness and orthostasis. The patient had another episode of loose melena and felt "like I was going to die". She was very weak and had shortness of breath and dyspnea on exertion. The patient also has a history of chronic sternal chest pain. The patient has previously been admitted in [**2195-3-19**], for massive epistaxis after starting on Coumadin. The patient has never had an esophagogastroduodenoscopy and her last colonoscopy was over ten years ago and was negative per the patient. No history of alcohol abuse or hepatitis. In the Emergency Department, her rectum was positive for melena. Hematocrit was 18.5 which is down from a baseline of 30.0 to 33.0. She had an INR of 1.7. Blood pressure was 103/53, heart rate 77, respiratory rate 16, 93% in room air. Nasogastric lavage was clear. The patient was started on blood transfusions. PHYSICAL EXAMINATION: Temperature 98.9, heart rate 92, blood pressure 140/44, respiratory rate 20, 100% on two liters. In general, a pleasant elderly white female in no acute distress. Head, eyes, ears, nose and throat - The oropharynx is clear, no retropharyngeal blood or blood in nares. The neck was supple with no lymphadenopathy. Faint left carotid bruit was heard. Cardiac examination - The patient was tachycardic with regular rhythm, no murmurs, rubs or gallops. The lungs were clear to auscultation bilaterally. The abdomen was soft with mild tenderness in the epigastrium, no rebound and no guarding. Positive bowel sounds, no hepatosplenomegaly, no costovertebral angle tenderness. Extremities - capillary refill less than two seconds. Dorsalis pedis pulses were not palpable. LABORATORY DATA: Esophagogastroduodenoscopy showed a hiatal hernia, antral gastritis and was otherwise normal. Colonoscopy revealed multiple polyps in the ascending colon. The polyps were removed. There was oozing blood from one polyp, no additional polyps were taken and the bleeding polyp was electrocauterized. Small bowel follow through showed no masses or lesions in the small bowel noted. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit where she was transfused four units of blood. The patient's Coumadin and Aspirin were held. The patient was ruled out for myocardial infarction with negative enzymes times three. The patient was transferred to the floor in stable condition. The patient's hematocrit stabilized to 32.0 to 34.0 range. DISCHARGE MEDICATIONS: 1. Lipitor 40 mg p.o. q.d. 2. Zestril 20 p.o. q.d. 3. Lopressor 50 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Lasix 40 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. 7. Combivent MDI. 8. K-Dur 20 meq p.o. q.d. 9. Synthroid 100 mcg p.o. q.d. 10. Multivitamins. 11. TUMS. The patient is to have follow-up colonoscopy with either Dr. [**Last Name (STitle) 6861**] or Dr. [**Last Name (STitle) **] in three months. The patient is to hold Coumadin and Aspirin for at least seven days. The patient is to follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**], within one week. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged to home. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed likely secondary to polyps. 2. Coronary artery disease, status post coronary artery bypass graft in [**2195-1-19**]. 3. Congestive heart failure with an ejection fraction of 55%. 4. Chronic obstructive pulmonary disease. 5. Graves' disease, status post thyroidectomy. 6. Hypertension. 7. Peripheral vascular disease. 8. Hypercholesterolemia. 9. Atrial fibrillation. 10. Gastroesophageal reflux disease. 11. History of pneumothorax. 12. Status post cholecystectomy. 13. Status post total abdominal hysterectomy. 14. Status post pulmonary wedge resection for hamartoma in [**2193**]. 15. Status post carotid endarterectomy times two. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 7112**] MEDQUIST36 D: [**2195-7-29**] 17:31 T: [**2195-7-29**] 21:03 JOB#: [**Job Number **]

[ "280.0", "496", "211.3", "414.01", "V58.61", "428.0", "427.31", "578.1", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "45.43", "45.25", "45.13" ]

icd9pcs

[ [ [] ] ]

4116, 5061

3376, 4006

2988, 3353

1797, 2970

121, 1774

4031, 4095

10,027

199,395

52362

Discharge summary

report

Admission Date: [**2190-7-13**] Discharge Date: [**2190-7-25**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Mitral valve prolapse, coronary artery disease Major Surgical or Invasive Procedure: 1. Coronary artery bypass grafting with the saphenous vein graft to the left anterior descending artery and to the first obtuse marginal artery. 2. Mitral valve replacement with a 27 mm [**Doctor First Name 7624**] pericardial model 2600 valve. History of Present Illness: This is an 82-year-old female with a history of dementia who was noted dyspneic on exertion to the point where she is almost wheelchair bound. She had work- up which showed coronary artery disease involving the left anterior descending artery and the first obtuse marginal artery, as well as severe mitral regurgitation with valve segments of the both the anterior and posterior leaflets. She also has moderate tricuspid regurgitation. After discussion with the patient and her family, it was felt that she would benefit from mitral valve replacement, as well as bypassing the coronary artery stenosis. The risks were explained to the patient and her family, and they agreed to proceed. Past Medical History: Hypercholesterolemia, HTN, DM, CHF, dementia, CRI, CVA/TIA Physical Exam: 96.4, HR 79, 140/74, 20, 94% room air No distress CTAB RRR Incision c/d/i, no erythema Soft, NTND, +BS Trace edema PICC line right arm Pertinent Results: [**2190-7-13**] 09:42PM WBC-6.7 RBC-3.76* HGB-11.0* HCT-30.1* MCV-80* MCH-29.2 MCHC-36.4* RDW-15.5 [**2190-7-13**] 09:42PM PLT COUNT-191 [**2190-7-13**] 12:59PM UREA N-30* CREAT-1.2* CHLORIDE-112* TOTAL CO2-21* Brief Hospital Course: The patient was admitted and underwent CABG procedure on [**2190-7-13**] (see op note). Postoperatively, she had dysrhythmias which persisted despite medical therapy. Cardiology was consulted and implanted a pacemaker on [**2190-7-19**]. She tolerated the procedure without complications and was transferred to the floor on POD 8. She was anticoagulated with Coumadin but had a supratherapeutic INR. Coumadin was readjusted and she was deemed fit for discharge to rehab on POD 12 with an INR of 3.3. Medications on Admission: ASA 81, Lipitor 20, Lisinopril 10, Lasix 20, Lopressor, exelon 1.5", Glipizid 7.5, Memantine 10", Diazepam prn Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: Disp:*60 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*0* 9. Rivastigmine 1.5 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days: then 400mg QD x 1 week then 200mg QD. Disp:*45 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1439**] [**Last Name (NamePattern1) 13089**] Care Center - [**Location (un) 1439**] Discharge Diagnosis: s/p MVR(#27 pericardial)CABGx2(SVG-OM, SVG-LAD)[**7-13**] PMH: HTN,^chol, DM, CHF, CRI,CVA,mild dementia 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 woounds. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) **] in 4 weeks Call for appointment, [**Telephone/Fax (1) 26721**]. Completed by:[**2190-7-25**]

[ "585.9", "250.00", "427.31", "424.0", "790.92", "426.6", "414.01", "428.0", "294.8", "569.1", "401.9", "397.0" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72", "99.07", "38.93", "99.05", "39.61", "99.04", "35.23", "99.62", "96.26", "36.12", "88.72" ]

icd9pcs

[ [ [] ] ]

3773, 3913

1772, 2273

315, 561

4062, 4069

1531, 1749

4271, 4432

2434, 3750

3934, 4041

2299, 2411

4093, 4248

1376, 1512

229, 277

589, 1279

1301, 1361

28,853

127,437

5090

Discharge summary

report

Admission Date: [**2150-9-19**] Discharge Date: [**2150-9-30**] Date of Birth: [**2075-6-25**] Sex: M Service: CARDIOTHORACIC Allergies: Ambien Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2150-9-21**] Cardiac catherization [**2150-9-24**] Coronary artery bypass graft x4 (Left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) History of Present Illness: 75 year old male started having left-sided CP, [**3-21**] non-radiating when woke up yesterday. Took nitro spray and ASA (325) without relief. Walked downstairs and then started having [**2153-7-19**] CP that radiated to jaw, took some more nitro and ASA and rested on couch without relief. Wife called ambulance who brought him to [**Hospital **] Hospital. At [**Doctor Last Name **] EKG was w/out ST changes and first set of enzymes nl. Second set w/ trop of 0.63, CKMB 9.1 and MB index 4.6. Third set: trop of 0.40, CKMB 7.2 and MB index 3.0. Pt was given 300mg of Plavix and 80mg of lovenox on admission, then given plavix 75mg and 100mg of lovenox today. OSH labs was also notable for BS of 210 on admission. This am pt was transferred here for cardiac evaluation. Past Medical History: Coronary Artery Disease Hypertension Dyslipidemia Subdural hematoma s/p skiing-accident Chronic Renal Insufficiency Gout Social History: Married. Lives with wife. Retired electrical engineer. Quit smoking 30 years ago; 15-20 pack-years prior to that. Drinks one glass of wine per day Family History: Father with a fatal MI at age 45. Brother died a sudden cardiac death at age 59. Sister had angioplasty and died at age 58 for unknown reasons. Physical Exam: VS - T 97.9 BP 140/64 P 51 RR 16 SaO2 97RA Wt: 196 lbs Gen: Very nice younger than appearing male in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: No JVD. CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. Very mild crackles at bases, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. No hair on toes. onychomycosis present both feet. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: [**2150-9-30**] 06:40AM BLOOD WBC-12.5* RBC-3.49* Hgb-11.1* Hct-31.4* MCV-90 MCH-31.7 MCHC-35.3* RDW-13.5 Plt Ct-402 [**2150-9-24**] 11:19AM BLOOD Neuts-83* Bands-1 Lymphs-10* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2150-9-30**] 06:40AM BLOOD PT-12.5 INR(PT)-1.1 [**2150-9-30**] 06:40AM BLOOD Plt Ct-402 [**2150-9-30**] 06:40AM BLOOD Glucose-106* UreaN-23* Creat-1.2 Na-137 K-4.8 Cl-96 HCO3-31 AnGap-15 [**2150-9-21**] 08:45AM BLOOD %HbA1c-6.0* [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 20943**], [**First Name3 (LF) **] [**Hospital1 18**] [**Numeric Identifier 20944**] (Complete) Done [**2150-9-24**] at 9:43:46 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2075-6-25**] Age (years): 75 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Coronary artery disease. Left ventricular function. Preoperative assessment. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [**2150-9-24**] at 09:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW209-9:4 Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - LVOT diam: 1.8 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV systolic function. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is moderately dilated. Right ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS Preserved biventricular systolic function. LVEF> 55%. Study otherwise unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician RADIOLOGY Final Report CHEST (PA & LAT) [**2150-9-28**] 2:39 PM CHEST (PA & LAT) Reason: evaluate effusion [**Hospital 93**] MEDICAL CONDITION: 75 y old s/p CABG x4 REASON FOR THIS EXAMINATION: evaluate effusion PA AND LATERAL VIEWS OF THE CHEST: REASON FOR EXAM: CABG followup. Comparison is made with prior study dated [**2150-9-25**]. There has been improvement in left lower lobe discoid atelectasis. Stable-to- small left pleural effusion. Cardiomediastinal contour is unchanged. The right lung remains clear. There is no pneumothorax. Patient is post median sternotomy and CABG. IMPRESSION: Continued improved left lower lobe aeration DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: WED [**2150-9-30**] 9:48 AM ?????? [**2146**] CareGroup Brief Hospital Course: He was admitted to for further work-up and treatment of his NSTEMI. He underwent cardiac evaluation and treatment for myocardial infarction. Cardiac catherization revealed three vessel coronary artery disease and cardiac surgery was consulted. He underwent preoperative workup and was brought to the operating [**2150-9-24**] underwent coronary artery bypass graft surgery. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one he was started on beta blockers and diuretics and transfered to the post operative floor. He developed atrial fibrillation that was treated with beta blockers and amiodarone and he converted to normal sinus rhythm. He was gently diuresed towards his pre-op weight. Physical followed patient during entire post-op course for strength and mobility. He continued to make steady process but remained in the hospital due to intermittent atrial fibrillation. He was not started on anticoagulation due to history of subdural hematoma. He was ready for discharge home with services on post operative day 6. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: Gemfibrozil 600 mg PO QAM and 300 mg PO QPM Allopurinol 150 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Amlodipine 5 mg PO DAILY Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Aspirin 325 mg PO DAILY Metoprolol 100 mg PO BID Atorvastatin 80 mg PO HS Moexipril HCl 15 mg PO QAM and 7.5 mg PO QPM Ezetimibe 10 mg PO QPM Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 4. Gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*0* 5. 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* 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*0* 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. 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* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 7 days: then decrease to 400 mg (2 tabs) daily for 1 week, then decrease to 200 mg (1 tab) daily until discontinued by cardiologist. Disp:*90 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Coronary artery disease s/p CABG Post op Atrial fibrillation Hyperlipidemia Hypertension Chronic renal insufficiency Gout h/o PE h/o subdural hematoma after head trauma Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**Last Name (STitle) 16968**] in 1 week ([**Telephone/Fax (1) 20945**]) Dr [**Last Name (STitle) 1016**] in [**2-14**] weeks Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2150-10-13**]

[ "272.4", "410.71", "427.31", "414.01", "997.1", "403.90", "585.9", "E878.2", "274.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.55", "37.22", "88.53", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

10659, 10730

7253, 8570

284, 555

10943, 10950

2588, 5291

11462, 11843

1690, 1837

8951, 10636

6448, 6469

10751, 10922

8596, 8928

10974, 11439

5340, 6411

1852, 2568

234, 246

6498, 7230

583, 1362

1384, 1507

1523, 1674

14,898

108,698

17315

Discharge summary

report

Admission Date: [**2158-5-22**] Discharge Date: [**2158-6-9**] Date of Birth: [**2096-4-23**] Sex: M Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: A 62-year-old male with end- stage liver disease, cirrhosis secondary to alcohol, encephalopathy, peripheral edema, ascites requiring paracentesis, upper gastrointestinal bleed from grade 2 varices one time, portal hypertension hepatocellular carcinoma non-metastatic, status post radiofrequency ablation in [**2157-11-7**], followed for availability of liver transplant. The patient is without new complaints at the time of admission. MEDICATIONS ON ADMISSION: 1. Lasix 40 mg once a day. 2. Lactulose one tablespoon once a day. 3. Propranolol 40 mg twice a day. 4. Lithium 900 mg once a day. 5. Protonix 40 mg twice a day. 6. Spironolactone 100 mg twice a day. 7. Mycelex five. 8. Meclizine 25 mg once a day. 9. NPH insulin 100 units q. a.m., 50 units q. p.m. 10. Doxazosin 1 mg once a day. PHYSICAL EXAMINATION: Upon admission this patient was afebrile with stable vital signs with a weight of 120.0 kilograms. Head, eyes, ears, nose and throat examination was normal. Neck was supple. Lungs clear to auscultation bilaterally. Cardiovascular examination: Regular rate and rhythm, no murmurs, rubs or gallops. Abdominal examination: Revealed mild ascites, non-tender throughout. Extremity examination revealed 1 plus ankle edema. LABORATORY ON ADMISSION: Hematocrit 38.5, white blood cell count 11.2, platelet count 140,000. Sodium 143, potassium 3.4, chloride 103, carbon dioxide 34, blood urea nitrogen 16, creatinine 1.0, glucose level 50. Calcium 10.0, phosphorus 82.6, magnesium 1.6. AST was 61, ALT was 52 and alk phos was 83. Total bilirubin was 1.7. His prothrombin time was 14.3, his PTT was 26.4. His fibrinogen was 267 and his INR was 1.4. HOSPITAL COURSE: So at this time the patient was admitted with end-stage liver disease for a liver transplant. He was placed nil per os. Consent was signed. CellCept, Solu- Medrol, Unasyn, fluconazole were started. Labs were drawn. Urinalysis was performed. A chest x-ray was performed and an electrocardiogram was performed. Anesthesia consent was also obtained as he was seen by their staff. On [**2158-5-23**], liver transplant was performed under general anesthesia. The patient was brought to the Surgical Intensive Care Unit after the operation. The patient was progressing well at this time and on postoperative day one the plan was to use morphine sulfate for pain as needed. A transesophageal echocardiogram had shown residual clot and adequate biventricular function. A chest x-ray was sent and the patient was weaned off of FiO2. The patient was also nil per os at this time and on an nasogastric tube. The patient was also on a Foley catheter to follow urine output closely. Infectious Disease: The patient was placed on Unasyn times three days. The patient was also transfused platelets, fresh frozen plasma and cryoprecipitate at this time and the patient began the immunosuppressive regimen with Solu-Medrol at 140 twice a day, CellCept 1 gram twice a day, ________ times one intraoperatively and, in terms of endocrine, patient was placed on a regular insulin sliding scale at this time with a plan to move to an insulin drip if glucose levels trended upwards. The patient continued to progress well during his stay and continued to oxygenate well and was able to be weaned off of oxygen, FiO2 as he was weaned off of propofol at this time. Prophylactic medications, Bactrim and fluconazole, were continued at this time. The patient continued to progress well at this time and on the [**5-25**] propofol was discontinued. An electrocardiogram was taken showing no ischemic changes. The patient did not need a beta blocker at this time. Patient was receiving Nipride which was being held for systolic blood pressure less than 160. The patient was given Lasix to diurese and established an adequate urine output. The patient was started on total parenteral nutrition and Unasyn was discontinued at this time. On [**2158-5-26**], the patient continued to progress taking Dilaudid p.r.n. for pain at this time. Stable vital signs. Patient receiving CPAP and his total bilirubin and other liver function tests including ALT and AST continued to trend downward. Good bile output out of the drain. His liver function tests on this day were 155 for AST, 614 for ALT and 64 for alk phos. The previous day on [**5-25**] were AST of 252, ALT of 309 and alk phos of 65. The patient was continued on Lasix diuresis and continued on prophylactic Bactrim, fluconazole and ganciclovir. The patient at this time was on an insulin drip. The patient continued to progress on the [**5-27**] and was being followed at this time by the inpatient clinical Nutrition team. They recommended titrating insulin drip as needed and set up a TPN to regiment with a goal of 2,150 kilocalories per day. On [**2158-5-28**], the patient continued to progress well. His wound was noted to be without pus or erythema at this time. He was continued on Dilaudid as needed for pain. He was still being followed by the SICU team in the Surgical Intensive Care Unit. At this time patient was able to change to largely oral medications. He had stable respiratory status and was now off of ventilation. On postoperative day nine, [**5-30**], the patient continued to be stable but appeared somewhat confused upon examination. It was recommended at this time the patient be transferred to the floor and later in the day he was transferred to [**Hospital Ward Name 121**] 10. Date of extubation for this patient was [**5-28**]. The patient began to be evaluated by Physical Therapy on [**2158-5-29**]. On [**2158-5-31**], it was noted they found the patient to be alert and oriented but mildly inappropriate with tangential speech. They noting that he was practicing even coordinated breathing. Their general impression was that this man's mobility would improve. He was tolerating being out-of-bed well but that he would require short term rehabilitation upon discharge to maximize functional status. They also stated that his potential to return to baseline was good. They recommended one to three more weeks of physical therapy or until discharge to rehabilitation. The patient began to be followed by the [**Last Name (un) **] consult team on the [**6-1**]. The [**Last Name (un) **] attending noted that the patient was now transitioning to eating meals and suggested starting Lentes and Humalog regimen. As per their request after they reviewed the chart they noted that his prior regimen was likely suboptimal and that his insulin needs would be significantly different after this liver transplantation due to the effects of steroids and his new liver and they began to discuss outpatient regimens for the patient. The patient was also receiving Occupational Therapy evaluations and it was noted on [**2158-6-1**], by Occupational Therapy that patient was minimally confused and that he would likely need rehabilitation prior to returning home. On the [**6-2**] the patient continued to progress well, complained of some mild abdominal pain but noted significant improvement since the immediate postoperative time. There were noted to be multiple ecchymotic areas over his right upper extremity at this time and four to five skin ulcerations on his left upper extremity. Ancef 1 gram every eight hours was started at this time and a full HUS workup was commenced and Hematology was consulted. A blood smear was sent that was viewed by Hematology not to contain any schistocytes and that most likely a hemolytic-uremic syndrome workup was not necessarily warranted but that they would follow the results. On postoperative day 12, [**6-3**], the patient continued to progress well and began to be screened for rehabilitation. He continued to be followed by [**Last Name (un) **] for glucose levels and was continued on Ancef at this time. His vital signs were stable and the patient was without pain at this time. He was passing gas and having bowel movements and was noted an increased appetite. The patient continued to be followed by Nutrition, Respiratory Care and his liver function tests continued to trend downwards. Cyclosporin levels were found to be therapeutic and it was determined again by Transplant staff that the patient would likely need rehabilitation. [**Last Name (un) **] continued to follow the patient at this time and recommended that the patient continue with current Lentes and Humalog sliding scale regimen. On the [**6-5**] the patient was doing well with only mild abdominal pain with lunging or reaching movements. He was still passing gas and having bowel movements and taking solid foods at this time. The patient still appeared somewhat distant in conversation and a Psychiatry consult was ordered. Per Psychiatry's request, the lithium level was sent and found to be 1.9. At this time Psychiatry recommended that lithium be held and Haldol be used as needed for agitation. At this time it was noted that the patient was not taking enough food orally and a feeding tube was placed by Interventional Radiology. Then on the morning of [**2158-6-7**], the patient went on to pull the feeding tube from its position and it was determined that total parenteral nutrition would be delivered through a PICC line placed on the [**2158-6-6**]. The patient continued to improve at this time and was followed again by Psychiatry who suggested 1 mg dose of Haldol for standing order at night and their formal consultation was noted in the chart. The patient's mental status was significant for confusion and inattention and tangential thought at this time. His lithium level and renal function were noted to be improving at this time. His lithium level was now down to 1.6. On [**6-8**] the patient continued to feel better and continued to note improving appetite. He was noted by the staff to be taking all of his meals. Calorie counts were occurring at this time. The patient continued to be screened for rehabilitation. The patient was continued on total parenteral nutrition. [**Last Name (un) **] was notified of the total parenteral nutrition and they advised adding 10 units of insulin to his TPN order which was done. On [**6-9**], the day of discharge, the patient was doing very well, not complaining of any pain, with increasing appetite. Had been out-of-bed three times the previous day. On physical examination vital signs were temperature maximum over the last 24 hours of 98.4 degrees. Current temperature 97.6 degrees. 59 beats per minute. Blood pressure 132/71. Respiratory rate of 20. Oxygen saturation 94 percent on room air. His weight was 123.3 kilograms. His fingersticks were in the low 100's. The patient was in no apparent distress. His cardiac examination revealed regular rate and rhythm with no murmurs, rubs or gallops. His respiratory examination revealed clear to auscultation bilaterally. No wheezes, rales or rhonchi. On abdominal examination the patient was noted to be non-distended, normoactive bowel sounds, soft and non-tender throughout with a well-healing wound. It was clean, dry and intact. Screening for rehabilitation at this time continued and it was determined that patient would be discharged on this day. His laboratory values at this time were the following: PT time 12.5, PTT 22.4, INR 1.0, fibrinogen 431. On [**2158-6-8**], his cyclosporin level was 944. His liver function tests revealed an ALT of 14, an AST of 15, alk phos of 127, a total bilirubin of 1.8 and albumin of 2.8. White count at this time was 12.9, hematocrit 27.6 and platelet count 137,000. DISCHARGE DIAGNOSES: Status post orthotopic liver transplant [**2158-5-22**], for hepatitis B/alcoholic cirrhosis. Cirrhosis with encephalopathy. Peripheral edema. Ascites requiring paracentesis. Upper gastrointestinal bleed with grade 2 varices with one episode of banding. Hepatocellular carcinoma status post radiofrequency ablation [**2157-11-7**]. Diabetes mellitus type 2. Congestive heart failure with diastolic dysfunction. Pulmonary hypertension. Hypertension. Benign prostatic hypertrophy. Left lower extremity deep venous thrombosis with pulmonary embolism in [**2156-12-8**]. Obstructive sleep apnea. Bipolar disorder. Post traumatic stress disorder. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: The patient was instructed to call if fevers, chills, nausea, vomiting or increased redness or drainage started to occur from the wound site. The patient was to be sent to rehabilitation at this time. Laboratory levels were to be drawn twice weekly to measure levels of immunosuppressive drugs and liver function tests. The patient's first appointment with the Liver [**Hospital 1326**] Clinic at the Transplant Center was to occur at the [**Last Name (un) 2577**] Building [**Hospital 1326**] Clinic on Wednesday, [**2158-6-14**], at 10:50 a.m. DISCHARGE MEDICATIONS: 1. Pantoprazole 40 mg by mouth once a day. 2. Bactrim one tablet by mouth once a day. 3. Metoprolol 75 mg by mouth twice a day with hold for heart rate less than 60 or systolic blood pressure less than 100. 4. Hydralazine 75 mg by mouth four times a day. Hold for systolic blood pressure less than 110. 5. Bisacodyl 20 mg per rectum once a day as needed. 6. Mycophenolate mofetil 1000 mg by mouth twice a day. 7. Insulin Glargine 60 units subcutaneously once per night. 8. Insulin sliding scale on fixed dose. 9. Fluconazole 200 mg by mouth once a day. 10. Valganciclovir 450 mg by mouth every other day. 11. Prednisone 50 mg by mouth once a day. 12. Doxazosin 1 mg by mouth at night. 13. Haldol 1 mg by mouth at night one tonight. 14. Meclizine 25 mg by mouth once a day. 15. Cyclosporin 150 mg by mouth twice a day, 8:00 p.m. and 8:00 a.m. 16. Furosemide 40 mg by mouth twice a day. 17. The patient received two more doses of Ancef at this time, 1 gram IV q. 8h. 18. Haldol 2.5 mg IV three times a day as needed for agitation. Again, labs are to be drawn on a twice weekly basis and levels to be followed by the Transplant team. DISPOSITION: To rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**] Dictated By:[**Last Name (NamePattern1) 48464**] MEDQUIST36 D: [**2158-6-9**] 12:44:51 T: [**2158-6-9**] 15:25:37 Job#: [**Job Number 48465**]

[ "276.2", "155.2", "571.2", "428.0", "E878.0", "997.1", "305.00", "070.44", "789.5" ]

icd9cm

[ [ [] ] ]

[ "99.15", "88.72", "96.6", "99.05", "87.54", "33.23", "99.07", "96.71", "50.59", "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

11781, 12438

13070, 14582

643, 980

1875, 11759

12497, 13047

1003, 1439

179, 617

1454, 1857

12463, 12472

27,204

184,178

33794

Discharge summary

report

Admission Date: [**2149-3-24**] Discharge Date: [**2149-4-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: TIPS Blood transfusion History of Present Illness: 84 yo M ETOH cirrhosis, [**Doctor First Name 329**] [**Doctor Last Name **] tear, varices s/p EGD with clips x2 +3cc Epi of [**Doctor First Name 329**] [**Doctor Last Name **] tear with underlying varix. Pt also with portal hypertension transferred to [**Hospital1 18**] for possible TIPS procedure. Pt started to notice hematemesis on friday. Pt presented to OSH on [**3-23**] with further hematemesis, +LH/dizziness. Pt denied any CP/palpitations/SOB. Pt had a similar presentation [**11/2148**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear, was lost to f/u, told not to continue ETOH consumption, has continued to drink ETOH. Pt denied any ASA, NSAID use. . OSH COURSE: Hematemesis in setting of underlying [**Doctor First Name 329**] [**Doctor Last Name **] tear in [**Month (only) **], EGD notable for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear s/p clips x2 + 2ccEpi cauterization, started octreotide gtt, pantoprazole 40mg IV BID, transferred for possible TIPS procedure. Post EGD, pt vomitted ~300cc red blood w/clots, [**Name (NI) 4650**] Pt received 2 UPRBC, 1UFFP, octreotide gtt increased to 100mcg/hr. Prior to transfer BP 85/35. Received banana bag, no further hematemesis noted. HCT 27.4 Transferred to [**Hospital1 18**]. . [**Hospital1 18**] ED COURSE: Initial BP 80/P, hematemesis x3 ~200-300cc each episode, ~200cc BRBPR w/clots, continued octreotide gtt, zofran 8mg IV x1, protonix 40mg IV x1. Received 2.5L IVF BP 174/54 HR 90s 86%RA, 96%4-6LNC, labs drawn, hung 1 UFFP prior to transfer to MICU. No PRBC transfusion in ED. Past Medical History: -ETOH Abuse, heavy drinking 3 8oz glasses vodka daily x30 years, now drinks 1 glass of beer daily -ETOH Cirrhosis --portal hypertension --varices s/p banding, cautery x1 -[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear -IDDM -HTN -BPH -GERD Social History: -Lives alone, daugther=HCP -ETOH Abuse, heavy drinking 3 8oz glasses vodka daily x30 years, now drinks 1 glass of beer daily -Quit TOB ~30years ago, smoked previously 1ppd x30years Family History: NC Physical Exam: VS: 97.5 BP 122/52 HR 89 RR 10 96%RA GEN: NAD HEENT: Bloody stains on lips, dry MM RESP: Distant BS, no crackles, no wheezing CV: Reg Nml S1, S2, no M/R/G ABD: Soft, mildly distended, NT, +BS, +fluid wave sign EXT: no peripheral edema, warm 2+DP pulses NEURO: A&O x3, no focal deficits Pertinent Results: Admission labs: [**2149-3-24**] 03:30AM WBC-5.5 RBC-2.85* HGB-8.4* HCT-24.7* MCV-87 MCH-29.6 MCHC-34.1 RDW-15.3 [**2149-3-24**] 03:30AM NEUTS-67.7 LYMPHS-24.0 MONOS-7.7 EOS-0.3 BASOS-0.2 [**2149-3-24**] 03:30AM PLT COUNT-110* [**2149-3-24**] 03:30AM GLUCOSE-184* UREA N-25* CREAT-0.8 SODIUM-143 POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13 [**2149-3-24**] 03:30AM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-3.3 MAGNESIUM-1.6 [**2149-3-24**] 03:30AM ALT(SGPT)-21 AST(SGOT)-32 LD(LDH)-196 ALK PHOS-54 TOT BILI-1.5 [**2149-3-24**] 03:30AM PT-13.7* PTT-25.8 INR(PT)-1.2* . Discharge labs: [**2149-4-1**] 07:15AM BLOOD WBC-4.5 RBC-3.40* Hgb-10.4* Hct-30.7* MCV-90 MCH-30.5 MCHC-33.8 RDW-16.6* Plt Ct-125* [**2149-4-1**] 07:15AM BLOOD Glucose-175* UreaN-15 Creat-0.7 Na-138 K-3.8 Cl-103 HCO3-26 AnGap-13 [**2149-4-1**] 07:15AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.7 [**2149-4-1**] 07:15AM BLOOD ALT-319* AST-93* LD(LDH)-237 AlkPhos-159* TotBili-1.5 [**2149-4-1**] 07:15AM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.2* . Studies: ABDOMEN U.S. (COMPLETE STUDY) [**2149-3-24**] IMPRESSION: 1. Coarse and nodular hepatic echotexture consistent with cirrhosis. Hepatic cyst. No hepatic masses identified. 2. Patent portal and hepatic veins. 3. Splenomegaly and ascites. 4. Left renal cyst. . TTE (Complete) Done [**2149-3-24**] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (abnormal septal motion; LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation. . EGD [**2149-3-25**] Findings: Esophagus: Protruding Lesions 4 cords of grade III varices were seen in the esophagus. There were stigmata of recent bleeding. Stomach: Contents: Clotted blood was seen in the stomach. Other 2 clips were seen adjacent to, but not overlying, a linear ulcer near the GE junction. There were no signs of active bleeding and no adjacent varices were seen. Duodenum: Contents: Clotted blood was seen in the duodenum. Impression: Esophageal varices 2 clips were seen adjacent to, but not overlying, a linear ulcer near the GE junction. There were no signs of active bleeding and no adjacent varices were seen. Blood in the duodenum Blood in the stomach . US GUID FOR NEEDLE PLACEMENT [**2149-3-25**] IMPRESSION: Successful TIPS placement with a 10 mm x 7 cm covered stent. The pressure gradient was recorded before and after placement of TIPS stent. The gradient was 29 mmHg before the TIPS stent placement and there was no gradient after the TIPS placement. Successful placement of a central venous line at the conclusion. . DUPLEX DOPP ABD/PEL [**2149-3-28**] IMPRESSION: 1. Patent TIPS with wall-to-wall flow. Patent portal and hepatic veins, with reversal of flow in the left portal vein. 2. Ascites. Gallstones and sludge is, unchanged since prior study. Cirrhotic liver. . ECG Study Date of [**2149-3-27**] Rate PR QRS QT/QTc P QRS T 100 0 134 390/460 0 7 64 Sinus tachycardia. Consider left atrial abnormality. Left bundle-branch block. Brief Hospital Course: AP: 84 yo M with ETOH Cirrhosis, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear, varices s/p cautery + clips of recurrent [**Doctor First Name **] [**Doctor Last Name **] tear, transferred for possible TIPS procedure. . #. Upper GI bleed--Variceal bleeding, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears: Pt had underlying portal hypertension from ETOH cirrhosis and h/o prior [**Doctor First Name 329**] [**Doctor Last Name **] tear in [**2148-11-16**] and presented with recurrent bleeding from subsequent [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. variceal bleeding. At the OSH he had clips placed + Epi. Liver U/S with doppler showed cirrhosis, splenomegaly and patent vessels. Pt was kept NPO on arrival. He remained initially hemodynamically stable w/o recurrent hematemesis. He was continued on octreotide gtt and protonix IV BID. He was transfused a total of 6U PRBC until [**3-26**] AM with a Hct of 28. He then had a brief hypotensive episode. NG lavage revealed blood, and repeat Hct was 24. Repeat EGD on [**3-25**] showed only 4 cords of grade III varices but no active bleed. He subsequently underwent TIPS on [**3-25**]. He was stabilized and transferred to the floor, where octreotide gtt was discontinued and his PPI was changed to po. He required 3 more transfusions with a HCT of 30. His last transfusion was on [**3-28**]. He had no further episodes of hematemesis on the floor and he remained hemodynamically stable. . #. Acute blood loss anemia . #. ETOH cirrosis: Post TIPs, he was started on lactulose and SBP ppx with Cipro to complete 7 days. He had no signs of encephalopathy on the floor. He will need Doppler US q3 mo to assess shunt patency. . # Urethra trauma: Pt sustained urethral trauma during Foley placement. He was initially started on CBI; however, the catheter was intermittently clogged. Urology evaluated the patient and placed a new catheter via cystoscopy. During the cystoscopy, a false passage was noted at the membranous urethra. Urology recommended a voiding trial 1-2 weeks from [**2149-3-29**] to allow the false passage to heal. He will need to follow up with Urology as an outpatient for this. . #. ETOH abuse: His last drink was 1 day PTA. He was monitored for withdrawal symptoms. He was written for ativan per CIWA scale and did not require any. This was discontinued. He was supplemented with thiamine and folate. . #. HTN: His home atenolol was held. He will need to be followed up as an outpatient on when to restart this. . #. DM: Pt's oral hypoglycemic meds were held, and he was started on a HISS. He will continue HISS at discharge to rehab. . #. BPH: Pt was continued on Flomax. Oxybutynin was held given his cirrhosis. . #. DNR/DNI-Intubate if temporary measure and for EGD procedures if necessary. . #. Communication: Daughter=HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 78140**] Medications on Admission: MEDS on Transfer: -octreotide gtt -protonix 40IV [**Hospital1 **] -ativan 1mg per CIWA scale . HOME MEDS: -Glyburide 5mg daily -Actos 30mg daily -Atenolol 25mg daily -Oxybutynin chloride 10mg daily -Omeprazole 20mg daily -Flomax 0.4mg daily -Insulin 5U HS Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 2. Insulin Lispro 100 unit/mL Solution Sig: 4-12 units Subcutaneous four times a day: Please see insulin sliding scale. 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab and skilled nursing Discharge Diagnosis: Primary: Variceal bleeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears Acute blood loss anemia . Secondary: Alcoholic cirrhosis Alcohol abuse Diabetes mellitus Benign prostatic hypertrophy Gastroesophageal reflux disease Discharge Condition: Stable, HCT 30 Discharge Instructions: You were admitted for vomiting up blood. On upper endoscopy, you were noted to have severe esophageal varices. A TIPs was placed in your liver to help prevent further bleeding from your esophageal varices. You have not had any episodes of vomiting up blood since the TIPs was placed. . During the Foley catheter placement in your bladder, your urethra was injured. You will need to keep the catheter in for 1-2 weeks. You will need to follow up with your Urologist, Dr [**Last Name (STitle) 78141**], in [**12-18**] weeks. Dr. [**Last Name (STitle) 78141**] will call the [**Hospital 5682**] Rehab and let them know when the catheter can be removed. . Please take your medications as prescribed. Your atenolol has been discontinued for now. Please talk to your primary care physician about restarting this medication for your blood pressure. Your actos and glipizide have been stopped as well and you will continue your Humalog insulin shots. You have been started on Protonix to help reduce your stomach acid. You will also need to continue the antibiotic Ciprofloxacin for another 3 days to prevent an abdominal infection. . If you develop further bleeding from the mouth or the rectum, black stools, abdominal pain, nausea/vomiting, lightheadedness, or any other concerning symptoms, please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12416**] at [**0-0-**] or go to the Emergency Department. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **], the liver doctor, on [**2149-4-17**] at 9:30 AM. The clinic number is [**Telephone/Fax (1) 2422**]. . You also have an appointment with Dr. [**Last Name (STitle) 78141**], your Urologist, on [**2149-4-11**] at 1:30PM. The clinic number is ([**Telephone/Fax (1) 75977**]. . Please also see your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12416**] within 3 weeks. His clinic number is [**0-0-**]. Please address if you need to restart your atenolol.

[ "572.3", "401.9", "789.59", "599.4", "456.20", "571.2", "867.0", "530.7", "250.00", "530.81", "E928.9", "531.90", "285.1", "599.7", "600.00", "303.91" ]

icd9cm

[ [ [] ] ]

[ "99.07", "45.13", "39.1", "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

10601, 10669

6404, 9358

272, 297

10962, 10979

2779, 2779

12478, 13028

2454, 2458

9664, 10578

10690, 10941

9384, 9384

11003, 12455

3380, 6381

2473, 2760

221, 234

325, 1953

2795, 3364

1975, 2240

2256, 2438

9402, 9641

74,687

147,864

33636

Discharge summary

report

Admission Date: [**2137-9-21**] Discharge Date: [**2137-10-1**] Date of Birth: [**2063-12-24**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Baclofen / adhesive bandage / penicillin G / Aldomet Attending:[**First Name3 (LF) 1406**] Chief Complaint: Non healing sternal wound Major Surgical or Invasive Procedure: Removal of hardware, bilateral pectoralis flap advancement. History of Present Illness: Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and wound was clean. She presented to the ER today from Rehab w/ fever, chills, sore throat, and buring with urination which started 24 hrs ago. Longterm plan was to remain at rehabilitation for 2-3 weeks and return for sternal closure device removal and flap closure with plastic surgery in 3 weeks. She will remain on antibiotics until that time. Discharged on IV Cefepime. Currently feels well. No fevers with good appetite. Remains active at rehab. Patient has improved energy. Past Medical History: s/p cabg x2 with reversed saphenous vein graft to the ramus intermedius artery and a free left internal mammary artery graft to the obtuse marginal artery Y'd to the vein graft [**2137-7-18**] PMH: coronary artery disease, dyspnea on exertion, bilateral knee replacement [**2132**], sleep apnea, hiatal hernia, GERD, diabetes mellitus, hypertension, Hyperlipidemia, Restless leg syndrome, s/p stent to LAD in [**2126**], Stent to RCA and OM in [**2128**], appendectomy, hysterectomy, CTR left wrist, laser surgery OU, cataract Social History: Occupation:retired Cigarettes: denies Other Tobacco use:denies ETOH: denies Illicit drug use:denies Lives with: alone in a senior complex, Ambulates with a four wheel walker. Contact:[**Name (NI) **] and [**Name (NI) **] (son and daughter-in-law) Family History: Premature coronary artery disease- Brother with CABG at age 65 Race:Caucasian Physical Exam: Physical Exam temp 98.5 Pulse:72 Resp:18 O2 sat: 97% RA B/P Right:140/70 Height: Weight: General: Obese female in NAD lying on stretcher in ER Skin: Dry [x] intact []- sternal wound vac in place HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x]- no lymph adenopathy Chest: Lungs clear bilaterally [x] Sternal incision: on [**2137-9-19**] wound bed with healthy granulation tissue, no exudate, no erythema. Wound measures 7 inches long by 1.5 inches wide by [**2-15**] deep Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema []none____ Lesser Saph incision: clean, dry and intact Left Picc line site w/o drainage or erythema Varicosities: None [x] Neuro: Grossly intact [x] Pertinent Results: [**2137-9-21**] 07:25PM URINE RBC-1 WBC-17* BACTERIA-NONE YEAST-NONE EPI-1 TRANS EPI-<1 RENAL EPI-<1 [**2137-9-21**] 04:00PM GLUCOSE-206* UREA N-20 CREAT-0.8 SODIUM-136 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-16 ECHO: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. There is mild symmetrical hypertrophy of the left ventricle. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with anteroseptal wall hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results at time of surgery. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2137-9-27**] 19:19 Chest CT: IMPRESSION: No evidence for discrete fluid collection. However, there is a slightly increasing gap along the manubrium and faintly increased sclerosis, so subacute osteomyelitis would represent a differential consideration. Brief Hospital Course: Mrs. [**Known lastname 77879**] is a 73 yo F well known to cardiac surgery, ID and plastics. Was last discharged back to rehab on [**2137-9-4**]. Was seen in cardiac surgery clinic on [**2137-9-19**]. Wound vac was changed and wound was clean. She presented to the ER [**2137-9-21**] from Rehab w/ fever, chills, sore throat, and buring with urination which started 24 hrs ago. Fever w/u revealed 1 out of 4 BC positive- possible contaminant. Her Picc was d/c'd and sent for culture which was neg. A new PICC was placed. Chest CT revealed no fluid colection. She was followed by ID and treated with vanco thru [**11-8**] and cefepime thru [**10-11**]. Her wound vac was changed and the wound bed was clean. She was taken to the OR for removal of hardware and bilateral pectoralis flap advancement with Dr. [**First Name (STitle) **] (see operative note). She has 2 JP drains left in place which will be managed byDr. [**Location (un) **]. [**9-30**] OR wound culture showed coag-negative staph - rare growth. ID service had followed patient and she is to be continued on Vanco/Cefepime for 6 week total course of each antibiotic. Her blood sugars had been elevated pre and postoperatively but were controlled on NPH at the time of discharge. She was in stable condition and was discharged to [**Hospital 31183**] Nursing and Rehab in [**Hospital1 1474**] on POD #3. Medications on Admission: CEFEPIME 2gm/12H,LIPITOR 80mg daily,SQH 5000unitTID,HYDROMORPHONE 2-4mg Q4prn,Humalog SSI,LISINOPRIL5mg daily, Lopressor 50 TID, PANTOPRAZOLE 40mg daily,KCl10mEq [**Hospital1 **], PRAMIPEXOLE 0.5 mg HS,ecASA81mg daily, CHOLECALCIFEROL 400 unit DAILY, FISH OIL-DHA-EPA 1,200 mg-144 mg 1 Capsule TID, MULTIVITAMIN 1 DAILY, NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension - 72 units twice a day ID/Plastics,Vanco.Continue Cefipime Discharge Medications: 1. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twenty-four(24) hours for 6 weeks: Check trough daily and dose for level <20 - end date [**2137-11-8**]. 2. cefepime 2 gram Recon Soln Sig: One (1) Injection every twenty-four(24) hours for 6 weeks: End date [**2137-10-11**]. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 2 weeks. Disp:*65 Tablet(s)* Refills:*0* 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 14. Insulin NPH 85 units Q AM and NPH 80 units Q dinnner. RISS - see attached or use own facilites SS 15. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) Mucous membrane once a day as needed for sore throat. 16. picc line care and flushes Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush followed by Heparin as above daily and PRN per lumen. 17. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 18. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 19. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once a day: for lower extermity edema- stop when resolved. Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Non healing sternal wound Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage - JP's in place - Keep JP's in place until follow up with Dr [**First Name (STitle) **] Leg 2+ Edema - teds in place Discharge Instructions: 1. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 2. Strip drain tubing, empty bulb(s), and record output(s) [**1-17**] times per day. 3. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 4. You may shower daily. No baths until instructed to do so by Dr. [**First Name (STitle) **]. 6. Keep your surgibra in place at all times except when showering. 7. Do not lift your arms out to the side to prevent stress on your midline incision. Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [**First Name (STitle) **]. Medications: 1. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take your antibiotic as prescribed. 6. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 7. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on 10/27th at 1:00 PM in the [**Hospital **] medical office building [**Hospital Unit Name **], [**Last Name (NamePattern1) **] Plastic surgery: Dr [**First Name (STitle) **] on [**10-8**] at 9:45 am Needs follow up with [**Hospital **] clinic - Clinic to call rehab with appointment Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 17918**] in [**3-19**] weeks [**Telephone/Fax (1) 17919**] PLEASE CHECK VANCO TROUGH, BUN/CREA/K in AM [**10-2**] and then weekly labs: CBC with diff, BMP, LFT's, ESR, CRP, VANCO TROUGH Q WEEK - PLEASE FAX ALL LAB RESULTS TO [**Telephone/Fax (1) 1419**] **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:[**2137-10-1**]

[ "996.67", "553.3", "530.81", "250.00", "V45.81", "333.94", "401.9", "041.19", "041.7", "584.9", "V45.01", "V85.37", "272.4", "V43.65", "780.57", "414.00", "278.00", "998.83" ]

icd9cm

[ [ [] ] ]

[ "38.93", "78.61", "83.82", "77.61" ]

icd9pcs

[ [ [] ] ]

8681, 8784

4655, 6025

357, 419

8854, 9129

2918, 4632

11362, 12299

1987, 2068

6518, 8658

8805, 8833

6051, 6495

9153, 11339

2083, 2899

292, 319

447, 1155

1177, 1706

1722, 1971

21,220

192,997

47450

Discharge summary

report

Admission Date: [**2175-3-8**] Discharge Date: [**2175-3-17**] Date of Birth: [**2112-4-1**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 5119**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: 3 Blood transfusions Colonoscopy Endoscopy (EGD) History of Present Illness: 62F with PMHx of Hep C & ETOH Cirrhosis, Gastritis/Duodenitis, HTN & CKD who presents with BRBPR for 24 hrs. She presented to [**Company 191**] complaining of BRBPR and was referred into the ED for evaluation. She reports decreased appetite and poor intake for the last week but denies F/C/CP/SOB/N/V and abd pain. Pt reported nausea & clear emesis approx 1 week ago but denies any coffee ground emesis. Pt denies ETOH use for the last [**2-28**] wks. In the ED, initial VS were: T 98 P 94 BP 159/89 RR 16 Sat 98% on RA. Pt was hypertensive in the ED, hct came back at 24 (baseline 25). GI & liver were consulted. She received Protonix 80mg IV, Ativan 1mg IV and 1L NS IVF. She had PIVs placed and was typed & crossed for 2u prbcs. On arrival to ICU, pt was comfortable, asking to eat and denying CP/SOB/Abd pain and lightheadedness. She denied any unusual ingestions or diarrhea. Foley was placed with urine return and stool guaic revealed brown stool mixed with some red blood. In the ICU pt was noted to have positive guaiaic stools and was placed on a CIWA scale for withdrawal. Tox screen came back positive for Cocaine , Ketoacidosis was attributed to starvation ketosis given her history of poor PO intake. Pt was started on thiamine, fluids, Hct was monitored. GI was consulted did not recommend any scoping as Hct was stable and bld most likely from chronic gastritis. ROS was otherwise essentially negative. The pt denies any feversm chills, nausea, vomiting, abdominal pain, chest pain, wheezing, shortness of breath. Past Medical History: Diabetes Mellitus, type 2 - on insulin Chronic Kidney Disease, baseline Cr 1.6-2.0 Hepatitis C-rebetron years ago discontinued after poor response h/o acute hepatitis from tylenol overdose Hypertension h/o Chronic Pancreatitis s/p TAH/BSO [**2155-1-26**] Substance Abuse (Cocaine, EtOH) h/o SBO with subsequent small bowel resection in [**7-1**] and again [**11-1**] Carpal Tunnel Syndrome Depression NSTEMI [**10-3**] in the context of cocaine use Anemia with baseline Hct 26-30, but has dropped into low 20s in past. Social History: Patient is known to abuse alcohol and cocaine. She reported that her last drink was 2 weeks ago, which she had also reported in a prior admission. She said her last cocaine use was 5 days before admission. She smoked x 10 pack years and quit 20 years ago. She lives with her boyfriend; he is her only sexual partner. She denies IV drug use. Family History: Hypertension. No history of premature CAD. Father with lung cancer who died in his early 60s, mother with sarcoid who died in her early 50s. No family hx of breast CA. Physical Exam: Vitals: Tm 97.4 Tc 96.3 BP:107-158/66-80 P:76-108 R:[**1-11**] SaO2:100% RA I/O: LOS + 6.2L General: Sleepy appearing A. American Female in NARD HEENT: EOMI, no scleral icterus, MMM Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, normoactive bowel sounds Extremities: No edema, 2+ radial, DP pulses b/l Skin: no rashes or lesions noted. Neurologic: Oriented x 3. Cranial nerves II-XII grossly intact. Pertinent Results: [**2175-3-8**] 12:55PM BLOOD WBC-5.4 RBC-2.38* Hgb-7.9* Hct-24.1* MCV-101* MCH-33.4* MCHC-33.0 RDW-17.5* Plt Ct-37* [**2175-3-8**] 05:46PM BLOOD WBC-7.1 RBC-2.35* Hgb-8.1* Hct-24.2* MCV-103* MCH-34.6* MCHC-33.7 RDW-17.6* Plt Ct-28* [**2175-3-9**] 01:58AM BLOOD WBC-7.3 RBC-2.16* Hgb-7.4* Hct-22.8* MCV-106* MCH-34.3* MCHC-32.5 RDW-17.6* Plt Ct-24* [**2175-3-9**] 05:50PM BLOOD Hct-25.2* Plt Ct-28* [**2175-3-10**] 03:27AM BLOOD WBC-5.8 RBC-2.63* Hgb-9.0* Hct-25.9* MCV-98# MCH-34.2* MCHC-34.7 RDW-17.6* Plt Ct-22* [**2175-3-10**] 11:11AM BLOOD WBC-5.8 RBC-2.77* Hgb-9.5* Hct-28.4* MCV-103* MCH-34.3* MCHC-33.4 RDW-17.3* Plt Ct-140*# [**2175-3-8**] 12:55PM BLOOD Glucose-55* UreaN-29* Creat-2.3* Na-141 K-4.7 Cl-101 HCO3-15* AnGap-30* [**2175-3-9**] 01:58AM BLOOD Glucose-80 UreaN-26* Creat-1.9* Na-138 K-4.4 Cl-101 HCO3-11* AnGap-30* [**2175-3-10**] 03:27AM BLOOD Glucose-37* UreaN-21* Creat-2.0* Na-138 K-3.7 Cl-105 HCO3-22 AnGap-15 [**2175-3-9**] 01:58AM BLOOD ALT-50* AST-135* LD(LDH)-286* AlkPhos-138* TotBili-3.1* [**2175-3-10**] 03:27AM BLOOD ALT-42* AST-90* AlkPhos-133* TotBili-3.5* [**2175-3-8**] 05:46PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2175-3-8**] 12:55PM BLOOD ASA-NEG Ethanol-145* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2175-3-8**] 09:25PM BLOOD Type-ART Temp-36.7 pO2-155* pCO2-21* pH-7.37 calTCO2-13* Base XS--10 [**2175-3-8**] 03:39PM BLOOD Lactate-4.4* [**2175-3-8**] 09:25PM BLOOD Glucose-112* Lactate-3.2* PROCEDURES: COLONOSCOPY ([**2175-3-14**]): A single pedunculated 5 mm polyp of benign appearance was found in the rectum. The polyp appeared benign and was not removed due to low platelet count. EGD ([**2175-3-14**]): Normal mucosa in the esophagus Small hiatal hernia Erythema, congestion and erosion in the whole stomach compatible with erosive gastritis Erythema and congestion in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 62 y/o Female with Hep C, ETOH cirrhosis presented with BRBPR, mild EtOH/cocaine withdrawal s/p 3u PRBC transfusion, EGD findings consistent with erosive gastritis most likely secondary to excessive alcohol use left against medical advice. # BRBPR: Pt was admitted to the ICU following a 1 day history of BRBPR, at which time her Hct 25, pt received 1 u PRBC, platelets. Pt was then transferred to the floor for observation where again she was noted to have a significant Hct drop to 21 requiring a further 2u PRBC transfusion. Given the requirement of blood transfusion from a suspected GI source pt underwent a colonoscopy and EGD. EGD was notable for erosive gastritis, for which pt has a history of. Pt was started on [**Hospital1 **] Pantoprazole, an H. Pylori was sent and ultimately negative, pt's gastritis likely secondary to her excessive EtOH use. Coloscopy revealed a pedunculated 5 mm polyp that was not removed due to risk of bleeding given pt's chronic thrombocytopenia. Pt's Hct was monitored and noted to be stable, pt only endorsed melena and BRBPR during her 24 hour stay in the ICU. Pt's GI bleed secondary to erosive gastritis secondary to excessive EtOH use, pt was advised not to continue EOTH use and started on oral Pantoprazole [**Hospital1 **]. Unfortunately pt left AMA during the night without any prescriptions or instructions for follow up. # Mild EtOH/cocaine withdrawal: Pt has a poor nutritional status and a long history of ETOH abuse. On admission her EtOH level was noted to be 145, Cocaine level was also positive. Pt was placed on CIWA scale requiring minimal amounts of Diazepam. Social work talked to pt regarding substance abuse programs however pt refused. Pt's daughter (who is very reasonable and truly hopes to get her mother the help she needs) filed for a section 35 for pt for treatment given her inability to take care of herself properly with her addictions. Unfortunately section 35 was not successful in court as there were no beds at detox available. Please see excellent social work OMR notes for more details. Ms. [**Known lastname 46**] left AMA soon after this. If patient returns to the ED for ETOH related problems, section 35 should be pursued again. # Anion gap acidosis: On admission pt was noted to be in a anion gap acidosis likely a combination from elevated lactate, EtOH, and starvation ketoacidosis. # Thrombocytopenia: Pt was also noted to be at her baseline for thrombocytopenia likely from longstanding ETOH abuse. During her ICU course she received 2 units of Platelet transfusion due to her concomitant GI bleeding. # Dispo: Pt left AMA from the hospital. Medications on Admission: Calcium + Vitamin D Lantus 4units qam Novolog sliding scale prn Zoloft 50mg daily Colchicine prn Albuterol prn Verapamil Hydralazine 50mg TID Verapamil SR unknown dose Discharge Medications: 1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation every six (6) hours. 3. Pancrease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*5* 6. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous once a day. 7. Insulin Aspart 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: Please take per your sliding scale. 8. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 9. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Discharge Disposition: Home Discharge Diagnosis: Patient left against medical advice without discharge plan. Discharge Condition: Patient left against medical advice without discharge plan. Discharge Instructions: Patient left against medical advice without discharge plan. Followup Instructions: Patient left against medical advice without discharge plan. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]

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icd9cm

[ [ [] ] ]

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5481

Discharge summary

report

Admission Date: [**2144-7-18**] Discharge Date: [**2144-7-28**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 1377**] Chief Complaint: Nausea and generalized weakness Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old female with hypertension, CAD, diabetes and peripheral vascular disease with LE ulcerations presenting with nausea and generalized weakness. The patient's overall health and functional status have been declining over the last [**4-29**] weeks, described by the family as decrease in walking due to sense of instability, difficulty with stairs, difficulty writing, insomnia and general tiredness, including falling asleep during ADLs and frequently during the day. Her cognition, in general, has been intact until recently when her family has noted mild clouding. Her brother passed away three days ago and the patient was able to travel to the funeral in [**Hospital1 789**]. Per her family, she has been eating and drinking normally, and taking her medications. She complains of leg pain and pain in her bottom. On the day of admission, she was in her most recent normal state of health. She ate breakfast and took all her pills. She tried to have a BM prior to a lunch party and was unable to get off the commode. She complained of nausea, shortness of breath and dizziness. Her family notes that she was particularly fatigued after this and would fall asleep while speaking. They called her PCP who recommended she come to the ED for evaluation. She normally sits on the toilet for 1-2 hours per day, and did this today, but when she went to get up she felt weak, nauseated and slightly short of breath. She presented to the ED for evaluation. In the ED, vitals were: 98.8 58 110/70 18 100. Laboratory evaluation revealed a potassium of 2.8 for which she received 40 mEq KCl, an indeterminate troponin, CRI at baseline renal function, and a leukocytosis with marked bandemia. She was found to have cellulitis associated with chronic LE ulcerations and was treated with ceftriaxone and vancomycin. CXR and UA were unrevealing for sources of infection. She was found to have brown, trace guaiac positive stool. While awaiting a bed on the medicine floor, the patient's heart rate dipped to 39. ECG obtained revealed a junctional rhythm. Her blood pressure varied between SBP 90 to SBP 170. Her HR stabilized in a sinus bradycardia with rate in 40s (without intervention). Her mental status remained stable. She complained of some back pain. It was reported that the patient was sleeping at the time of the bradycardia. She was given 1 L NS at 200 cc/hr and 1 L NS with 40 mEq KCl at 150 cc/hr. Per HHA, right leg erythema and ankle wound new over last several days. Other LE changes stable. Past Medical History: Diabetes mellitus--A1c in [**3-30**] was 7.2% Hypertension Peripheral vascular disease with ulcers-Dr. [**Doctor Last Name 22151**]/p angioplasty (right) and stenting of the right above knee popliteal and SFA in [**2142**] for poorly healing ulcers Hyperlipidemia Hard of Hearing Ischemic heart disease-Acute IMI s/p CABG'sx3 [**2133**] Right hip fracture s/p total right hip replacement Sigmoid colon cancer s/p sigmoid colectomy Anemia of chronic disease Anxiety Social History: Mrs. [**Known lastname 22152**] is widowed and lives at home with 24 hour home health aid. No tobacco, no alcohol. Family History: Has a child with Cystic Fibrosis. Physical Exam: On admission: T 98.8, BP: 91/36, HR: 49, RR: 13, O2Sat: 100% 2L NC Gen: elderly, alert, oriented to self and "[**Hospital3 22153**], speech fluent HEENT: PERRL, OP with food particles, MM dry Neck: JVP not visualized Car: bradycardic, irregular, no audible murmur Resp: crackles 1/3 up bilaterally, no wheeze, no ronchi Abd: + BS, s/nt/nd Ext: cool toes, dopplerable pulses, ischemic lesions on distal toes left foot (2nd, 3rd, 5th digits). 3+ edema on right, 2+ on left. Erythema/tendernes R>L to knee bilaterally. Skin tear right ankle. Neuro: MAE, no focal deficits Pertinent Results: Admission Labs: IMPRESSION: Cardiomegaly without evidence of congestive heart failure. RUQ Ultrasound: Slightly limited study, but no sign of biliary ductal dilatation. Pulsatile flow in the portal [**Hospital3 5703**] could suggest a degree of right heart failure. Admission Labs: [**2144-7-18**] 03:20PM WBC-16.0*# RBC-4.43 HGB-11.2* HCT-35.4* MCV-80*# MCH-25.2* MCHC-31.5 RDW-17.6* [**2144-7-18**] 03:20PM NEUTS-72* BANDS-20* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2144-7-18**] 03:20PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-2+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ACANTHOCY-2+ [**2144-7-18**] 03:20PM PLT SMR-NORMAL PLT COUNT-163 [**2144-7-18**] 03:20PM PT-13.8* PTT-26.2 INR(PT)-1.2* [**2144-7-18**] 03:20PM PHOSPHATE-3.4 MAGNESIUM-2.7* [**2144-7-18**] 03:20PM cTropnT-0.09* [**2144-7-18**] 03:20PM CK-MB-5 [**2144-7-18**] 03:20PM ALT(SGPT)-32 AST(SGOT)-50* CK(CPK)-149* ALK PHOS-165* TOT BILI-1.4 [**2144-7-18**] 03:20PM GLUCOSE-131* UREA N-118* CREAT-1.8* SODIUM-138 POTASSIUM-2.8* CHLORIDE-91* TOTAL CO2-37* ANION GAP-13 [**2144-7-18**] 06:24PM LACTATE-2.4* [**2144-7-18**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2144-7-18**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 Brief Hospital Course: Mrs. [**Known lastname 22152**] was admitted for generalized weakness and nausea but taken to the medical ICU because of an incidental finding of bradycardia in the emergency department. After holding her home dose of beta blocker for less than twenty-four hours, she was transferred to the floor. # Gram Positive Bacteremia: Mrs. [**Known lastname 22152**] was found to have Gram Positive Bacteremia, identified as corynebacterium stratium. Portal of entry was likely skin/soft tissue. Due to prolonged QTc and bradycardia on admission and transfer to the floor, she was evaluated for Diphtherial infection with toxin-induced myocarditis and placed on droplet precautions. Patient had not received an updated TDap immunization as an outpatient, and she is somewhat immunocompromised due to her age and her chronically uncontrolled diabetes mellitus, but she was thought to have very unlikely exposure to diphtheria. Patient states that she has had no pharyngeal symptoms in the past month. Per family, she has had a cough which is only associated with difficulty swallowing. Diphtherial toxoid tests were drawn from the serum, and a nasopharyngeal swab was taken for culture and sent to the [**Hospital3 14659**] for diagnosis. A Transthoracic Echo was done, which showed no signs of valvular vegetations or endocarditis. Patient was initiated on intravenous penicillin therapy for the bacteremia, which would empirically cover diphtherial infection as well as other species of Corynebacterium; when culture results showed only intermediate sensitivity to penicillin, patient was started on intravenous vancomycin therapy, which is to be continued at a therapeutic level for two weeks, counting day 1 as [**2144-7-19**]. This was presently being dosed ever 48 hours given her clearance less than 30cc/min. Patient was followed by Infectious Disease team, who stated that there was no indication for diphtheria anti-toxin due to the low possibility of a diphtheria diagnosis and the dangerous potential for serum sickness if given. The ID team recommended also that she get repeat blood cultures after finishing course of antibiotics to ensure they are negative; otherwise, Transesophageal Echo and treatment for endocarditis could be considered but would involve additional risk. Droplet precautions for possible diphtheria were removed prior to discharge because of the extremely low likelihood of the patient having the specific illness. #. Gastrointestinal Bleed, likely gastritis The patient developed semi-formed melenotic stools during admission. She was briefly anticoagulated during part of her stay, but this occured following cessation. She required 4 units of blood, last occuring on [**2144-7-25**] and has maintained her hematocrit in the mid-30s. She was advanced to fulls, and restarted on SC heparin. Her plavix was discontinued during this episode, and her aspirin was reduced to 81mg from 325mg po daily. #. Altered Mental Status: Per patient's family, patient had clouded mental status the day prior to admission, but returned to baseline the day following admission. Celexa, Ferrous sulfate were held due to possible contribution to mental status. Patient likely was delirious secondary to bacteremic infection, which improved with start of antibiotics. She was alert and oriented to [**Hospital **] Hospital and roughly the accurate date. She is followed by [**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) 3532**] of behavioral neurology at [**Hospital1 18**]. At time of discharge she was oriented and near baseline/sharp. #. Functional Decline: Per family and home health aide, patient's executive function and activities of daily living have been declining over the past four to eight weeks, in addition to increased generalized weakness. Home health aide states she takes two hours to eat her meals and has increased difficulty paying her bills. After an inpatient Gerontology Consult, it was shown that patient has some level of dementia and could benefit from increased structure in her schedule in addition to an outpatient Geriatrics consult. She was also evaluated by physical therapy during the course of her hospital stay. Per Speech and Swallow study, patient was shown to have difficulty swallowing thin liquids with increased risk of aspiration. She was placed on a dysphagia diet with nectar thickened liquids. #. Bradycardia/Tachycardia: Patient was admitted with bradycardia, which had since resolved with discontinuing her beta blocker. She was monitored on telemetry for the duration of her hospital stay. The bradycardia could have been secondary to ischemic heart disease and vasovagal reaction, but likely is due to sick sinus syndrome. After holding beta blockers, her heart rate increased and appeared to be in atrial fibrillation, but less than 48 hours most likely. The arrhythmia has resolved and given her bruising and in the setting of illness, she was not treated with anticoagulation for this indication. This has been monitored on telemetry and did not recur, and likely is related to infection. If she has ongoing tachycardia/bradycardia, pacemaker can be considered. Referral could be to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**], MD, cardiologist/EP at [**Hospital1 18**]. #. Questionable Deep Venous Thrombosis: With Right Lower Extremity Ultrasound on [**2144-7-19**], patient was thought to have deep venous thrombosis in superficial femoral [**Last Name (LF) 5703**], [**First Name3 (LF) **] heparin drop was started the following day and titrated until therapeutic. Followup ultrasound on [**2144-7-21**], per Vascular Surgery request, showed no absolutely signs of a superficial femoral [**Date Range 5703**] DVT in that region. After confirmation with the radiologist and discussion with the patient's PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**], the decision was made to stop the heparin drip due to low probability of DVT and high bleeding risks associated with heparin in the elderly patient. Patient continued to have good oxygen saturation at 95-98% on room air and denied shortness of breath, despite transition to tachycardia and a singular episode of chest pain on [**2144-7-21**]; she was determined unlikely to have had a Pulmonary Embolism due to stable respiratory status and no further evidence of DVT on lower extremity ultrasound. #. Chronic Venous Stasis and Peripheral Vascular Disease: Patient was initially treated with Vancomycin and Ceftriaxone for cellulitis secondary to chronic venous stasis as source for presenting profound leukocytosis. These antibiotics were stopped after source of infection was found to be in bloodstream, but vancomycin was restarted based on sensitivities. Patient is well known to Vascular Surgery and was followed by their team during inpatient stay. #. Chronic Left Ventricular Systolic Heart Failure: On Transthoracic Echo, patient was noted to have an estimated EF of 30% and global left ventricular dysfunction. Her diuretics were held in the setting of acute renal failure and due to overall picture of decreased intravascular volume status. #. Acute on Chronic Renal Failure: Patient presented with acute renal failure on top of chronic renal insufficiency. Her creatinine was 1.9 on admission but had returned to her baseline of 1.4 by the time of discharge, so her acute renal failure had resolved. Patient was not given extra intravenous fluids, aside from the preparations of intravenous antibiotics due to her history of chronic systolic heart failure. Her chronic renal insufficiency likely secondary to Diabetes Mellitus and Hypertension. #. Diabetes Mellitus: Throughout her stay on the floor, patient's blood sugars were very uncontrolled, many times above 400. Her basal dose of glargine was increased significantly, and she was uptitrated slowly on an insulin lispro sliding scale to better control sugars yet avoid hypoglycemia. #. Hypertension: Patient had relative hypotension with systolic blood pressure most often in the 100s-120s, despite her history of hypertension. Her atenolol was held in the setting of bradycardia on admission and acute on chronic renal failure. After resolution of the bradycardia, she was started on low dose metoprolol and titrated up slowly. She was also started on low dose lisinopril, due to her heart failure. #. Coronary Artery Disease: Due to her history of ischemic heart disease, Mrs. [**Known lastname 22152**] was ruled out for acute myocardial infarction on admission to the medical ICU as well as after her episode of chest discomfort on [**2144-7-21**]. Her troponins were mildly elevated on admission at 0.09 but stable and determined to be secondary to her heart disease in the setting of chronic renal insufficiency. After the singular episode of chest discomfort, her troponins were stable at 0.11, which is a minor bump from 0.09, not enough to be an acute myocardial infarction. Patient was continued on home doses of aspirin, plavix, simvastatin throughout her hospital course. #. Anemia: Patient has a history of Anemia of Chronic Disease. Low normal ferritin level and MCV suggest iron deficiency anemia. Ferrous sulfate was held on admission due to possible contribution to altered mental status. She was further monitored for signs of bleeding while on the heparin drip; she was found to have some increased bruising but her hematocrit was stable. Medications on Admission: Atenolol 25 mg daily Celexa 20 mg daily Plavix 75 mg daily Folate 1 mg daily Lasix 80 mg [**Hospital1 **] Lantus 15 u qhs Metolazone 5 mg daily Simvastatin 20 mg daily Aspirin 81 mg daily Colace 100 mg [**Hospital1 **] Ferrous Sulfate 325 mg daily Glucosamine 1,000 mg daily MVI 1 tab daily Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS DIRECTED). 7. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Insulin, glargine and sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary Diagnoses: Sepsis Gram Positive Bacteremia with Corynebacterium Striatum Bradycardia Gastrointestinal Bleed Acute on Chronic Kidney Disease Stage IV Chronic Systolic Congestive Heart Failure Secondary Diagnoses: Chronic Left Ventricular Systolic Heart Failure Diabetes Mellitus Coronary Artery Disease Hyperlipidemia Discharge Condition: Hemodynamically stable. Good condition. Discharge Instructions: You were admitted to the hospital with a severe bacterial infection in your bloodstream and a very low heart rate. Studies revealed a bloodstream infection, and you were started on IV antibiotics for a course of 2 weeks total. During your hospital stay, you were thought to have a blood clot in your right leg and were given a blood thinner for two days. After this time, it was confirmed that you do not have a blood clot in that leg. You were then found to have a gastrointestinal bleed, which was very stable, but you were transfused with 4 units of blood to prevent further problems in case the bleeding were to worsen. After two days of monitoring, you were found to be stable and ready to transfer to [**Hospital 100**] Rehab. You are being discharged to a rehabilitation facility where you will get your medications, including the intravenous antibiotics to continue treating your infection. Your medications have changed. Please review your medication list, and upon discharged from [**Hospital 100**] Rehab please review that medication list. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] after the course of your antibiotic treatment. Dr.[**Name (NI) 22154**] clinic phone number is the following: [**Telephone/Fax (1) 719**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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248, 254

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1821

Discharge summary

report

Admission Date: [**2166-10-20**] Discharge Date: [**2166-10-27**] Date of Birth: [**2102-4-8**] Sex: F Service: Thoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 64 year old female smoker with 1+ pack year smoking history, status post median sternotomy with intrapericardial left pneumonectomy and radical mediastinal lymph node dissection on [**2166-10-9**], for Stage IV, nonsmall cell lung carcinoma of the left upper lobe who was recently discharged from the [**Hospital6 1760**] on [**2166-10-15**]. The patient was readmitted complaining of anxiety and feeling short of breath since being at home and described noting chest pain in the inferior aspect of the rib cage bilaterally which served as an intermittent pain and became pain that was not tolerable even with pain medication at home. At that time, the patient denies having any fevers or chills but has nausea without any vomiting. Given this intense pain and nonresolving nausea, the patient was unable to eat while being at home. PAST MEDICAL HISTORY: Her past medical history as noted above is significant for nonsmall cell carcinoma of the left upper lobe, Stage T4 with involvement of the left laryngeal nerve. The patient was also noted to have a hiatal hernia and a history of radiation esophagitis. The patient also has a medical history significant for hypertension and anxiety. PA[**Last Name (STitle) 10200**]GICAL HISTORY: Significant for median sternotomy and intrapericardial left pneumonectomy with radical mediastinal lymph node resection on [**10-9**] by Dr. [**Last Name (Prefixes) **] and Dr. [**Last Name (STitle) 952**]. MEDICATIONS ON ADMISSION: The patient's medication on admission was Protonix 40 mg p.o. q.d., Ativan 0.5 mg p.o. b.i.d., Percocet 5/325 mg one to two tablets p.o. q. 4-6 hours prn pain, Colace 100 mg p.o. b.i.d., Levaquin 250 mg p.o. q.d. times one week. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a busdriver. She has a smoking history of 40+ pack year and she quit several months ago. FAMILY HISTORY: Significant for coronary artery disease and myocardial infarction at age 60 for father and breast cancer for mother. Sister also has a breast cancer. PHYSICAL EXAMINATION: On admission temperature was 100.4, the patient was tachycardiac with a heartrate of 110. Blood pressure was 125/53, respiratory rate 20. Oxygenating at 80% on room air and 95% on 2 liters of nasal cannula. The patient was alert and oriented times three and not in apparent distress at that time. The patient's cardiac examination was sinus tachycardiac with regular rate and rhythm, S1 and S2, no murmurs appreciated. The patient's right lung fields were clear to auscultation. There were no breathsounds appreciated on the left side, as expected. The patient was slightly tender at the inferior aspects of the ribs bilaterally, near the incision sites. The abdomen was with bowel sounds, soft, nontender, nondistended. LABORATORY DATA: Laboratory values on admission revealed white count of 10.4 with hematocrit of 25.4, platelets 373. The differential on white count was 87% neutrophils, 4% bands, 5% lymphocytes and 2% monocytes. PT/PTT were 14.0 and 33.5 with an INR of 1.3. Urinalysis was clear yellow with specific gravity of 0.013, pH of 7.0, trace blood, otherwise negative. Sodium was 129 initially with chloride of 99, repeat sodium was 133, potassium 0.7, chloride 94, carbon dioxide 25, BUN 6, creatinine 0.7 and glucose of 119. Chest x-ray done at the Emergency Department showed large hydropneumothorax at the left lung fields with a fluid level noted at the extreme apex. There was some displacement of the heart in the mediastinum to the right. The right lung appeared well inflated and structurally unremarkable with minimal blunting of the costophrenic angle. HOSPITAL COURSE: The patient was admitted under Dr.[**Name (NI) 1816**] care in the Thoracic Surgery Service. The patient was found to have fever on hospital day #2 with a temperature maximum of 102.2. Blood cultures were sent. The patient also underwent a left chest thoracentesis on hospital day #2. The analysis of the left pleural fluid showed a white count of 3,444 cells/ml, 90% PMNs and 7% lymphocytes. The gram stain analysis of the pleural fluid again showed 1+ PMNs and no microorganisms seen in the cultures of those pleural fluids. Culture of the pleural fluid eventually grew back no aerobic or anaerobic bacteria and no fungus. On hospital day #2 the patient also received packed red blood cell transfusions for a hematocrit of 25.4 and symptoms of shortness of breath and was found to have fevers with chills with a temperature of 103.1. At the time a transfusion miss-match was suspected and appropriate measures were taken. The repeat test of the transfused packed red blood cells and the patient's blood sample showed no reaction against each other. The patient received Tylenol, intravenous Morphine and also was started on intravenous Zosyn and Ampicillin empirically. Later on that night, the patient remained tachycardiac to a heartrate of 130 to 140 and remained tachypneic with increasing oxygen requirement of 4 to 6 liters/minute, nasal cannula to remain saturated at 94%. The patient was hypertensive as well with a systolic blood pressure to 170. At the time the patient was very uncomfortable, anxious and agitated. Stat chest x-ray showed a worsening mediastinal shift to the right, away from the left pneumonectomy site. The patient also underwent an urgent transthoracic echocardiogram to assess the status of the right heart and that showed no obvious strains or ischemic events to the right side of the heart. Given the concern for tension left hydropneumothorax, the patient was emergently transferred to the Cardiac Surgery Recovery Unit for urgent left tube thoracotomy. A left chest tube was placed and was connected to a balanced system, draining at approximately 2 liters of fluid. At the time the patient verbally reported feeling better and her vital signs, heartrate, respiratory rate and oxygen saturations improved. The patient remained in the Cardiac Surgery Recovery Unit and again was found to be tachycardiac to 101 with blood pressures 95/62. The patient underwent emergent thoracic angiogram to rule out any aneurysms of the thoracic aorta which was found to be negative. The patient was started on Neo-Synephrine to maintain a mean arterial pressure of 60 and Cardiology Service was consulted. Review of the transthoracic echocardiogram showed a global hypokinesis with an ejection fraction estimated at 25 to 30% with unknown etiology. The patient was initially start on Dopamine drip in order to wean off of Neo-Synephrine but the patient responded with tachycardia of greater than 120 beats/minute. The patient was eventually started on Milrinone at a low dose in addition to a Neo-Synephrine drip to maintain a mean arterial pressure of greater than 90. The patient was gradually weaned off of Milrinone and Neo-Synephrine drips and by hospital day #6 the patient was maintained on a blood pressure of 114/56 without any Milrinone or Neo-Synephrine. Because of her tachycardia, the patient was started on low dose Lopressor and Captopril for her hypertension. Therefore on hospital day #6 the patient was transferred to the floor from the Cardiac Surgery Recovery Unit. While the patient remained anxious as she had been throughout her admission and often not able to sleep at night, the patient did well on the floor. While on the floor she was discontinued from Zosyn and Ampicillin and was switched over to p.o. Levaquin, and was discharged home on hospital day #8. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSIS: 1. Status post left intrapericardial pneumonectomy and left tension hydropneumothorax. 2. Congestive heart failure 3. Anxiety 4. Hiatal hernia 5. Hypertension DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Digoxin 125 mcg p.o. q.d. 3. Lopressor 25 mg p.o. b.i.d. 4. Captopril 25 mg p.o. t.i.d. 5. Levaquin 250 mg p.o. q. 24 for 8 days 6. Ambien 5 mg p.o. q.h.s. 7. Megace 40 mg p.o. b.i.d. FOLLOW UP: The patient was discharged to follow up with Dr. [**Last Name (STitle) 952**] on [**11-6**] and also was instructed to follow up with Dr. [**Last Name (STitle) 911**] of Cardiology within ten days for repeat echocardiogram. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2166-10-30**] 14:39 T: [**2166-10-30**] 16:54 JOB#: [**Job Number 10202**]

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Discharge summary

report+report

Admission Date: [**2188-8-20**] Discharge Date: [**2188-9-11**] Date of Birth: [**2104-12-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: thoracic spine ulcer Major Surgical or Invasive Procedure: PICC [**8-21**] IR-guided drainage of superficial paravertebral abscess [**8-22**] PICC [**8-25**] Intubation with subsequent extubation History of Present Illness: 83F with h/o chondrosarcoma s/p thoracic fusion/resection and XRT who presented to OSH with complaint of non-healing thoracic ulcer for one year with recent increase in drainage/purulence. Her Neurosurgeon is at MWH - Dr. [**Last Name (STitle) 67171**]. She was supposed to be taken straight to [**Hospital1 18**] per her neurosurgeon at MWH but somehow went there first. In the MWH ED she was documented as having a normal neurologic exam, a UA done for workup of fever which was negative, she was reportedly given CTX and was transferred here for evaluation of her ulcer. In the ED at [**Hospital1 18**] her initial vs were: 98.5 80 112/58 16 96. Exam significant for low rectal tone, guaiac negative. [**2-7**] strength lower extremities bilaterally. Decreased sensation in lower extremities. CN intact. Upper extremities intact. Received NS and Vanc. Patient had been walking prior to this per ED staff. However, lower extremity weakness, bowel incontinence, bladder incontinence is old per neurosurgery. Neurosurgery felt that the weakness and low rectal tone in the lower extremities was chronic and thus did not feel it was a neurosurgical emergency. In all of the documentation sent from [**Hospital **] hospital the neurologic exams are recorded as normal, however, in a report from the NH it notes that she has a paraplegia from the T10 level down and the patient reports that she has not been able to walk since the wintertime and has had weakness for at least a year. MR T spine was performed, which showed paraspinal abscess with probable mass effect causing cord compression, as well as likely osteomyelitis/diskitis. . VS prior to transfer to the floor: 99 96 131/70 18 96% 2L . On presentation to the floor patient was HOH but denied pain. Denied new weakness. Reported bowel and bladder incontinence was old - has had since at least last winter. Denied fevers, chills, nightsweats, back pain, dysuria, rash. Past Medical History: - CAD s/p CABG x4 - Chondrosarcoma originally dx [**2182**], s/p resection, with recurrence in 06, s/p T5-T8 posterior fixation in 07 and resection with indwelling hardware in her spine and also s/p radiation treatment - chronic thoracic ulcer, non-healing, approx. 1 yr - HTN - hyperlipidemia - severe kyphoscoliosis - mild rhabdomyolysis - dementia - ?paraplegia from T10 level [**2-4**] hardware malalignment (per NH notes) Social History: Lives at nursing home. Per discussion with HCP, patient has complicated family life in which ?niece in the past refused treatment and only wanted supportive measures obo the patient, but that the patient really wanted to be full code, full care. HCP was recently set as a neigbor of the [**Last Name (ambig) 228**], [**Doctor Last Name (ambig) **]. Home phone: [**Telephone/Fax (1) 67172**], Cell: [**Telephone/Fax (1) 67173**]. Liaison at NH is [**Doctor First Name 553**], [**Telephone/Fax (1) 67174**]. PCP: [**Name Initial (NameIs) 8051**] [**Telephone/Fax (1) 8058**]. Family History: Not able to obtain given poor historian. Physical Exam: VITALS: T 99 HR 90 BP121/66 RR 22 O2 97% 2L GEN: Slim elderly F in NAD HEENT: NC/AT anicteric sclera Dry MM NECK: Supple. No LAD LUNGS: CTAB HEART: RRR no m/r/g ABD: Soft. NT/ND, +BS. Foley in place RECTAL: brown stool with low rectal tone BACK: 2X2 cm purulent draining ulcer at about level of T4 with hardware showing through ulcer and surrounding erythema. Severe kyphoscoliosis EXTREM: No edema NEURO: A+OX3. CN 2-12 in tact. Unable to passively move legs or toes. No sensation in lower extremities bilaterally below approx. T10 level. Reflexes 3+ bilateral lower extremity (patellar) and 1 bilateral upper extrem (brachioradialis). Sensation and strength intact in bilateral upper extremities. Pertinent Results: [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] WBC-19.6* RBC-4.08* Hgb-11.4* Hct-34.3* MCV-84 MCH-28.0 MCHC-33.3 Plt Ct-562* [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] Neuts-85* Bands-1 Lymphs-4* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] PT-14.0* PTT-30.8 INR(PT)-1.2* [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] ESR-120* [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] CRP-GREATER THAN 300 [**2188-8-20**] 08:32PM [**Month/Day/Year 3143**] Lactate-1.5 [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.5 Mg-1.9 [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] ALT-33 AST-30 AlkPhos-105 TotBili-0.5 . BCx [**8-20**], [**8-21**]: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aspiration of superficial paravertebral collection [**8-22**]: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . PLEURAL ANALYSIS ([**9-9**]) WBC 174, RBC 139, Polys 23, Lymphs 38, Monos 20, Macro 18 Other 1 . PLEURAL CHEMISTRY ([**9-9**]) TotProt 3.4, Glucose 177, LD(LDH) 113 . EKG ([**8-20**]): Sinus rhythm. Consider left ventricular hypertrophy by voltage. Modest inferolateral ST-T wave changes are non-specific. No previous tracing available for comparison. . T-spine XR ([**8-20**]): Nondiagnostic thoracic spine radiographs. . CXR ([**8-20**]): Severely limited study due to severe kyphoscoliosis. There is a left pleural effusion. A left lower lobe consolidation cannot be excluded. . MR [**Name13 (STitle) 2854**] ([**8-20**]): 1. Interval development of osteomyelitis and discitis extending from the T6- T9 vertebral bodies with prevertebral, paravertebral, and epidural extension resulting in stenosis of the spinal canal at T7/8. Recommend continued interval follow-up to exclude recurrent neoplasm. 2. Interval increase in bilateral pleural effusions, left greater than right. . CT T-spine ([**8-21**]): 1. Osteomyelitis and discitis, with fragmentation of vertebral bodies T6-T8, but better appreciated on MRI scan from one day prior. 2. Soft tissue defect posteriorly at level of T7, with left paraspinal abscess at this level. 3. Right anterior paraspinal soft tissue enhancing lesion with loculated fluid and gas, most likely to represent abscess and adjacent phlegmon with inflammatory change. However, underlying soft tissue neoplasm at this site is difficult to exclude given IV contrast enhancement, and recommendation was already made for surveillance. 4. Bilateral pleural effusions, large on the left causing near-collapse of the left lower lobe. NOTE ADDED AT ATTENDING REVIEW: I agree with the above findings. Note particularly the fragmentation of the T8 vertebral body anteriorly and dramatic lucency within the body posterolaterally. There is lucency surrounding the T8 pedicle screws, suggesting loosening and premably infection. These findings also suggest advanced osteomyelitis. . Abscess aspirate ([**8-22**]): Successful ultrasound-guided aspiration of superficial paravertebral collection. . TTE ([**8-22**]): No vegetations seen. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. . PICC ([**8-25**]): Uncomplicated ultrasound and fluoroscopic-guided single-lumen PICC line placement via the right brachial venous approach. Final internal length is 33 cm, with the tip positioned in SVC. The line is ready to use. Note is made of arterial puncture of the left brachial artery with pressure held for five minutes with no immediate post-procedure complications without developing hematoma or loss of distal pulses noted. . Video swallow ([**8-29**]): Barium passed freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration . CHEST (PORTABLE AP) Study Date of [**2188-9-9**] 3:58 PM Compared to prior radiographs from ealier today, there has been marked reduction in size of the left pleural effusion, now small, consistent with history of thoracentesis. There is no pneumothorax. A small- to-moderate left pleural effusion persists. Minimal right perihilar opacity is not significantly changed. A right PICC line is unchanged in position. Patient is status post median sternotomy with thoracic fixation hardware again noted. Healed posterior rib fractures are seen on the left. IMPRESSION: No pneumothorax status post left thoracentesis. Brief Hospital Course: #Hypercarbic Respiratory Distress - On the evening of [**8-27**], the patient became acutely dyspnic and confused while receiving two units of PRBC. ABG showed hypercarbia with PCO2 in 105, shortly thereafter patient became less reponsive and code blue was called for respiratory failure. She was intubated without complication and transferred to the ICU. Most likely cause is volume overload secondary to PRBC transfusion in patient with poor baseline pulmonary reserve given previous kyphoscoliosis, bilateral effusion and inablility to fully expand lungs as previously noted in pulmonary consultation. Effusion appeared acutely worse on CXR. Concern for possible aspiration however bedside bronch did not reveal any obstruction/consolidation. She was started on cefepime and vancomycin for presumed HAP, but cultures were all negative and patient remained afebrile with no white count. Upon transfer from the MICU, she was on only Ancef (for paraspinal abscess and osteomyelitis). She was extubated without complication, and remained stable from a respiratory standpoint and was saturating 97% on 2LNC upon transfer from the MICU. Her improvement was attributed to diuresis with lasix with a goal of 2L negative a day. She does have a right sided effusion, which does not require thoracentesis at this time in light of respiratory improvement. She had an effusion tapped by interventional pulmonology, which appeared transudative. Following this procedure, she had stable respiratory status on 2L NC. - cytology on effusion is pending # paraspinal abscess/osteomyelitis/bacteremia - MR [**First Name (Titles) **] [**Last Name (Titles) **] imaging strongly suggestive of T6-T8 osteomyelitis, diskitis, hardware infection, and prevertebral, paravertebral, and epidural extension resulting in stenosis of the spinal canal at T7/8. Examination of wound showed clearly exposed hardware with no overlying barrier. PICC was placed. IR-guided drainage of abscess performed, initially the patient was placed on Vanc + Ceftazidime (HD [**1-7**]). Pt was then switched to Nafcillin monotherapy (HD [**6-8**]) when BCx and abscess cx grew out MSSA. Pt was then switched to Cefazolin (HD 8-discharge) when Nafcillin potentially caused AIN (see below). TTE was performed and showed no vegetations; BCx negative as of HD 3. Patient was initially scheduled for removal of implanted thoracic spine hardware by neurosurgery and surgery, but was delayed once for ARF, and a second time by GI bleeding. Patient was subsequently seen by pulmonology to assess chances of her coming off of the ventilator should the surgery occur. Due to severe kyphosis, low respiratory reserve, and generalized weakness, patient would likely require a prolonged course on the ventilator, likely needing a tracheostomy. Patient is stable, afebrile, and pain free on medical treatment of infected hardware, for the time being will be continued on antibiotics. [**Name (NI) **] HCP [**Name (NI) 67175**] with the more conservative medical management, saying that pt would not have wished to been on the ventilator. Patient was also in agreement with deferring surgery indefinitely. Infectious disease made antibiotic recommendations in light of her hardware remaining, which are cefazolin for 6 weeks starting from [**8-22**], to be followed by cefalexin PO for chronic suppression. . # ARF - Creatinine rose to 1.3 (from 0.5), diminished urinary output, elevated WBC noted on HD7. UA positive for eosinophils. Pt had suffered diarrhea on HD6. ARF attributed to volume depletion and possible AIN. Pt was volume resuscitated, Nafcillin was discontinued and replaced with Cefazolin. The patient's creatinine initially remained stable but after 72-96 hrs began to improve. This is clinically consistent with AIN from nafcillin exposure. Creatinine trended down to 0.9 over course of admission and was stable during diuresis in the MICU as well as on readmission to the medical floor. . # GI bleed - pt was found to have a few episodes of melenotic stool and was observed ot have a hematocrit drop of 5. Patient was transfused 2 units of pRBC twice to maintain a goal hematocrit of >30 given her history of CAD. Patient was started on pantoprazole IV BID, and ASA and heparin was discontinued in light of GI bleed. Gastric lavage was performed which returned heme negative aspirate. GI was consulted and did not do an EGD. . # INR - Unclear why patient had elevated INR of 4.6, thought to be likely due to poor nutrition, as patient has been eating poorly as well as receiving antibiotics. Pt was given Vit K 5 mg and 4 units of FFP with INR correcting to 1.4. INR on discharge was 1.0. . # nutrition/swallow - Pt was noted to have poor swallowing during meals. Soft meals with thickened liquids with 1:1 observation during meals per Nutrition recs. No aspiration seen on video swallow study. . # diarrhea - Pt with numerous BM starting on HD6. Concern for C. diff given antibiotic therapy. C. diff EIA toxin A+B neg x 3. . # CAD s/p CABG - Patient had no complaints of chest pain. Was initially continued on home doses of metoprolol and aspirin. Metoprolol was increased to 25mg [**Hospital1 **] for better BP control. . # Dementia - Patient was continued on home dosage of aricept. Medications on Admission: metoprolol 12.5mg [**Hospital1 **] thiamine 100mg daily MVI folic acid 1 mg daily ASA 81mg daily HCTZ 12.5mg daily natural tears 1gtt [**Hospital1 **] colace 100mg [**Hospital1 **] aricept 5mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for wheeze. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 23 days: please continue IV cefazolin until [**2188-10-3**]. Then start on PO keflex as prescribed. 18. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours: please start on [**2188-10-4**] after IV antibiotic course if completed. 19. Outpatient Lab Work Please draw weekly CBC, AST, ALT, electrolytes, BUN, creatinine and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (infectious diseases) at ([**Telephone/Fax (1) 16411**] 20. Wound Care Thoracic spine ulcer: Pack loosely with damp AMD gauze 1" Cover with 4 x 4s, ABD Secure with Medipore tape Change dressing 2 - 3 x a day 21. Pressure Ulcer Precautions Pressure ulcer care per guidelines: Turn and reposition off back q 2 hours and prn Limit sit time to 1 hour at a time using a pressure redistribution cushion Discharge Disposition: Extended Care Facility: Riverbend of [**Location (un) 40116**] Discharge Diagnosis: Primary diagnoses: Osteomyelitis Paraspinal abscess with cord compression Bacteremia ARF likely due to AIN Secondary diagnoses: CAD s/p CABG x4 h/o chondrosarcoma s/p T5-T8 posterior fixation in [**2186**] and resection with indwelling hardware in her spine and also s/p radiation treatment hypertension hyperlipidemia kyphoscoliosis mild rhabdomyolysis dementia Discharge Condition: Awake, alert, comfortable, saturating well on 2L nasal canula Discharge Instructions: You were admitted for an infection in your back. You were given antibiotics for the infection. During your hospitalization, your kidneys suddenly worsened in function. After some additional laboratory work, we believe that this was due to an uncommon reaction to the antibiotics you were being given for your infection. This antibiotic was immediately stopped and replaced with another antibiotic that would also be effective for your infection. Your kidney function gradually improved after the medication change. You also had [**Year (4 digits) **] in your stool, which resolved on its own. You were transferred to the ICU briefly and intubated for difficulty breathing. You had some fluid surrounding your lungs removed which helped with the breathing. It was decided that the risks outweighed the benefits for the hardware in your spine to be removed. You will be kept on IV antibiotics until [**2188-10-3**] and then switched to oral antibiotics. There were changes made to your medications, please take them as prescribed. If you notice pain, fever, chills, loss of your ability to move your arms, or any symptom that concerns you, please return to the Emergency Department immediately. Followup Instructions: Provider: [**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-10-2**] 11:30 Admission Date: [**2188-8-20**] Discharge Date: [**2188-9-11**] Date of Birth: [**2104-12-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: thoracic spine ulcer Major Surgical or Invasive Procedure: PICC [**8-21**] IR-guided drainage of superficial paravertebral abscess [**8-22**] PICC [**8-25**] Intubation with subsequent extubation History of Present Illness: 83F with h/o chondrosarcoma s/p thoracic fusion/resection and XRT who presented to OSH with complaint of non-healing thoracic ulcer for one year with recent increase in drainage/purulence. Her Neurosurgeon is at MWH - Dr. [**Last Name (STitle) 67171**]. She was supposed to be taken straight to [**Hospital1 18**] per her neurosurgeon at MWH but somehow went there first. In the MWH ED she was documented as having a normal neurologic exam, a UA done for workup of fever which was negative, she was reportedly given CTX and was transferred here for evaluation of her ulcer. In the ED at [**Hospital1 18**] her initial vs were: 98.5 80 112/58 16 96. Exam significant for low rectal tone, guaiac negative. [**2-7**] strength lower extremities bilaterally. Decreased sensation in lower extremities. CN intact. Upper extremities intact. Received NS and Vanc. Patient had been walking prior to this per ED staff. However, lower extremity weakness, bowel incontinence, bladder incontinence is old per neurosurgery. Neurosurgery felt that the weakness and low rectal tone in the lower extremities was chronic and thus did not feel it was a neurosurgical emergency. In all of the documentation sent from [**Hospital **] hospital the neurologic exams are recorded as normal, however, in a report from the NH it notes that she has a paraplegia from the T10 level down and the patient reports that she has not been able to walk since the wintertime and has had weakness for at least a year. MR T spine was performed, which showed paraspinal abscess with probable mass effect causing cord compression, as well as likely osteomyelitis/diskitis. . VS prior to transfer to the floor: 99 96 131/70 18 96% 2L . On presentation to the floor patient was HOH but denied pain. Denied new weakness. Reported bowel and bladder incontinence was old - has had since at least last winter. Denied fevers, chills, nightsweats, back pain, dysuria, rash. Past Medical History: - CAD s/p CABG x4 - Chondrosarcoma originally dx [**2182**], s/p resection, with recurrence in 06, s/p T5-T8 posterior fixation in 07 and resection with indwelling hardware in her spine and also s/p radiation treatment - chronic thoracic ulcer, non-healing, approx. 1 yr - HTN - hyperlipidemia - severe kyphoscoliosis - mild rhabdomyolysis - dementia - ?paraplegia from T10 level [**2-4**] hardware malalignment (per NH notes) Social History: Lives at nursing home. Per discussion with HCP, patient has complicated family life in which ?niece in the past refused treatment and only wanted supportive measures obo the patient, but that the patient really wanted to be full code, full care. HCP was recently set as a neigbor of the [**Last Name (ambig) 228**], [**Doctor Last Name (ambig) **]. Home phone: [**Telephone/Fax (1) 67172**], Cell: [**Telephone/Fax (1) 67173**]. Liaison at NH is [**Doctor First Name 553**], [**Telephone/Fax (1) 67174**]. PCP: [**Name Initial (NameIs) 8051**] [**Telephone/Fax (1) 8058**]. Family History: Not able to obtain given poor historian. Physical Exam: VITALS: T 99 HR 90 BP121/66 RR 22 O2 97% 2L GEN: Slim elderly F in NAD HEENT: NC/AT anicteric sclera Dry MM NECK: Supple. No LAD LUNGS: CTAB HEART: RRR no m/r/g ABD: Soft. NT/ND, +BS. Foley in place RECTAL: brown stool with low rectal tone BACK: 2X2 cm purulent draining ulcer at about level of T4 with hardware showing through ulcer and surrounding erythema. Severe kyphoscoliosis EXTREM: No edema NEURO: A+OX3. CN 2-12 in tact. Unable to passively move legs or toes. No sensation in lower extremities bilaterally below approx. T10 level. Reflexes 3+ bilateral lower extremity (patellar) and 1 bilateral upper extrem (brachioradialis). Sensation and strength intact in bilateral upper extremities. Pertinent Results: [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] WBC-19.6* RBC-4.08* Hgb-11.4* Hct-34.3* MCV-84 MCH-28.0 MCHC-33.3 Plt Ct-562* [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] Neuts-85* Bands-1 Lymphs-4* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2188-8-20**] 08:20PM [**Month/Day/Year 3143**] PT-14.0* PTT-30.8 INR(PT)-1.2* [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] ESR-120* [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] CRP-GREATER THAN 300 [**2188-8-20**] 08:32PM [**Month/Day/Year 3143**] Lactate-1.5 [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.5 Mg-1.9 [**2188-8-21**] 06:45AM [**Month/Day/Year 3143**] ALT-33 AST-30 AlkPhos-105 TotBili-0.5 . BCx [**8-20**], [**8-21**]: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aspiration of superficial paravertebral collection [**8-22**]: STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . PLEURAL ANALYSIS ([**9-9**]) WBC 174, RBC 139, Polys 23, Lymphs 38, Monos 20, Macro 18 Other 1 . PLEURAL CHEMISTRY ([**9-9**]) TotProt 3.4, Glucose 177, LD(LDH) 113 . EKG ([**8-20**]): Sinus rhythm. Consider left ventricular hypertrophy by voltage. Modest inferolateral ST-T wave changes are non-specific. No previous tracing available for comparison. . T-spine XR ([**8-20**]): Nondiagnostic thoracic spine radiographs. . CXR ([**8-20**]): Severely limited study due to severe kyphoscoliosis. There is a left pleural effusion. A left lower lobe consolidation cannot be excluded. . MR [**Name13 (STitle) 2854**] ([**8-20**]): 1. Interval development of osteomyelitis and discitis extending from the T6- T9 vertebral bodies with prevertebral, paravertebral, and epidural extension resulting in stenosis of the spinal canal at T7/8. Recommend continued interval follow-up to exclude recurrent neoplasm. 2. Interval increase in bilateral pleural effusions, left greater than right. . CT T-spine ([**8-21**]): 1. Osteomyelitis and discitis, with fragmentation of vertebral bodies T6-T8, but better appreciated on MRI scan from one day prior. 2. Soft tissue defect posteriorly at level of T7, with left paraspinal abscess at this level. 3. Right anterior paraspinal soft tissue enhancing lesion with loculated fluid and gas, most likely to represent abscess and adjacent phlegmon with inflammatory change. However, underlying soft tissue neoplasm at this site is difficult to exclude given IV contrast enhancement, and recommendation was already made for surveillance. 4. Bilateral pleural effusions, large on the left causing near-collapse of the left lower lobe. NOTE ADDED AT ATTENDING REVIEW: I agree with the above findings. Note particularly the fragmentation of the T8 vertebral body anteriorly and dramatic lucency within the body posterolaterally. There is lucency surrounding the T8 pedicle screws, suggesting loosening and premably infection. These findings also suggest advanced osteomyelitis. . Abscess aspirate ([**8-22**]): Successful ultrasound-guided aspiration of superficial paravertebral collection. . TTE ([**8-22**]): No vegetations seen. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. . PICC ([**8-25**]): Uncomplicated ultrasound and fluoroscopic-guided single-lumen PICC line placement via the right brachial venous approach. Final internal length is 33 cm, with the tip positioned in SVC. The line is ready to use. Note is made of arterial puncture of the left brachial artery with pressure held for five minutes with no immediate post-procedure complications without developing hematoma or loss of distal pulses noted. . Video swallow ([**8-29**]): Barium passed freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration . CHEST (PORTABLE AP) Study Date of [**2188-9-9**] 3:58 PM Compared to prior radiographs from ealier today, there has been marked reduction in size of the left pleural effusion, now small, consistent with history of thoracentesis. There is no pneumothorax. A small- to-moderate left pleural effusion persists. Minimal right perihilar opacity is not significantly changed. A right PICC line is unchanged in position. Patient is status post median sternotomy with thoracic fixation hardware again noted. Healed posterior rib fractures are seen on the left. IMPRESSION: No pneumothorax status post left thoracentesis. Brief Hospital Course: #Hypercarbic Respiratory Distress - On the evening of [**8-27**], the patient became acutely dyspnic and confused while receiving two units of PRBC. ABG showed hypercarbia with PCO2 in 105, shortly thereafter patient became less reponsive and code blue was called for respiratory failure. She was intubated without complication and transferred to the ICU. Most likely cause is volume overload secondary to PRBC transfusion in patient with poor baseline pulmonary reserve given previous kyphoscoliosis, bilateral effusion and inablility to fully expand lungs as previously noted in pulmonary consultation. Effusion appeared acutely worse on CXR. Concern for possible aspiration however bedside bronch did not reveal any obstruction/consolidation. She was started on cefepime and vancomycin for presumed HAP, but cultures were all negative and patient remained afebrile with no white count. Upon transfer from the MICU, she was on only Ancef (for paraspinal abscess and osteomyelitis). She was extubated without complication, and remained stable from a respiratory standpoint and was saturating 97% on 2LNC upon transfer from the MICU. Her improvement was attributed to diuresis with lasix with a goal of 2L negative a day. She does have a right sided effusion, which does not require thoracentesis at this time in light of respiratory improvement. She had an effusion tapped by interventional pulmonology, which appeared transudative. Following this procedure, she had stable respiratory status on 2L NC. - cytology on effusion is pending # paraspinal abscess/osteomyelitis/bacteremia - MR [**First Name (Titles) **] [**Last Name (Titles) **] imaging strongly suggestive of T6-T8 osteomyelitis, diskitis, hardware infection, and prevertebral, paravertebral, and epidural extension resulting in stenosis of the spinal canal at T7/8. Examination of wound showed clearly exposed hardware with no overlying barrier. PICC was placed. IR-guided drainage of abscess performed, initially the patient was placed on Vanc + Ceftazidime (HD [**1-7**]). Pt was then switched to Nafcillin monotherapy (HD [**6-8**]) when BCx and abscess cx grew out MSSA. Pt was then switched to Cefazolin (HD 8-discharge) when Nafcillin potentially caused AIN (see below). TTE was performed and showed no vegetations; BCx negative as of HD 3. Patient was initially scheduled for removal of implanted thoracic spine hardware by neurosurgery and surgery, but was delayed once for ARF, and a second time by GI bleeding. Patient was subsequently seen by pulmonology to assess chances of her coming off of the ventilator should the surgery occur. Due to severe kyphosis, low respiratory reserve, and generalized weakness, patient would likely require a prolonged course on the ventilator, likely needing a tracheostomy. Patient is stable, afebrile, and pain free on medical treatment of infected hardware, for the time being will be continued on antibiotics. [**Name (NI) **] HCP [**Name (NI) 67175**] with the more conservative medical management, saying that pt would not have wished to been on the ventilator. Patient was also in agreement with deferring surgery indefinitely. Infectious disease made antibiotic recommendations in light of her hardware remaining, which are cefazolin for 6 weeks starting from [**8-22**], to be followed by cefalexin PO for chronic suppression. . # ARF - Creatinine rose to 1.3 (from 0.5), diminished urinary output, elevated WBC noted on HD7. UA positive for eosinophils. Pt had suffered diarrhea on HD6. ARF attributed to volume depletion and possible AIN. Pt was volume resuscitated, Nafcillin was discontinued and replaced with Cefazolin. The patient's creatinine initially remained stable but after 72-96 hrs began to improve. This is clinically consistent with AIN from nafcillin exposure. Creatinine trended down to 0.9 over course of admission and was stable during diuresis in the MICU as well as on readmission to the medical floor. . # GI bleed - pt was found to have a few episodes of melenotic stool and was observed ot have a hematocrit drop of 5. Patient was transfused 2 units of pRBC twice to maintain a goal hematocrit of >30 given her history of CAD. Patient was started on pantoprazole IV BID, and ASA and heparin was discontinued in light of GI bleed. Gastric lavage was performed which returned heme negative aspirate. GI was consulted and did not do an EGD. . # INR - Unclear why patient had elevated INR of 4.6, thought to be likely due to poor nutrition, as patient has been eating poorly as well as receiving antibiotics. Pt was given Vit K 5 mg and 4 units of FFP with INR correcting to 1.4. INR on discharge was 1.0. . # nutrition/swallow - Pt was noted to have poor swallowing during meals. Soft meals with thickened liquids with 1:1 observation during meals per Nutrition recs. No aspiration seen on video swallow study. . # diarrhea - Pt with numerous BM starting on HD6. Concern for C. diff given antibiotic therapy. C. diff EIA toxin A+B neg x 3. . # CAD s/p CABG - Patient had no complaints of chest pain. Was initially continued on home doses of metoprolol and aspirin. Metoprolol was increased to 25mg [**Hospital1 **] for better BP control. . # Dementia - Patient was continued on home dosage of aricept. Medications on Admission: metoprolol 12.5mg [**Hospital1 **] thiamine 100mg daily MVI folic acid 1 mg daily ASA 81mg daily HCTZ 12.5mg daily natural tears 1gtt [**Hospital1 **] colace 100mg [**Hospital1 **] aricept 5mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-4**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) treatment Inhalation Q4H (every 4 hours) as needed for wheeze. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 11. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 23 days: please continue IV cefazolin until [**2188-10-3**]. Then start on PO keflex as prescribed. 18. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8) hours: please start on [**2188-10-4**] after IV antibiotic course if completed. 19. Outpatient Lab Work Please draw weekly CBC, AST, ALT, electrolytes, BUN, creatinine and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (infectious diseases) at ([**Telephone/Fax (1) 16411**] 20. Wound Care Thoracic spine ulcer: Pack loosely with damp AMD gauze 1" Cover with 4 x 4s, ABD Secure with Medipore tape Change dressing 2 - 3 x a day 21. Pressure Ulcer Precautions Pressure ulcer care per guidelines: Turn and reposition off back q 2 hours and prn Limit sit time to 1 hour at a time using a pressure redistribution cushion Discharge Disposition: Extended Care Facility: Riverbend of [**Location (un) 40116**] Discharge Diagnosis: Primary diagnoses: Osteomyelitis Paraspinal abscess with cord compression Bacteremia ARF likely due to AIN Secondary diagnoses: CAD s/p CABG x4 h/o chondrosarcoma s/p T5-T8 posterior fixation in [**2186**] and resection with indwelling hardware in her spine and also s/p radiation treatment hypertension hyperlipidemia kyphoscoliosis mild rhabdomyolysis dementia Discharge Condition: Awake, alert, comfortable, saturating well on 2L nasal canula Discharge Instructions: You were admitted for an infection in your back. You were given antibiotics for the infection. During your hospitalization, your kidneys suddenly worsened in function. After some additional laboratory work, we believe that this was due to an uncommon reaction to the antibiotics you were being given for your infection. This antibiotic was immediately stopped and replaced with another antibiotic that would also be effective for your infection. Your kidney function gradually improved after the medication change. You also had [**Year (4 digits) **] in your stool, which resolved on its own. You were transferred to the ICU briefly and intubated for difficulty breathing. You had some fluid surrounding your lungs removed which helped with the breathing. It was decided that the risks outweighed the benefits for the hardware in your spine to be removed. You will be kept on IV antibiotics until [**2188-10-3**] and then switched to oral antibiotics. There were changes made to your medications, please take them as prescribed. If you notice pain, fever, chills, loss of your ability to move your arms, or any symptom that concerns you, please return to the Emergency Department immediately. Followup Instructions: Provider: [**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-10-2**] 11:30

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Discharge summary

report

Admission Date: [**2116-12-31**] Discharge Date: [**2117-1-5**] Date of Birth: [**2049-11-16**] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 17813**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 67 year-old woman with a PMH of GSW, shunt and subsequent seizures. She was reportedly in her USOH this morning when she fell and was then witnessed to have "GTC" lasting 20-25 minutes as well as earlier briefer seizures the specifics of which are not known. She is afebrile and her exam reveals L sided weakness and spasticity consistent with her PMH of brain injury. I am not able to access for nuchal rigidity given her C collar but she does not have a Brudzinski sign. Her work-up to date has included a negative UA and CXR as well as normal electrolytes and liver fxn. Her WBC at the OSH was 8 and here it is 14. This may be due to her seizures or intubation, however underlying infection must be evaluated. She will therefore need a tap of her shunt in the ED. She will also need a shunt series to evaluate for shunt malfunction given her prior history of shunt failure causing seizures. She also has a mildly elevated troponin which may be due to demand ischemia from her prior tachycardia, however I will check her CE to evaluate for an NSTEMI. Given her presentation and low Tegretol level of 6 at the OSH, she may have seized merely from being subtherapeutic on her AED. Infection or structural etiologies including meningitis, shunt failure or other infections will need to be evaluated as well. Will therefore admit to neuro ICU for further care. Past Medical History: PMH: - GSW in [**2096**] years ago to the head, burr holes at the time and a shunt, unsure if metal residual brain - one history of shunt failure and seizures 7 years ago - L sided weakness at baseline from GSW and uses a cane and "shuffling gait"; limited short term memory and minimal insight - seizures per report generalized, has been associated with shunt failure - ? HTN - L mastectomy for breast CA, no hx of mets 3 years - abm surgery ? PEG given the scars on her abm - bilateral hip replacements Social History: -Ex husband her shot her -lives with support -EtOH: not her HCP -tobacco: not per HCP -drug use: not per HCP Family History: Non-contributory Physical Exam: Physical Exam upon admission Vitals: T: 99.4 (PR) P: 90 R: [**11-29**] BP: 141-187/85-87 SaO2: 100% on ET General: intubated, off sedation HEENT: NC/AT, no scleral icterus noted, ET in place, some blood at nare; palpable burr holes which are easily depressable Neck: in C collar; no Brudzinski Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, + BS but multiple scars, with mastectomy of the L breast and several well healed abm incisions Extremities: LLE pitting edema Skin: no rashes Neurologic: this exam is done 5 minutes off of propofol -Mental Status: initially drowsy and difficult to arouse, moving her R leg intermittently (non-rhythmically); 5 minutes later she as able to follow basic commands (squeezes with R hand, opens eyes, shows 1 finger) and nod Y to simple questions inconsistently. CN I: not tested II,III: no blink to threat bilaterally, pupils 1.5->1mm bilaterally, unable to visualize fundi due to miosis III,IV,V: no dolls, No nystagmus V: + corneals and nasal tickle bilaterally VII: no gross facial asymmetry but very difficult to assess as pt has ET in place VIII: UA IX,X: + gag [**Doctor First Name 81**]: UA XII: UA (ET in place) Motor: Normal bulk and tone on the R arm and leg, L arm and leg have increased tone and atrophy; moves R arm and leg spontaneously but not the L side (even to nox stim) Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2+ ----------- 1 Up R 1------------- 0 Flexor -Sensory: withdraws to nox stim on the R arm and leg but not the L side -Coordination: NA -Gait: NA Pertinent Results: [**2116-12-31**] EEG IMPRESSION: A markedly abnormal portable EEG due to the persistent and frequent spike and sharp and slow wave bursts in the right anterior quadrant and due to the irregular slowing in the left central region as well as the mildly slow background. The right anterior quadrant sharp wave activity suggests an acute structural lesion in the right anterior quadrant, likely with epileptogenic potential. Nevertheless, the discharges did not become rapid enough or evolve so as to suggest an ongoing seizure during the course of this recording. The left-sided slowing suggests an additional subcortical dysfunction there. The background reflected the use of the propofol early in the recording and a subsequent mild encephalopathy later. EEG [**2117-1-3**] IMPRESSION: Abnormal EEG due to the presence of persistent frequent spike and sharp slow waves bursts in the right temporal region as well as irregular slowing in the left central region and a mildly slow background. The right temporal activity suggests an area of epileptogenesis. The left central slowing indicates an area of subcortical dysfunction. The generalized background slowing is indicative of mild encephalopathy. Medications, metabollic disturbances and infection are among the most causes. There is no area ongoing seizure during this recording. Head CT [**2116-12-31**] IMPRESSION: 1. No hemorrhage. 2. The distal tip of the shunt terminates in the frontal [**Doctor Last Name 534**] of the right lateral ventricle with no signs of hydrocephalus. 3. Diffuse encephalomalacic changes of the brain in a linear pattern, bullet fragments inside the brain and bilateral skull defects are most likely related to the bullet injury. 4. Depressed fracture fragment of the left frontal area. Shunt series [**2116-12-31**] FINDINGS: At least two separate craniotomies are identified. There is a shunt catheter extending to the central cerebrum through a right posterior burr hole. Catheter tubing extends through the soft tissues of the posterior scalp and occiput to the right neck where there is a single loop. The catheter then traverses and projects over the midline chest, coursing into the abdomen with the tip is located in the left upper quadrant. There is a coiled presumably remnant catheter in the right hemipelvis. Incidental note is made of left base atelectasis and at least four lamellated calcified gallstones. Total hip replacements are also incidentally noted. IMPRESSION: Shunt catheter as described above. No discontinuity is noted. Incidental findings as above. Echo cardiogram [**2117-1-1**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. No pericardial effusion. EKG [**2116-12-31**] Sinus rhythm. Left axis deviation. Left anterior fascicular block. No previous tracing available for comparison. Sinus rhythm. Left axis deviation. Left anterior fascicular block. There is a late transition that is probably normal. Compared to the previous tracing of [**2116-12-31**] there is no significant change [**2116-12-31**] LEFT LOWER EXTREMITY ULTRASOUND: The left common femoral, superficial femoral and popliteal veins demonstrate normal waveforms, augmentation and flow and compressibility. There is no intraluminal thrombus. IMPRESSION: No evidence of DVT in the left lower extremity. [**2116-12-31**] 08:54PM CK(CPK)-477* [**2116-12-31**] 08:54PM CK-MB-14* MB INDX-2.9 cTropnT-0.17* [**2116-12-31**] 04:15PM TYPE-ART TIDAL VOL-550 O2-40 PO2-124* PCO2-31* PH-7.49* TOTAL CO2-24 BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [**2116-12-31**] 03:44PM URINE HOURS-RANDOM [**2116-12-31**] 03:44PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2116-12-31**] 01:15PM GLUCOSE-83 UREA N-18 CREAT-0.6 SODIUM-137 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16 [**2116-12-31**] 01:15PM estGFR-Using this [**2116-12-31**] 01:15PM ALT(SGPT)-22 AST(SGOT)-34 CK(CPK)-280* ALK PHOS-69 TOT BILI-0.6 [**2116-12-31**] 01:15PM LIPASE-23 [**2116-12-31**] 01:15PM CK-MB-10 MB INDX-3.6 [**2116-12-31**] 01:15PM cTropnT-0.25* [**2116-12-31**] 01:15PM ALBUMIN-3.8 PHOSPHATE-2.3* MAGNESIUM-1.9 [**2116-12-31**] 01:15PM ASA-NEG ETHANOL-NEG CARBAMZPN-5.2 ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2116-12-31**] 01:15PM WBC-14.5* RBC-4.26 HGB-13.6 HCT-37.9 MCV-89 MCH-31.8 MCHC-35.8* RDW-13.6 [**2116-12-31**] 01:15PM NEUTS-87.1* LYMPHS-8.2* MONOS-4.5 EOS-0.1 BASOS-0.1 [**2116-12-31**] 01:15PM PT-11.7 PTT-20.1* INR(PT)-1.0 [**2116-12-31**] 01:15PM PLT COUNT-304 [**2116-12-31**] 12:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2116-12-31**] 12:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG Brief Hospital Course: Neurologically: The pt is a 67 year-old woman with a PMH of GSW, shunt and subsequent seizures, who was admitted for convulsive status epilepticus and her initial Tegretol level was low at 5.2. She was successfully extubated and transferred to the neurology floor. The Tegretol was changed to XR formulation and increased to 600mg [**Hospital1 **] and she did not have additional seizures. Her initial EEG showed frequent epileptiform discharges in the R anterior quadrant although no clear electrographic seizures were seen. After the medication adjustment, a repeat EEG was done and showed persistent discharges but signficantly improved and were much less frequent. A shunt series demonstrated no obstruction or evidence of dysfunction. Initially, on exam she was lethargic and slow to answer and had profound left arm and leg weakness, which were likely postictal phenomenon, as this improved with time. The R arm and leg strength improved to baseline and she was able to ambulate with a cane and assistance. Her physical exam upon discharge: slow to answer, but alert and responsive. oriented to place and person, not to time. Moderate left hemiparesis with strength of [**3-14**] in lower and upper extremities. She stated that she has an outpatient neurologist who has been following her and she will follow him after discharge. 2) CV: -troponins elevated but trending downward -TTE Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. No pericardial effusion -monitor on telemetry with variable elevated heart rate with no identified cause. PCP was [**Name (NI) 653**] and no previous history of tachicardia 3) RESP: -extubation without complications -monitor for aspiration PNA 4) RENAL: -no active issues, replete lytes as needed 5) ENDO: -normoglycemia 6) FEN/GI: -patient had feeding by NGTube, passed on swallow test and diet with restriction was initiated. 7) ID: - CSF no signs of infection -Negative blood & urine cx Medications on Admission: - amlodipine 5mg PO QD - gabapentin 600mg PO QD - detrol LA 4mg PO QD - Tegretol XR 40mg PO BID - folic acid 1mg PO QD - clindamycin 150mg PO QD ? - spironolactone 25mg PO QD Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) 7658**] Discharge Diagnosis: Seizures VP shunt Discharge Condition: stable. No further seizures Discharge Instructions: You were admitted to this hospital after having seizures. You have history of epilepsy and VP shunt placement. During your admission no signs of infection was noted. No evidence of shunt mal-function was detected. You will be transfered to rehabilitation facility to continue your care. Followup Instructions: Please contact your PCP Dr [**Name (NI) **] [**Numeric Identifier 60301**] for a follow up appointment and to referal for a neurologist. Also, you need to follow up with a Neurologist. Please call [**Location (un) 4368**] Neurological at [**Telephone/Fax (1) 60302**] to schedule a follow up.

[ "729.89", "V15.88", "780.93", "V43.64", "781.2", "V10.3", "E969", "345.70", "V45.2", "907.0" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

11720, 11797

9466, 10493

284, 291

11859, 11889

4050, 9443

12225, 12523

2366, 2384

11818, 11838

11520, 11697

11913, 12202

2399, 3005

236, 246

319, 1694

3020, 4031

1716, 2223

2239, 2350

10514, 11494

17,566

156,549

20511

Discharge summary

report

Admission Date: [**2201-4-7**] Discharge Date: [**2201-5-20**] Date of Birth: [**2130-9-26**] Sex: F Service: NSU HISTORY OF HOSPITAL COURSE: The patient is a 70 year old woman who was admitted on [**4-7**], status post a right frontal hemorrhage with midline shift. She had had previous clipping of an unruptured right MCA aneurysm 8 years ago in elective fashion at an outside institution. The patient was taken emergently to the Operating Room on [**2201-4-7**] for evacuation of sylvian fissure hematoma which led to herniation syndrome with a blown pupil in the ED. She subsequently underwent cerebral angiography which showed that she had a large MCA aneurysm recurrence/regrowth under the clip blades. Accordingly, on [**2201-4-8**], she was taken back to the Operating Room for clipping of a right middle cerebral artery aneurysm. She had a vent drain placed on [**4-10**] and an angio on [**4-11**], that showed good placement of the clip. The previous clip could not be removed because it had fused to the tissue. She was intubated in an outside hospital for transport to [**Hospital6 2018**]. She was awake and alert preintubation. On arrival to the Emergency Room she was withdrawing her lower extremities, flexor posturing her upper extremities with no eye opening. She had serratia in her blood and sputum on [**4-14**] and fungus in her blood on [**4-14**]. Postoperative neurologically the patient's pupils were equal and reactive, she had localized stimulation on the right, flexors on the left. She continued to be followed by the Infectious Disease Service for serratia and fungus in her blood. She was on Kefzol, Levofloxacin and Fluconazole for intravenous antibiotic coverage. On [**2201-4-28**], for neurologic status she withdrew her arm with noxious stimulation. Her left arm appeared to be posturing. Bilateral toes were positive Babinski, opening eyes occasionally with noxious stimulation, did not follow commands and did not track with her eyes. Spontaneous movement of the right arm only. Pupils equal, round and reactive to light. Vent drain was leveled at 10 cm above the tragus and opened to drainage. She had multiple surveillance cultures sent, and her cerebrospinal fluid came back negative. On her second craniotomy, she did have her craniectomy as well as craniotomy and her flap remained full and soft. Her dressing was clean, dry and intact. She had a tracheostomy placement on [**2201-4-29**] without complications, and percutaneous endoscopic gastrostomy placed at the same time. She had a repeat head computerized tomography scan on [**2197-4-30**] which showed minimal subacute left frontal fluid and no new hemorrhage or mass effect. On [**2201-5-8**], the patient was responding to voice, squeezing of the right hand. Her flap was soft, and she continued to have a hemiparesis on her left side. [**2201-5-15**], the patient was taken to the Operating Room for replacement of craniectomy. There was no intraoperative complications. She also had a right ventriculoperitoneal shunt placed. Postoperative vital signs were stable. She was afebrile. She was awake, responding to commands on the right side. Her incision was clean, dry and intact. She remained neurologically stable and was transferred to the regular floor on [**2201-5-17**]. She remains neurologically stable, following commands on the right side. Her dressing is clean, dry and intact. Her head computerized tomography scan on [**5-18**], showed good placement of the ventriculoperitoneal shunt with effacement of the lateral ventricle. She continued to be assessed by physical therapy and occupational therapy and was found to require acute rehabilitation. DISCHARGE MEDICATIONS: 1. Insulin sliding scale. 2. Metoprolol 50 mg p.o. b.i.d. 3. Piperacillin 4.5 gm intravenously q. 8 hours. 4. Fluconazole 400 mg p.o. q. 24 hours. 5. Hydralazine 10 intravenously q. 6 prn. 6. Albuterol inhaler 1 to 2 puffs q. 6 hours prn. 7. Dilantin 100 mg q. 8 hours. 8. Senna one tablet p.o. b.i.d. 9. Pantoprazole 40 intravenously q. 24 hours. 10. Heparin 5000 subcutaneously q. 12 hours. CONDITION ON DISCHARGE: Stable. FOLLOW UP: He will follow up with Dr. [**Last Name (STitle) 1132**] in one month with repeat head computerized tomography scan. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2201-5-19**] 17:42:30 T: [**2201-5-19**] 19:18:27 Job#: [**Job Number 54885**]

[ "331.3", "518.5", "348.4", "430", "401.9", "276.0", "272.4", "482.83", "117.9" ]

icd9cm

[ [ [] ] ]

[ "39.51", "02.34", "31.1", "88.41", "02.03", "96.6", "99.04", "01.31", "43.11", "02.2" ]

icd9pcs

[ [ [] ] ]

3744, 4144

163, 3721

4190, 4560

4169, 4178

31,985

174,213

34719

Discharge summary

report

Admission Date: [**2161-7-29**] Discharge Date: [**2161-8-13**] Date of Birth: [**2087-2-5**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: seizure Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 79582**] is a 74-year-old man with a history of HTN, a fib not anti-coagulated, alcoholism who presents with two seizures. His wife says they had taken a drive up to [**Location (un) 28318**] and stopped for lunch in [**Location (un) **] on the way home. She says she thought he was going to order a beer, but when he came back he had a mixed drink. When she asked what it was, he said it was an "encyclopedia." Shortly after that, his right arm extended and became rigid, followed seconds after by a generalized rigidity and then generalized shaking. She caught him, and an EMT and fireman in the restaurant helped lower him to the floor. She believes it lasted for 3-4 minutes. There was no cyanosis. He seemed confused afterwards, but was back to his normal self when the ambulance got to [**Hospital **] Hospital, about 10 minutes later. At [**Hospital1 **], notes document an "expressive aphasia." He also had an elevated blood pressure at 202/97 and received labetalol. About an hour after his first seizure, his wife saw his right hand start to shake, progressing to his whole arm, and within seconds it had generalized again. It's documented as lasting 1 minute 20 seconds. He received 2 mg of Ativan and 1000 PE of fos-phenytoin. He was transferred to [**Hospital1 18**]. On arrival, he was noted to "respond only to pain." He was therefore intubated. He received 20 mg etomidate and 120 mg succinylcholine at 4:30 pm, and placed on a propofol drip. Although he cannot answer ROS questions, his wife says he had not complained of any headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty; she denied that he had any difficulties producing or comprehending speech. Denied focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, she also noted no recent fever or chills. No night sweats or recent weight loss or gain. He does cough frequently with his bronchitis. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Stroke [**7-/2160**], presenting with left arm and leg weakness, symptoms resolved now per wife. HTN Atrial fibrillation not on Coumadin due to alcoholism per wife Chronic Bronchitis Alcoholism Inguinal hernia, not repaired Social History: Heavy alcohol use for a long time; now down to 4 drinks per day. Last drink at dinner on [**2161-7-28**]. Family History: Mother died at 86 with CHF, DM. Father died of ruptured abdominal aneurysm. Physical Exam: Vitals: T: afeb P: 67 R: 14 BP: 191/97 SaO2: 100% on AC 500x14, FiO2 1.0 General: Intubated, sedated. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: Regular. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Eyes closed, unresponsive, having received etomidate and succ at 2 hours prior and having been on propofol 5 mins prior. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: No doll's eyes. V: Corneals intact. VII: No facial droop, facial musculature symmetric. VIII: Not tested. IX, X: Gag with deep suctioning. [**Doctor First Name 81**]: Not tested. XII: Not tested. -Motor: Flaccid throughout. Withdraws all four extremities antigravity even having received paralytics and sedation recently, perhaps right arm less vigorously. -Sensory: Intact to pain in all 4. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 4 4 4 2 2 R 2 2 2 2 1 Plantar response was extensor bilaterally. -Coordination & Gait: Not testable given clinical situation. Brief Hospital Course: This 74 yo M with hx AF, not anticoagulated, HTN, EtOH abuse, presented with 2 secondarily GTC seizures (starting with R hand focus) and found to have a L parietal hemorrhage, thought to be c/w amyloid angiopathy. Pt intubated and sedated for airway protection and treated in the ICU with Dilantin and later switched to Keppra. Pt extubated 2 days after admission on [**2161-7-31**], however, developed an aspiration PNA and was treated with Zosyn. This improved over the course of days, but pt developed some RLL collapse, and O2 sats have been in the 93-94% range. Pt had a CT of the C/A/P to better characterize pulm path and found incidentally to have 3.9 cm AAA and renal calcifications, possibly contributing to stenosis. BP control remained an issue and pt was put on Norvasc and a large dose of metoprolol (100 mg Q6hrs) for both rate and pressure control. On [**2161-8-10**], pt had an episode of temporary unresponsiveness with head-tilting back, was shaken by family and pt returned to baseline. However, tele correlate showed pt sustained a ~10 sec sinus pause. Chem-10, trop, and CK sent and stat EKG done. Cardio consult called who recommended transfer to cardiac floor and EP consult. He was on cardiology service for 48 hours where beta-blockers were held and thought to be the etiology of the pause, although pt was noted to have at least one shorter pause in the setting of having been off the beta-blockers. Discussion with the cardiology team suggested that given the pt's other risk factors that the risks outweighed the benefits for pacemaker placement. He was discharged to rehab on [**2161-8-13**]. Medications on Admission: Cartia XT 240 mg po daily Metoprolol 75 mg po bid Omeprazole 20 mg po daily Combivent 2 puffs [**Hospital1 **] Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 1-2 tabs PO Q6H (every 6 hours) as needed for temp > 100.4, pain. 2. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed. 3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 4. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). 7. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 8. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 10. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) units Injection TID (3 times a day). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q4H (every 4 hours) as needed. 12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q4H (every 4 hours) as needed. 13. Levetiracetam 1,000 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. 14. Valsartan 80 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: left parietal intracerebral hemorrhage Discharge Condition: stable Discharge Instructions: You have had a left parietal brain hemorrhage, likely secondary to amyloid angiopathy. This manifested itself as seizures. You will need to continue on your anti-seizure meds and work to maintain a good blood pressure. Please return to the ER if you experience any sudden weakness, change in sensation, headache, vertigo, double vision, change in speech, or have any seizures manifested by altered consciousness, focal repetitive motor movements, or generalized convulsions. Followup Instructions: Please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 41132**] to arrange follow up for after dischargef rom rehab. with Dr. [**Last Name (STitle) **] for neurological follow-up: [**Telephone/Fax (1) 2574**]. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2161-9-29**] 4:00 Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] [**Location (un) **]. You have a cardiology follow up appointment with [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], JR. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2161-9-2**] 9:40 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2161-8-13**]

[ "303.90", "277.30", "780.79", "507.0", "438.89", "431", "401.9", "427.31", "780.39" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8008, 8080

4557, 6182

322, 329

8163, 8172

8695, 9560

3032, 3110

6344, 7985

8101, 8142

6208, 6321

8196, 8672

3784, 4534

3125, 3630

275, 284

357, 2645

3645, 3767

2667, 2893

2909, 3016

5,163

102,782

18332+56935

Discharge summary

report+addendum

Admission Date: [**2111-9-28**] Discharge Date: Date of Birth: [**2085-3-12**] Sex: M Service: MICU CHIEF COMPLAINT: Shortness of breath and fever. HISTORY OF PRESENT ILLNESS: This 26-year-old male with no significant past medical history with the exception of a pneumonia three months prior to arrival found to be a pneumococcal pneumonia, who presented with fever, cough, sore throat to [**Hospital3 3834**] on [**2111-9-27**]. The patient became progressively more hypoxic, tachypneic, and tachycardic. On Tuesday, patient went on a business trip to [**Location (un) 2725**], then Wednesday to [**Country 6607**] in the [**Location (un) 14336**] area, and then Thursday came back to [**State 350**]. He had no lower extremity edema, no chest pain. Patient developed sore throat and fever with chills and cough, and has a temperature max of 102 with rigors. Patient stayed home from work on Friday and Saturday, and patient noted a vesicular, nonpruritic, nonpainful rash that erupted on his anterior chest, arms, and back with sparing of his palms and soles. The patient also noticed conjunctivitis with no discharge or itching. He also had positive sputum productive of yellowish tan-colored sputum. He also had some shortness of breath, but was able to speak in full sentences. No headache. No neck stiffness. No mental status changes. Patient has had his vaccinations. His last measle booster was at age 20. Patient has never had a PPD placed. Otherwise, he reports no sick contacts, but does report a worker in his job currently got the varicella vaccine placed. Additionally, the patient states that his son has had a runny nose for the past week. REVIEW OF SYSTEMS: Otherwise negative. PAST MEDICAL HISTORY: Pneumonia three months ago, which was treated with an overnight admission in [**Hospital3 **]. Patient was treated at that time with ceftriaxone and levofloxacin, and then discharged home. Otherwise, no significant past medical history. ALLERGIES: Penicillin. It causes a rash. MEDICATIONS ON TRANSFER: 1. Acyclovir, 1,000 mg IV q.8h. 2. Rocephin 1 gram q.d. 3. Diflucan 100 p.o. q.d. 4. Doxycycline 100 b.i.d. 5. Motrin 800 p.o. q.8h. FAMILY HISTORY: Patient has no family history. SOCIAL HISTORY: He works as a buyer at [**Doctor First Name **] Foods. No outdoor activity. No hiking. No swimming. No pets. No occupational exposures. Patient has never been tested for TB. Was last sexually active two months ago and was protected. Currently, patient is divorced. He has a 3-year-old son. Social EtOH. Occasional tobacco. No IVDU. PHYSICAL EXAM: Vitals: Temperature 99.0, heart rate 120, blood pressure 143/68, respirations 23, sating at 91% on room air and then 100% on a nonrebreather. Generally: The patient is young, shortness of breath, is speaking in full sentences, and appears in mild respiratory distress. HEENT: Extraocular movements are intact. Patient has red conjunctivae sparing the limbus with positive cervical lymphadenopathy. The heart is tachycardic with normal S1, S2. Lungs: Left base crackles with E:A change at the left base, right basilar crackles are also noted, but left worse than right. Abdomen has good bowel sounds, soft, nontender, nondistended. Extremities have no clubbing, cyanosis, or edema. Skin: There is a vesicular rash with an erythematous base, which is nonpruritic and blanchable noted on the anterior chest, arms, as well as back crusted over and appeared dry. The lesions on the anterior chest and arms appear to be of the same age. Neurologic examination: Cranial nerves II through XII are intact. Strength is [**5-4**] and symmetric. Reflexes are 2+ throughout. DATA: Laboratories: White count 3.1, hematocrit 42.6, platelet count 181. Differential was initially pending. Neutrophils 67, bands 12, lymphocytes 14, monocytes 2, eosinophils 0, basophils 0, 2 atypicals, 3 metamyelocytes. His PT was 13.4, PTT 27.8, INR 1.2. Sodium 138, potassium 4.2, bicarb 31, chloride 100, BUN 8, creatinine 0.8, glucose 120, calcium 8.6, magnesium 1.8, phosphorus of 2.1. AST of 17, ALT 17, LDH 210, alkaline phosphatase 37, amylase 18.3, T bilirubin 0.5, albumin is 3.0. ABG: 7.43, 43, 61 on 100% nonrebreather. CHEST X-RAY: Bilateral hazy infiltrates with left retrocardiac consolidation. HOSPITAL COURSE BY SYSTEMS: 1. Pneumonia: When patient initially presented to the hospital, patient had studies sent off for varicella zoster, herpes simplex types I and II, [**Month/Day (1) 50508**] and Gram stain for fungi as well as PCP, [**Name10 (NameIs) 50508**] of the nasal swab for viruses, testing for Mycoplasma pneumonia by antibodies as well as by PCR, and antibody testing for [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus. Blood culture and urine culture as well as sputum [**Doctor Last Name 50508**] were also sent off. Additionally, skin biopsies of the patient's vesicular rash was done x2 to test for varicella. The patient's microdata was all negative with the exception of elevated IgM as well as elevated IgG for Mycoplasma pneumonia. Additionally, the first two smears of the vesicles for varicella were negative. Patient had a deep skin biopsy, which was then taken which was positive for erythema multiforme. Patient was initially treated with Vancomycin, acyclovir, ceftriaxone, and later changed to Vancomycin, levofloxacin, and then later changed to azithromycin for a total of 21 days of antibiotics. Patient's chest x-ray by time of completion of antibiotic regimen revealed that he had small bilateral pleural effusions and a left middle lobe infiltrate with resolution of the left lower lobe infiltrate. Again, patient was maintained on antibiotics for a total of 21 days. Otherwise, the patient had two bronchoalveolar lavages done along with brushings, and these were completely negative for microorganisms. The patient also had a CT of his chest performed on [**2111-10-6**] which was consistent with a new right middle lobe infiltrate which was felt to be secondary to BAL of the right middle lobe. By the time of discharge, this infiltrate was stable. Otherwise, patient was intubated on [**2111-9-28**], and remained intubated until [**2111-10-19**] at which time, a trache was placed in the OR. Throughout his hospitalization, patient had very thick blood-tinged expectorant from his lungs, which was felt to initially be consistent with desquamation caused by [**Known lastname **]-[**Location (un) **] syndrome, and later given that his course was complicated by a left lower lobe pulmonary embolus which arose from a right upper extremity DVT, his blood-tinged sputum was thought to be caused by supratherapeutic PTT and airway changes from [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **]. By time of this discharge summary, his sputum became nonbloody and was mostly purulent in nature. It should be noted that the patient had a very traumatic intubation on [**2111-9-28**]. The anesthesiologist that performed that intubation noted that patient's posterior pharynx was desquamated, ulcerated, and "raw appearing". His intubation was complicated by pneumomediastinum as well as a small pneumothorax on the left side. These resolved spontaneously . It was felt that given patient's traumatic intubation, that patient should be extubated with trache placement on [**10-19**] in the OR given that patient could have possible subglottic stenosis. 2. Ventilation: Patient was initially maintained on assist-control ventilation. As his pulmonary examination improved, he was maintained on pressure support ventilation and tolerated pressure support and PEEP of 5 without any complications. His main limiting factors to extubation included very thick secretions as well as the patient becoming extremely agitated, diaphoretic, and tachypneic at extubation. For sedation, the patient was maintained initially on Fentanyl and Versed, and then on propofol by time of discharge. 3. Fevers: Initially when patient presented, he was afebrile, but then shortly thereafter, he had daily fevers every hour on the hour to a max of 104. In an effort to search for sources of infection, ultrasound and CT of the abdomen were performed which were entirely normal with the exception acalculous cholecystitis. General Surgery was consulted in effort to determine whether placement of a percutaneous drain would be indicated. Surgery felt that was not indicated during the current admission given the patient's hepatic enzymes were not consistent with a cholecystitis picture. Patient predominantly had elevations in AST and ALT, which by the time of discharge, were trending down and felt most likely secondary to his Tylenol usage for his fevers as well as his sedatives. Patient also had an elevated lipase, and it was felt that this chemical pancreatitis was again caused by the enumerable medicines that the patient was on. Again, by time of discharge, his lipase was trending downwards. Otherwise, a CT of the head and sinuses was performed and revealed that the patient did have sinusitis. ENT was called, and ENT felt that the sinusitis was not infectious in nature, but secondary to the patient's prolonged intubation. 4. Another source contributing to the fevers included a right upper extremity DVT, which involved the axillary vein, but spared the superior vena cava and subsequently resulted in a small pulmonary embolus to the left lower lobe. This is treated with Heparinization during the patient's hospitalization. 5. Line infections: Patient had central lines placed in the subclavian, which was resighted on two occasions given the patient had persistent fevers. Wound [**Month/Year (2) 50508**] of these lines were negative to date. Otherwise, all of patient's blood [**Month/Year (2) 50508**] remained no growth to date. 6. It was felt that patient's fevers could be secondary to drugs, in particular medicines such as Vancomycin. Once these medicines were discontinued, it was noted that patient's fever curve trended down and that by time of discharge, patient had no further spikes of fevers. 7. Reactive thrombocytosis: During his hospitalization, it was noted that the patient had elevated platelet count to a high of 636. By the time of discharge, the patient's platelet count was normalizing to the 500. 8. Ophthalmology: During his hospitalization, patient was noted to have very thickened conjunctivae with subconjunctival inflammation. Ophthalmology was consulted and felt that b.i.d. ophthalmologic care with bacitracin ointment was indicated. This was applied and patient's conjunctivae as well as subconjunctival irritation cleared by time of discharge. 9. Endocrine: Patient had hyperglycemic episodes during his hospitalization. He was maintained initially on an insulin drip and then transitioned into an insulin-sliding scale with good glycemic control. 10. Renal function: When patient initially presented to the hospital, he was given aggressive fluid resuscitation, and then later was diuresed with Lasix with a bump in his creatinine from baseline of 0.8 to 1.3. However, given that he was quite fluid overloaded to a max of 19 liters, the patient was diuresed daily with a goal of anywhere from 500 cc to -1.5 liters/24 hour. He tolerated this well, and by time of discharge, his creatinine was at baseline. 11. Heme: Patient's hematocrit remained stable throughout his hospitalization, but he did have one episode of hematocrit decreased to 22 felt secondary to his significant amounts of blood tinged sputum as well as phlebotomy. Patient received a total of 1 unit of packed red blood cells with good response. His hematocrit remained stable during his hospitalization. 12. Prophylaxis: Patient was maintained on carafate, then changed to Protonix, Heparin gtt., pneumoboots, Colace, Senna, cooling blanket initially, then lactulose, and Reglan. Communication throughout his hospitalization remained with patient's parents, who were quite involved in his care. The patient remained a full code. The rest of the [**Hospital 228**] hospital course as well as medications at discharge and follow-up plans will be dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 50509**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. Dictated By:[**Last Name (NamePattern1) 5843**] MEDQUIST36 D: [**2111-10-18**] 13:10 T: [**2111-10-20**] 11:07 JOB#: [**Job Number 50510**] Name: [**Known lastname **], [**Known firstname **] E Unit No: [**Numeric Identifier 9360**] Admission Date: [**2111-9-28**] Discharge Date: [**2111-10-23**] Date of Birth: [**2085-3-12**] Sex: M Service: MICU This is an addendum to the previous dictation covering the dates [**2111-9-28**] to [**2111-10-18**]. HOSPITAL COURSE: 1. Pneumonia - The patient completed a 21 day course of Azithromycin. The patient had been intubated on [**2111-9-28**]. Initially the patient was difficult to wean from the vent secondary to issues of anxiety and agitation. Originally the plan was made for tracheostomy in the Operating Room by the Interventional Pulmonary Staff. The patient was taken to the Operating Room on [**2111-10-21**] for rigid bronchoscopy and laryngoscopy. At that time tracheostomy was scheduled to be performed. However, tracheostomy was not performed as the Interventional Pulmonary Staff felt that the patient did not have evidence of severe supraglottic or subglottic stenosis and as such they felt that he was a good candidate to be safely extubated. He continued to improve in his respiratory status and was able to be weaned from the ventilator as well as weaned from sedation. He tolerated extubation on [**2111-10-22**]. At the time of discharge, his arterial blood gases were normalized. He was breathing comfortably as well as saturating in the high 90s on room air. 4. (Addendum) Right upper extremity deep vein thrombosis and pulmonary embolus - The patient requires a total of six months of anticoagulation with Coumadin for his right upper extremity deep vein thrombosis and subsequent small pulmonary embolus at the left lower lung base. He was initially heparinized during his hospital course but was changed to Lovenox and Coumadin prior to discharge. He will require daily monitoring of his INR levels as subsequent discontinuation of the Lovenox when his INR is greater than 2.0. 8. (Addendum) Ophthalmology issues - The patient is to follow up with Dr. [**Last Name (STitle) 9361**] at [**Telephone/Fax (1) 8301**], approximately one week after discharge from the hospital. In the interim, he is to continue his inpatient regimen of ophthalmological ointments as well as eyedrops until he sees Dr. [**Last Name (STitle) 9361**] in follow up. CONDITION ON DISCHARGE: Stable, good oxygen saturation on room air. Per physical therapy evaluation, the patient would benefit from acute rehabilitation setting. DISCHARGE STATUS: The patient was discharged to [**Hospital3 7766**] Hospital. DISCHARGE DIAGNOSIS: 1. Mycoplasma pneumonia 2. Acute respiratory failure requiring intubation 3. Right upper extremity deep vein thrombosis 4. Pulmonary embolus 5. [**Known lastname **]-[**Location (un) **] syndrome 6. Acute respiratory distress syndrome 7. Ileus 8. History of delirium MEDICATIONS ON DISCHARGE: 1. Colace 100 mg one tablet p.o. b.i.d. 2. Tylenol 325 mg one to two tablets p.o. q. 6 hours as needed for pain or fever 3. Reglan 10 mg one tablet p.o. q.i.d. as needed for nausea or gastrointestinal upset 4. Tobramycin Sulfate/Dexamethasone ointment one application each eye every other day 5. Sodium chloride nasal spray, one to two sprays each nostril t.i.d. as needed for nasal dryness 6. Erythromycin 2% solution, one application topically b.i.d. as needed for skin lesion secondary to [**Known lastname **]-[**Location (un) **] syndrome. 7. Nystatin 100 units/ml oral suspension 5 ml orally four times a day as needed for oral thrush. 8. Polyvinyl alcohol 1.4% eyedrops one drop each eye q. 6 hours 9. Coumadin 5 mg p.o. q.d. 10. Lovenox 80 mg one injection subcutaneously q. 12 hours. Please continue until the patient has a therapeutic INR greater than 2.0 on Coumadin, at that time Lovenox can be discontinued. 11. Senna one tablet p.o. b.i.d. as needed for constipation 12. Lanolin/mineral oil/petroleum ointment one application each eye as needed 13. Bacitracin Polymyxin Sulfate 1 application topically q. 6 hours as needed for the next seven days. FOLLOW UP PLAN: The patient is to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 55**] [**Last Name (NamePattern1) 4943**], at [**Telephone/Fax (1) 9362**] upon discharge from the rehabilitation facility. Additionally he should call Dr. [**Last Name (STitle) 9361**] from Ophthalmology at [**Telephone/Fax (1) 8301**] to schedule a follow up appointment. Ideally he should be seen within the next seven to ten days. He is to continue all of his ophthalmological treatments until that time. [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**], M.D. [**MD Number(1) 2099**] Dictated By:[**Last Name (NamePattern1) 3083**] MEDQUIST36 D: [**2111-10-23**] 13:04 T: [**2111-10-23**] 12:11 JOB#: [**Job Number 9363**] cc:[**Hospital3 9364**]

[ "512.1", "483.0", "695.1", "415.19", "372.00", "780.6", "560.1", "453.8", "518.81" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.6", "96.04", "96.72", "33.23", "86.11", "99.15" ]

icd9pcs

[ [ [] ] ]

2211, 2243

15250, 15526

15552, 17578

13021, 14983

4353, 13003

2621, 3567

1708, 1729

134, 166

195, 1688

3591, 4325

2060, 2194

1752, 2035

2260, 2605

15008, 15229

19,941

115,370

14420

Discharge summary

report

Admission Date: [**2111-5-19**] Discharge Date: [**2111-5-23**] Date of Birth: [**2033-12-17**] Sex: F Service: ICU HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old woman with a history of hypertension, peripheral vascular disease, former smoker who had presented to [**Hospital6 42638**] on [**2111-5-8**] with four to six weeks of a hoarse voice and a few days of cough and shortness of breath. Initially the patient was thought to be in congestive heart failure and was treated as an outpatient, but represented on [**5-10**] to the outside hospital for worsening shortness of breath. She was admitted with presumptive diagnosis of chronic obstructive pulmonary disease flare. She had been evaluated by ENT and was found to have right cord paralysis. She had a chest CT, which showed a mediastinal mass compressing her trachea and she was transferred to the [**Hospital1 188**] on [**2111-5-19**] for evaluation for possible causes of airway mass. She was sent over for evaluation and for treatment. PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2. Hypertension. 3. Chronic renal insufficiency. 4. Osteoporosis. 5. Abdominal tumor status post resection in [**2103**]. ALLERGIES: Aspirin question response. MEDICATIONS: Zestril, Albuterol, Atrovent, Plavix, Celebrex, Fosamax, Xanax, Humibid, Prednisone. SOCIAL HISTORY: Widowed, former smoker. FAMILY HISTORY: Positive lung cancer. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.4. Blood pressure systolic equals 100. Heart rate 78. Intubated on SIMV mode, FIO2 0.3. In general, the patient is intubated. Neck edematous, erythematous. Lungs coarse breath sounds bilaterally. Neurologically sedated. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit and was evaluated for the possibility of PE and SVC thrombus. The patient's clinical condition continued to deteriorate despite the involvement of interventional pulmonology and the hematology/oncology service and on hospital day five the patient was made CMO by her health care proxy. She had been on blood pressure support and medications, which were discontinued. The patient expired later that day hospital day five. FINAL DIAGNOSIS: Airway obstruction from tumor. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 1897**] MEDQUIST36 D: [**2111-6-22**] 16:56 T: [**2111-6-30**] 06:48 JOB#: [**Job Number **]

[ "276.2", "518.81", "164.9", "478.30", "512.1", "998.81", "459.2", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.05", "99.29", "96.71" ]

icd9pcs

[ [ [] ] ]

1418, 1462

1736, 2213

2230, 2500

162, 1034

1477, 1718

1057, 1359

1376, 1401

27,574

110,660

10410

Discharge summary

report

Admission Date: [**2129-11-20**] Discharge Date: [**2129-11-29**] Date of Birth: [**2080-5-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 896**] Chief Complaint: nausea, vomitting Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 49M with medical history of type I diabetes, narcotics abuse, hypertension presented to [**Hospital3 **]hospital on [**2129-11-18**] after several day history of nausea and vomiting. Per the wife who had spoken with him over phone daily prior to hospitalization, he had been sick to his stomach on Wednesday and thursday with poor po intake. He sounded confused and short of breath on the phone. Not clear if fever or chills or diarrhea. Of note, the patient obtained a perocet rx on wednesday [**11-16**] for #30 tablets that was supposed to last 10 days but by Friday all the tablets were gone (of note two weeks prior very depressed, sent to [**Hospital1 **]? psychiatric unit, from there went to day program [? drug recovery] in [**Location (un) 1157**] although not clear that going). . In the ED, initial vitals were BP 215/78 HR:107, RR 24, O2 96% NRB. WBC of 24.4, HCT of 37.8, platelets 327. Glucose of 581, anion gap of 23, urine with positive ketones. Na 136, K 5.5, Cr 1.4. EKG sinus tachycardia with rate of 116, CK 165 and troponin I of 0.05. Blood gas 7.31/29/96 15 on NRB. CXR read as bilateral upper lobe infiltrates suspicious for pulmonary edema, pneumonia, or both. CT head with no abnormality except for air fluid level in maxillary sinus consistent with sinusitis. He was given ceftriaxone and azithromycin for suspected pneumonia, insulin gtt and 2L IVF and admitted to the ICU. . The patient was maintained on an insulin gtt until his anion gap closed after which he was transitioned on [**2129-11-19**] to his daily lantus and insulin sliding scale with FS in 200s. He developed worsening respiratory distress with repeat ABG showing hypoxemic respiratory failure with PO2 of 35 and was intubated on [**2129-11-19**]. Chest x-ray reported showed pulmonary edema and he was given lasix 40mg IVx2 with good response. Looks like antibiotics changed from ceftriaxone/azithro to levaquin on [**11-20**]. Vent settings on tranfer AC TV 400, 65% FiO2, PEEP 10. Today temp of 101.3, has been hemodynamically stable with BP 132/50 HR 70s. Was given lasix 40IV and has put out 1300cc. Has 2PIV (20 in R foot and 20 in L forearm). Labs on transfer ([**11-20**]) sodium 143, K 4.0, Chloride 112, CO2 26, anion gap 9, Cr 1.1, BUN 21, calcium 7.2, magnesium 2.2, phosphorus 2.9, BNP 1190 ([**11-20**]). . Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + HTN 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - IDDM c/b peripheral neuropathy, gastroparesis, CKD - Mild regional LV systolic dysfxn on [**1-/2128**] TTE (on lasix in past) - Impaired speech and swallow, hx of aspiration (thin liquid/puree). - History of hospital acquired MRSA pneumonia ([**2128-12-21**]) - History of C. diff s/p 14 days of flagyl [**1-/2128**] - Chronic kidney disease (baseline 0.9-1.3) - Medullary sponge kidney - foot ulcers - Nephrolithiasis - history of narcotic abuse - gastritis - depression/anxiety - HTN Social History: Divorced though still in contact with ex-wife. Lived with his father in [**Name (NI) **], MA, prior to hospitalization in [**Month (only) 1096**]. Smoked [**1-22**] ppd x 20 yrs but no longer smokes. ?history of substance abuse based on prior OMR notes. Family History: Mother: Leukemia, currently undergoing chemotherapy Father: CAD, HTN Physical Exam: Admission Exam: VS: Temp (rectal) 102 140/76 78 Vent: 550 80% FIO2 8 PEEP GENERAL: intubated and sedated HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm, no carotid bruits. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: symmetric expansion, crackles bibasilarly ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: trace lower extremity 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+ Pertinent Results: [**11-21**] CXR: The decreased radiodensity of widespread heterogeneous pulmonary consolidation may be due to decrease in edema, but the abnormality itself is still concerning for widespread pneumonia. Careful followup advised. No pleural effusion, mediastinal widening, cardiomegaly or vascular congestion. ET tube in standard placement. Nasogastric tube ends in the region of pylorus. No pneumothorax. Dr. [**First Name (STitle) 4587**] and I discussed the findings and their clinical significance over the telephone at the time of dictation. [**2129-11-20**] 08:56PM proBNP-1675* [**2129-11-20**] 11:48PM %HbA1c-11.1* eAG-272* . [**2129-11-29**] 05:49AM BLOOD WBC-7.7 RBC-3.50* Hgb-10.5* Hct-31.2* MCV-89 MCH-30.2 MCHC-33.8 RDW-14.8 Plt Ct-483* [**2129-11-28**] 06:07AM BLOOD WBC-8.5 RBC-3.58* Hgb-10.8* Hct-31.8* MCV-89 MCH-30.3 MCHC-34.1 RDW-14.5 Plt Ct-466* [**2129-11-25**] 04:57AM BLOOD WBC-10.6 RBC-3.54* Hgb-10.6* Hct-31.5* MCV-89 MCH-29.9 MCHC-33.6 RDW-13.8 Plt Ct-322 [**2129-11-24**] 12:40PM BLOOD WBC-8.0 RBC-3.59* Hgb-10.7* Hct-33.2* MCV-93 MCH-29.9 MCHC-32.3 RDW-13.7 Plt Ct-291 [**2129-11-29**] 05:49AM BLOOD Plt Ct-483* [**2129-11-29**] 05:49AM BLOOD PT-14.3* PTT-25.5 INR(PT)-1.2* [**2129-11-28**] 06:07AM BLOOD Plt Ct-466* [**2129-11-25**] 04:57AM BLOOD Plt Ct-322 [**2129-11-24**] 12:40PM BLOOD Plt Ct-291 [**2129-11-29**] 05:49AM BLOOD Glucose-297* UreaN-13 Creat-1.1 Na-135 K-4.4 Cl-104 HCO3-22 AnGap-13 [**2129-11-27**] 04:56AM BLOOD Glucose-250* UreaN-12 Creat-1.0 Na-136 K-3.9 Cl-100 HCO3-24 AnGap-16 [**2129-11-26**] 05:47AM BLOOD Glucose-186* UreaN-11 Creat-1.0 Na-135 K-3.9 Cl-99 HCO3-23 AnGap-17 [**2129-11-27**] 03:49PM BLOOD CK(CPK)-36* [**2129-11-26**] 10:05PM BLOOD CK(CPK)-48 [**2129-11-24**] 12:40PM BLOOD ALT-21 AST-28 LD(LDH)-325* AlkPhos-120 TotBili-0.3 [**2129-11-23**] 04:56PM BLOOD ALT-15 AST-14 LD(LDH)-297* AlkPhos-79 TotBili-0.1 [**2129-11-27**] 04:56AM BLOOD CK-MB-3 cTropnT-<0.01 [**2129-11-26**] 10:05PM BLOOD CK-MB-3 cTropnT-<0.01 [**2129-11-21**] 03:57AM BLOOD cTropnT-<0.01 [**2129-11-20**] 08:56PM BLOOD proBNP-1675* [**2129-11-29**] 05:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1 [**2129-11-28**] 06:07AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.3 Iron-85 [**2129-11-27**] 04:56AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2 [**2129-11-28**] 06:07AM BLOOD calTIBC-280 VitB12-839 Folate-13.7 Ferritn-158 TRF-215 [**2129-11-20**] 11:48PM BLOOD %HbA1c-11.1* eAG-272* [**2129-11-21**] 03:40PM BLOOD Osmolal-308 [**2129-11-22**] 05:59AM BLOOD Vanco-14.8 [**2129-11-21**] 03:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2129-11-24**] 01:05PM BLOOD pH-7.39 Comment-GREEN TOP [**2129-11-22**] 03:36PM BLOOD Type-ART Temp-37 Tidal V-550 FiO2-50 pO2-109* pCO2-52* pH-7.44 calTCO2-36* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU [**2129-11-20**] 10:24PM BLOOD Lactate-1.4 [**2129-11-24**] 01:05PM BLOOD freeCa-1.02* . Microbiology: Ucx, Bcx, Sputum Cx were all NTD at time of discharge . Urine legionella was negative. Stool for C.dif toxins was negative. Brief Hospital Course: 49M with history of type I diabetes, hypertension presented with nausea found to be in DKA, hypoxic respiratory failure likely secondary to pneumonia and course complicated by DKA who was initially admitted to the ICU. . #HYPOXIC RESPIRATORY FAILURE: CXR on admission equivocal for multifocal PNA vs. pleural effusions. He has been treated for both with antibiotics (broadened to vancomycin, zosyn, and azithromycin) as well as IV lasix diuresis complicated by hypernatremia. TTE showing preserved EF and therefore unlikely to be cardiogenic.. Patient was successfully extubated and tolerated room air/NC well,with no tachypnea and oxygen saturations above 95%. Continued HCAP tx with vanc, zosyn X 7 days , azithromycin X 5 days. ubsequently extubated and transferred to the medical floor where he was observed for another two days and started physiotherapy. On discharge patient respiratory status is improved with normal oxygen saturations. Will need repeat CXR 6 weeks following discharge. . #.ALTERED MENTAL STATUS: Patient mental status post extubation remained altered in the ICU where he was was slow in answering questions, slept for prolonged amounts of time alternating with episodes of agitation. This was attributed to prolomnged effect of sedatives he was receiving during intubation. Mental status on the medical floor was back at baseline and zyprexa was discontuinued. . # DIABETIC KETOACIDOSIS: Presented with DKA likely secondary to infection. Was followed in the ICU by [**Last Name (un) **], initially treated with Insullin gtt then after Anion gap closed transitioned to lantus + insulin sliding scale. .. # NARCOTIC ABUSE - question of ingesting large amount of oxycodone before admission , which the patient currently denies.Avoided narcotics. Held neurontin for given mental status changes. . #Diarrhea: may be due to opiate withdrawal. C.diff was negative. . #HYPERTENSION Continued metoprolol po. Started low dose acei lisinopril 5mg daily for elevated BPs; uptitrate to 10mg daily . #DEPRESSION Continued celexa Medications on Admission: Lantus 20u in AM -NPH 12 units at bedtime -novolog sliding scale -Toprol xL 100mg daily -Remeron 30mg daily -Propranolol 10mg TID -Celexa 40mg daily -Neurontin 1600mg TID Discharge Medications: 1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for diarrhea for 3 days. Disp:*6 Capsule(s)* Refills:*0* 6. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twenty Four (24) units Subcutaneous once a day. 7. insulin lispro please use according to attached sliding scale Discharge Disposition: Home Discharge Diagnosis: Multifocal pneumonia Respiratory failure Diabetic ketoacidosis 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: It was a pleasure taking care of you at [**Hospital1 827**]. You were originally admitted to the intensive care unit due to respiratory failure and found to have a pneumonia as well as a diabetic ketoacidosis. You were given a long course of IV antibiotics with significant improvement in your symptoms. You were evaluated by physical therapy and have been cleared to return home. You will need to follow up with the diabetes physicians as an outpatient to ensure that your sugars are well controlled. We have made the following changes to your medications: 1) Loperamide 2mg tablet was started for your diarrhea. Please take one tablet once every 12h as needed. only for 3 more days 2) Lisinopril 10mg tablet was started. Please continue taking 1 tablet once daily for control of your blood pressure. 3) Propranolol was stopped. Please consult your primary care doctor about the need to continue this medication. 4) Neurontin was stopped. Please consult your PCP about restarting this medication. 5) We have made changes to your insulin: - Please stop NPH insulin - continue to take Lantus injection 24 units once every morning. - continue to take Insulin lispro according to attached sliding scale Followup Instructions: Please follow up with your primary care physician. [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28955**] Address: [**Location (un) 28950**], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) **] Please follow up with your diabetes physician as below: ............ Completed by:[**2130-3-19**]

[ "250.63", "428.0", "276.0", "305.50", "250.53", "518.81", "293.0", "357.2", "428.23", "362.01", "486" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.97", "96.71" ]

icd9pcs

[ [ [] ] ]

10477, 10483

7529, 8537

322, 330

10590, 10590

4499, 7506

12003, 12397

3660, 3730

9804, 10454

10504, 10569

9608, 9781

10773, 11307

3745, 4480

2778, 2851

11336, 11980

265, 284

358, 2693

10605, 10749

2882, 3372

2715, 2758

3388, 3644

72,324

168,851

47694

Discharge summary

report

Admission Date: [**2197-11-19**] Discharge Date: [**2197-11-24**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Neurontin / Xalatan Attending:[**First Name3 (LF) 905**] Chief Complaint: right hip pain s/p fall Major Surgical or Invasive Procedure: Right hip hemiarthroplasty History of Present Illness: [**Age over 90 **]yo woman who presents with right hip pain s/p fall from standing. Pt is a poor historian. Per report, pt fell backwards while ambulating with her walker. No LOC. Pt was unable to bear weight on that leg after the fall. She denies pain elsewhere, numbness or tingling, or new weakness. Denies CP, SOB, palpitations, light-headedness. Past Medical History: 1. Alzheimer's Dementia 2. Hx of Breast cancer s/p lumpectomy 3. Hx of MGUS 4. Hypertension 5. Left carotid artery stenosis 6. First degree AV block 7. Peripheral neuropathy 8. Hx glaucoma 9. Hx of hyponatremia 10. Depression/Anxiety Social History: Lives at [**Location 35689**] house. Quit smoking 10 years PTA. [**Name (NI) **] nephew [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 100730**] cell, [**Telephone/Fax (1) 100731**]). Family History: non-contributory Physical Exam: General Evaluation Exam Sensorium: Awake (x) Awake impaired () Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable (x) Unstable () Circulation: Stable (x) Unstable () Musculoskeletal Exam Neck Normal (x) Abnormal () Comments: Spine Normal () Abnormal () Comments: Clavicle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Shoulder R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Arm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Elbow R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Forearm R Normal () Abnormal (x) Comments: laceration and ecchymosis at mid forearm L Normal (x) Abnormal () Comments: Wrist R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Pelvis R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hip R Normal () Abnormal (x) Comments: slightly shortened L Normal (x) Abnormal () Comments: Thigh R Normal () Abnormal (x) Comments: swollen proximally L Normal (x) Abnormal () Comments: Knee R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Leg R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Ankle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Foot R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Vascular: Radial R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () Ulnar R Palpable () Non-palpable () Doppler () L Palpable () Non-palpable () Doppler () Femoral R Palpable () Non-palpable () Doppler () L Palpable () Non-palpable () Doppler () Poplitea R Palpable () Non-palpable () Doppler () L Palpable () Non-palpable () Doppler () DP R Palpable (x) Non-palpable () Doppler () L Palpable (x) Non-palpable () Doppler () PT R Palpable () Non-palpable () Doppler () L Palpable () Non-palpable () Doppler () Neuro: Deltoid R (5) L (5) Biceps R (5) L (5) Triceps R (5) L (5) Wrist Flx R (5) L (5) Wrist Ext R (5) L (5) Finger Flx R (5) L (5) Finger Ext R (5) L (5) Thumb Ext R (5) L (5) 1st DIP R (5) L (5) Index Abd R (5) L (5) Thumd Add R (5) L (5) Quad R (deferred due to pain) L (5) Ant Tib R (5) L (5) [**Last Name (un) 938**] R (5) L (5) Peroneal R (5) L (5) GS R (5) L (5) Pertinent Results: Admission Labs ([**11-19**]): WBC-12.6* RBC-4.42 HGB-13.0 HCT-39.8 MCV-90 MCH-29.4 MCHC-32.6 RDW-13.7 GLUCOSE-140* UREA N-9 CREAT-0.6 SODIUM-131* POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-12 PT-13.3 PTT-30.1 INR(PT)-1.1 . Cardiac Markers: [**2197-11-20**] 10:48AM BLOOD CK(CPK)-259* [**2197-11-20**] 05:03PM BLOOD LD(LDH)-191 CK(CPK)-289* [**2197-11-21**] 03:33AM BLOOD CK(CPK)-314* [**2197-11-21**] 12:00PM BLOOD CK(CPK)-238* [**2197-11-23**] 02:57AM BLOOD CK(CPK)-88 [**2197-11-23**] 08:45AM BLOOD CK(CPK)-68 . [**2197-11-20**] 10:48AM BLOOD CK-MB-6 cTropnT-0.31* [**2197-11-20**] 05:03PM BLOOD CK-MB-7 cTropnT-0.20* [**2197-11-21**] 03:33AM BLOOD CK-MB-6 cTropnT-0.17* [**2197-11-21**] 12:00PM BLOOD CK-MB-6 cTropnT-0.19* [**2197-11-23**] 02:57AM BLOOD CK-MB-3 cTropnT-0.08* [**2197-11-23**] 08:45AM BLOOD CK-MB-3 cTropnT-0.07* . [**2197-11-21**] 05:13PM BLOOD TSH-1.5 . Radiology: Xray of L hip ([**11-18**]): IMPRESSION: Impacted right femoral neck fracture with varus configuration. Remainder of the right femur appears normal. . Xray s/p surgery ([**11-19**]) FINDINGS: There is a new right hip prosthesis in good location. Gas is seen in the soft tissues. . CXR ([**11-20**]): FINDINGS: Cardiomediastinal contours are without change allowing for lower lung volumes on the current study. New hazy opacity has developed at the left base, with lack of definition of lateral costophrenic sulcus, most likely due to acute pleural effusion. If there has been history of fall, consider left rib series to exclude the possibility of rib fractures adjacent to this region. No pneumothorax. . Fluro PICC placement ([**11-21**]): IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 5 French double lumen PICC line. Final internal length is 49 cm, with the tip positioned in the SVC. The line is ready to use. . ECHO (TTE [**11-22**]): The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with depressed free wall contractility. The ascending aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Trivial 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. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal LV systolic function. Dilated and hypokinetic right ventricle. Moderate calcific aortic stenosis. Mild mitral stenosis due to annular calcification. Moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2197-10-24**], the current study is more complete. As a result, the degrees of aortic and mitral stenosis can be assessed. The right ventricle appears dilated and hypokinetic on the current study. . CTA of lungs ([**11-23**]): FINDINGS: A right upper extremity peripherally inserted central venous catheter tip terminates in the distal superior vena cava. There is no pathologic enlargement of the axillary or supraclavicular lymph nodes. Prominent lymph nodes in both hilar stations measure up to 9 mm on the right and 6 mm on the left (4:31, 34). The esophagus is thick walled throughout without evidence of dilatation. Small bilateral pleural effusions with bilateral lower lobe atelectasis. A filling defect in the subsegmental left lower lobe artery is consistent with an isolated subsegmental pulmonary embolism.The pulmonary artery is mildly enlarged measuring 34 mm in transverse dimension (normal <30 mm). Mitral annulus calcification is moderately severe. The cardiac size is normal without evidence of pericardial effusion. Atherosclerotic calcification of the aortic arch, its branches and the coronary arteries are moderately severe. Anterior indentation of the posterior membrane of the trachea suggests an expiratory phase CT, there is moderately severe bronchus intermedius collapse with a 50% decrease in anteroposterior diameter (4:28). Air trapping in both lower lobes is moderately severe. Centrilobular emphysema is mild. Two bullae are present in the left upper and left lower lobes(4:55, 33). There are four noncalcified pulmonary nodules: two in the left upper lobe posterior segment (3:28, 30), one in the superior segment of the left lower lobe (3:30) and one in the anterior segment of the right upper lobe (3:30). These measure 2-5 mm, the largest nodule is in the left upper lobe (2:23). This study is not tailored for subdiaphragmatic evaluation, only to confirm a hiatal hernia and normal-appearing adrenals. Mid thoracic osteophytosis is moderately severe. IMPRESSION: Left lower lobe subsegmental isolated pulmonary embolism. Four 2-5 mm pulmonary nodules in this ex-smoker, a 12-month surveillance CT is suggested . Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2197-11-24**] 03:43 9.4 4.09* 11.9* 34.5* 84 29.0 34.4 14.1 260 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2197-11-19**] 00:30 88.8* 7.6* 3.2 0.2 0.2 BASIC COAGULATION (PT, PTT, PLT, INR) [**2197-11-24**] 03:43 16.2* 39.2* 1.4 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2197-11-24**] 03:43 132 15 0.5 129* 3.8 92* 31 10 Brief Hospital Course: ID: This is a [**Age over 90 **] y.o. Female patient with a history of dementia, HTN, recent section 12 for SA, SI who presented [**Last Name (un) 834**] Newbridge on the [**Doctor Last Name **] s/p fall w/ rt femoral neck fx now with fracture repair but post-op hypoxia leading to discovery of PE on CTA from today. . Patient was admitted to the Orthopaedic Surgery Trauma service following right basicervical femoral neck fx s/p fall from standing. She was seen and cleared for surgery by medicine. She underwent a right hip hemiarthroplasty on HD#1. She tolerated the procedure well, see op report for full details. After a brief stay in the PACU, she was transferred to the floor. . Post-op, her pain seemed well controlled but there was concern that pt might be underreporting pain [**3-14**] to dementia. She was started lovenox for DVT prophylaxis postoperatively. . On post-op day #2 she experienced an episode of hypotension and unresponsiveness. She was transferred to the trauma SICU where she recieved 2 units PRBCs with an appropriate increase in Hct. Her BP normalized and she did not require vasopressors. She was also noted to have a troponin bump to 0.3 with hypotension and unresponsiveness associated with Q=waves in III and aVF which trended down following transfer to the ICU, thought to be due to demand ischemia. In the ICU she was noted to be in atrial fibrillation with normal rate. Pt had new hypoxia for which she was started on nasal cannula oxygen. . A medicine consult was obtained and recommendation was made for CTA to work-up PO and beta-blockers to control heart rate. On [**11-22**] ECHO showed mildly dilated LA and moderately dilated RA. RV cavity was dilated with depressed free wall contractility. Moderate Pulm HTN was noted. These findings combinened with the troponin leak and new onset of tachycardia which appeared to be sinus increased concern for PE. CTA on [**11-23**] showed left lower lobe subsegmental isolated pulmonary embolism. CT incidentally showed four 2-5 mm pulmonary nodules in this ex-smoker, a 12-month surveillance CT is suggested by radiology. Due to PE pt was started on therapeutic lovenox 70mg SubQ Q12hrs and metoprolol was uptitrated to 25mg [**Hospital1 **] to help control heart rate and prevent rate related ischemia. Pt was also started on warfarin on [**11-23**] with plan to bridge to warfarin with lovenox, INR goal 2.0-3.0. . Pt had elevated BPs a day or two post op which combined with intermittent heart rate elevations was determined to be [**3-14**] to untreated pain. Pt continued to deny pain in any areas including hip - there was concern that combination of dementia and overall sickness was causing pt to under-report pain but due to elderly age it was difficult to give standing narcotics. When narcotics were given BP would come back down into more normal ranges and pt seemed more comfortable overall. . At time of discharge pt was sating in the low to mid 90s on RA and mid 90s on 2L NC. Pt with long smoking history so unlikely has baseline O2 sats in high 90s. Her respiratory status was deemed to be near baseline as a result although she was deemed severely deconditioned [**3-14**] to the hip surgery and bed rest. . Medications on Admission: CLONAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth at bedtime FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE - (Prescribed by Other Provider) - 25 mcg Tablet - 1.5 Tablet(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed MIRTAZAPINE - (Prescribed by Other Provider) - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 2.5 mg Tablet - 1 Tablet(s) by mouth qAM OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime RANITIDINE HCL - (Prescribed by Other Provider) - Dosage uncertain SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day TOLTERODINE [DETROL LA] - (Prescribed by Other Provider) - 2 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day TRAVOPROST [TRAVATAN Z] - (Prescribed by Other Provider) - 0.004 % Drops - 1 drop/eye ophthalmic at bedtime Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - (Prescribed by Other Provider) - 400 unit Capsule - 2 Capsule(s) by mouth daily FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily SODIUM CHLORIDE - (Prescribed by Other Provider) - 1 gram Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. enoxaparin 80 mg/0.8 mL Syringe Sig: 70mg Subcutaneous twice a day: Continue until warfarin level acceptable with INRs 2.0-3.0. 7. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a day. 8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 9. clonazepam 0.5 mg Tablet Sig: [**2-11**] Tablet PO QHS (once a day (at bedtime)). 10. tolterodine 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. ondansetron in 0.9 % sod chlor 8 mg/50 mL Piggyback Sig: 4mg Intravenous every eight (8) hours as needed for nausea. 16. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] Discharge Diagnosis: femoral neck fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after a fall. You were found to have a fracture of your R hip which was fixed by the orthopedic surgeons. After surgery your oxygen levels were found to be low. A CT scan of your lungs was done which showed evidence of a clot in the arteries of your L lung. You were started on a blood thinner to prevent spread of your clot. You have been started on warfarin to thin your blood but until it reaches a therapeutic level you will receive lovenox shots to help thin your blood. You will be discharge to a rehab facility to help provide threapy to help you strengthen after your hip surgery. You should see the orthopedic surgeons in follow up in 2 weeks. . You will need to have your warfarin levels monitored while at rehab with INR checks. Your warfarin dose should be adjusted to obtain INR levels between 2.0-3.0. Surgical Recovery: 1. Wound Care: - Keep Incision clean and dry. - Do not soak the incision in a bath or pool. 2. Activity: - Continue partial weight bearing on your right leg. 3. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots until your warfarin is therapeutic - You have also been given Additional Medications to control your pain. You have not been asking for your pain medications but we believe you have still been in pain due to elevated blood pressures and elevated heart rates. You should make sure to take pain medications including tylenol as you recover from your surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room. Followup Instructions: Please follow-up in Orthopaedic Surgery clinic in 2 weeks- please call [**Telephone/Fax (1) 1228**] to make an appoitment. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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Discharge summary

report+addendum+addendum

Admission Date: [**2131-4-21**] Discharge Date: [**2131-4-27**] Date of Birth: [**2087-2-12**] Sex: M Service: Medicine Intensive Care Unit This dictation will cover hospital stay through [**4-27**]. Note, the remainder of hospital stay will be dictated by subsequent intern. HISTORY OF PRESENT ILLNESS: This is a 44 year old male with a past medical history significant for multiple medical problems including coronary artery disease, status post four vessel coronary artery bypass graft, atrial fibrillation on Coumadin, end stage renal disease on hemodialysis, diabetes mellitus, and left embolic middle cerebral artery cerebrovascular accident, who presents from nursing home with hypotension and bright red blood per rectum. Per nursing home report, the patient had a one day history of dark red blood per rectum. He was incontinence of stool and stool amount was unable to further be quantified. His blood pressure dropped to the 80s systolic and he was also noted to be febrile to 102.0. No abdominal pain, nausea, vomiting or hematemesis was noted. The patient had been noted to have a recent INR of 1.6 to 1.8 with a hematocrit of 25, down from his baseline of 29. Upon arrival in the Emergency Department, the patient was tachycardiac with heart rate in the 120s to 140s with a rhythm of atrial fibrillation. His systolic blood pressure was in the 100s. His hematocrit was 27.5 and his INR was 2.0. Soon after arrival to the Emergency Department he had two episodes of dark red blood per rectum with subsequent drops in his blood pressure to a systolic of 70s to 80s. He received 1 liter of normal saline and 2 units of packed red blood cells. He also received 30 ml of Proplex to reverse his INR, in addition to 10 mg subcutaneous Vitamin K. Proplex was chosen given the patient's anuric end stage renal disease and concern for volume overload. The patient also received Protonix 40 mg intravenously. Following volume resuscitation his blood pressure increased to 110 systolic. He had an nasogastric lavage which showed no evidence of blood or clot. The patient was then admitted to the Medicine Intensive Care Unit for further management. PAST MEDICAL HISTORY: End stage renal disease on hemodialysis, anuric; diabetes mellitus; diabetic neuropathy; coronary artery disease, status post myocardial infarction; four vessel coronary artery bypass graft in [**2127**]; congestive heart failure with unknown ejection fraction; peripheral vascular disease; dry gangrene; chronic lower extremity edema, status post left middle cerebral artery, stroke with residual right hemiparesis and Wernicke's syndrome; bilateral carotid stenosis, less than 40%, history of Methicillin-resistant Staphylococcus aureus infection in sacrum on Linezolid since [**4-17**]; hyperparathyroidism; calciphylaxis; chronic anemia; decubitus ulcers; status post pneumonia. SOCIAL HISTORY: Nursing home resident, sister guardian, no current tobacco or alcohol use. FAMILY HISTORY: Mom with cerebrovascular accident, Dad with myocardial infarction at age 50. MEDICATIONS ON ADMISSION: Lopressor 100 t.i.d., Aspirin 325 q. day, Coumadin 2.5 q. day, Digoxin .125 q. 72 hours, Lipitor 40 mg q.h.s., Imdur 60 mg q. day, Risperdal .75 q.h.s., 70/30 insulin, 32 units in the morning, 30 units in the evening, Zoloft 25 q.h.s., Colace and Senokot q. day, Verapamil 40 mg q.i.d., Renagel 4000 mg t.i.d., Colchicine .6 q. day, Linezolid 600 b.i.d., started on [**4-17**]. PHYSICAL EXAMINATION: On admission temperature was 101.5, heart rate 118, blood pressure 101/65, respiratory rate 16, oxygen saturation 100% on 2 liters of oxygen. General: Somnolent, confused, garbled speech in no acute distress. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact, sclera anicteric. Dry mucous membranes. Neck: Soft and supple, no jugulovenous distension. Cardiovascular: Tachycardiac, irregular rate and rhythm, no murmurs. Pulmonary: Clear to auscultation bilaterally. Abdomen, obese, soft, nontender, positive bowel sounds auscultated. Extremities: Bilateral lower extremity and feet bandages. Multiple large eschar to calciphylactic lesions on bilateral thighs, groins, buttocks and sacral decubitus ulcer. No grossly purulent discharge or erythema noted from leg lesion. Neurological: Confused with waxing and [**Doctor Last Name 688**] mental status. Positive confabulation. Follows simple commands. Moves bilateral lower extremities and left upper extremities. LABORATORY DATA: On admission white count 11.8, hematocrit 27.5, platelets 391, PT 17.3, PTT 28.3 with an INR of 2.0. Sodium 145, potassium 4.9, chloride 105, bicarbonate 31, BUN 34, creatinine 3.9, glucose 72. Lactate of 1.4. Liver function tests were within normal limits. Electrocardiogram, atrial fibrillation, read of 136. Chest x-ray, no effusion or infiltrate. HOSPITAL COURSE: 1. Gastrointestinal bleed - The patient presented from the nursing home with bright red blood per rectum. He initially had an nasogastric lavage which was negative. He was evaluated by the Gastroenterology Service. He underwent endoscopy which showed no acute lesions. He then underwent colonoscopy which did show residual old blood, however, no clear source of bleeding was able to be localized. The patient was placed on a high dose proton pump inhibitor. Serial hematocrits were followed and he was transfused as needed. In addition, he was taken off of his anticoagulation. The patient's presenting gastrointestinal bleed did occur in the context of an elevated INR on Coumadin therapy. Initially his INR was reversed with Proplex. He also received Vitamin K with normalization of his INR off anticoagulation therapy. He did have no further episodes of bleeding. Initially plans were made for a repeat colonoscopy to further look for a bleeding source. However, following discussion with the family, it was decided that given the patient's multiple medical issues, further colonoscopy or gastrointestinal studies would not be pursued at this time. 2. Hypertension - The patient presented with acute hypotension, presumably due to hypovolemia due to his gastrointestinal bleed. He was fluid-resuscitated with blood and intravenous fluids and his blood pressure responded accordingly. He continued to receive blood and fluids as needed throughout the hospital stay. 3. Gram negative rod bacteremia - The patient was initially febrile at presentation and was cultured with no organism isolated. He then was afebrile until [**4-25**] when he again spiked a fever. Subsequent blood culture did grow out gram negative rods. Given the patient's extensive calciphylactic lesions on his lower extremity and potential for contamination with stool given the fecal incontinence he was thought to have likely seated his blood with bowel organisms via his lower extremity lesions. He was started on Zosyn with resolution of his fever on antibiotics. Cultures continued to be followed with plans to further tailor his antibiotic therapy once an organism is isolated. He received intravenous fluids as needed to support his blood pressure. He also received blood as needed for sepsis protocol. Cortisol level was sent which did show appropriate renal response. Plan to continue to follow up cultures. 4. Methicillin-resistant Staphylococcus aureus - Patient admitted with known Methicillin-resistant Staphylococcus aureus in his sacral decubitus ulcer. He had been on Linezolid. He was switched to Vancomycin at admission and was continued on this. No further Methicillin-resistant Staphylococcus aureus was isolated from blood cultures or wound cultures. His Vancomycin was renally dosed, given his renal failure. 5. Atrial fibrillation - The patient was admitted with a history of atrial fibrillation for which he had been on Lopressor for rate control and Coumadin anticoagulation. Given his gastrointestinal bleed as detailed above, he was taken off of the Coumadin. Initially his Lopressor was held given his hypotension, however, as this resolved, he was slowly started back on his Lopressor and his dose was titrated up as tolerated. 6. Calciphylaxis - The patient was with extensive calciphylactic lesions for which he had previously had a prolonged hospitalization. He was followed by renal for this and received daily hemodialysis for his calciphylaxis. He was also treated with high dose of Renagel. Plastics was consulted to evaluate his lesions and he did undergo debridement. However, the patient suffered significant pain and discomfort with debridement and per discussion with the family decided that no further debridement would be undertaken in order to manage the patient's comfort. 7. Coronary artery disease - The patient's aspirin was held given his gastrointestinal bleed. Initially his beta blocker was held given his hypotension. This was slowly added back on with plans to titrate up. He was also maintained on his statin per his outpatient regimen. 8. Diabetes mellitus - The patient was admitted with diabetes with multiple complications. He was maintained on NPH insulin with sliding scale supplementation, per his outpatient regimen. Given his decreased p.o. intake, his insulin dosing was subsequently adjusted. He was actually taken off of his NPH insulin and was covered with his sliding scale insulin. Should his blood sugars again trend up and his dietary needs change, he will be restarted on his NPH. Blood sugars were followed q.i.d. 9. End stage renal disease on hemodialysis - The patient was followed by the Renal Team throughout his stay and was dialyzed as per schedule. His original schedule was for q. Monday, Wednesday and Friday but in the setting of calciphylaxis he did receive pulmonary more frequent dialysis sessions with less fluid taken off. 10. Fluids, electrolytes and nutrition - The patient is initially NPO for his gastrointestinal bleed. As this stabilized he was advanced on clears and then to a regular diabetic diet as tolerated. 11. Heme - The patient's hematocrit and INR followed as detailed above. He received multiple blood products to support his counts as needed. 12. Code status - Given the patient's multiple medical problems, it was decided he would want to be Do-Not-Resuscitate, Do-Not-Intubate with no pressors. He also will not receive debridement of his wound or further gastrointestinal workup in an effort to maximize comfort. The remainder of the hospital course, diagnoses and discharge medications will be dictated by the subsequent intern. Should he have a cardiac or respiratory code, it was also decided that he would not wish for pressors. Given goals of maximizing patient comfort, he will not have any further debridement of his extremity wounds, nor will he undergo repeat colonoscopy for bleed. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 5212**] MEDQUIST36 D: [**2131-4-27**] 12:25 T: [**2131-4-27**] 14:38 JOB#: [**Job Number 53253**] Name: [**Known lastname 9918**], [**Known firstname **] Unit No: [**Numeric Identifier 9919**] Admission Date: [**2131-4-21**] Discharge Date: [**2131-5-2**] Date of Birth: [**2087-2-12**] Sex: M Service: [**Last Name (un) 9920**] Medicine This discharge summary is an addendum to the dictated hospital course up until [**2131-4-27**] until the day of discahrge [**2131-5-2**]. HOSPITAL COURSE: 1. Gastrointestinal bleed: After transfer out of the medical Intensive Care Unit, the patient's hematocrit remained stable and did not require any further transfusions. All of his anticoagulants and antiplatelet agents were held and will continue to be held. It was decided with the family in the medical Intensive Care Unit that no further gastrointestinal procedures were to be done, but that if the patient required transfusions, transfusions will be given. 2. Hypotension: The patient had no further issues with hypotension and maintains normal heart rates and blood pressures on just beta-blocker and digoxin for rate control for his atrial fibrillation. 3. Gram negative rod bacteremia: The patient has had surveillance cultures which have been negative to date for his initial bacteremia with pseudomonas. He was continued on Zosyn and Levaquin was also initiated for double coverage of pseudomonas. The patient remained afebrile. 4. Methicillin resistant staph aureus: The patient had a history of MRSA in the sacral decubitus ulcers and was continued on vancomycin renally dosed and will be continued on this for at least four weeks. 5. Atrial fibrillation: The patient is in chronic atrial fibrillation. All of his anticoagulants and antiplatelet agents will continue to be held in the setting of gastrointestinal bleed and the family not wanting any further gastrointestinal intervention. The patient is at risk for further strokes and the family is aware of this. His rate is controlled well on Lopressor and digoxin. 6. Calciphylaxis. The patient has a history of extensive calciphylactic lesions. His phosphorus and calcium are followed closely with daily labs and he is on Renagel as a phosphate binder with good control. He will receive one dose of Medronate 60 mg IV before discharge to prevent calcium deposition in his wound. 7. Coronary artery disease: The patient's aspirin will continue to be held in the face of gastrointestinal bleeding. His beta-blocker was restarted at a lower dose and this may be slowly titrated back up as his blood pressure tolerates. 8. Diabetes mellitus type I; The patient has a long history of diabetes mellitus with multiple complications. He was maintained on his NPH insulin and sliding scale. 9. End stage renal disease on hemodialysis: The patient continues to be followed by the renal team during his stay on the floor and continued on Monday, Wednesday and Friday hemodialysis schedule. He is to continue Epogen injection as well as phosphate binders. 10. Code status: Given the patient's multiple medical problems, extensive discussions were had with the family in the medical Intensive Care Unit and he is currently a Do Not Resuscitate and Do Not Intubate and no pressors. It was also decided that the family did not any further debridements of his wounds or ulcers and no further gastrointestinal procedures. The family decided to continue with antibiotics, transfusions as necessary and hemodialysis at this time. DISCHARGE STATUS: Stable, bed bound, satting well on room air. DISCHARGE DISPOSITION: The patient is to be transferred to a facility closer to his home per his family's request. DISCHARGE MEDICATIONS: 1. levofloxacin 250 mg p.o. q.d. 2. Alamur 4800 mg p.o. t.i.d. with meals. 3. colchicine 0.6 mg p.o. q.d. 4. Metoprolol 25 mg p.o. t.i.d. 5. Regular insulin sliding scale. 6. Zosyn 2.25 grams IV q.8. 7. Morphine sulfate 2 to 4 mg IV q. 4 hours p.r.n. for dressing changes. 8. Tylenol 325 to 650 mg p.o. PR q. 4 to 6 hours p.r.n. 9. Pantoprazole 40 mg p.o. b.i.d. 10. Calorigenic gluconate 15 cc p.o. t.i.d. p.r.n. 11. Digoxin 0.125 mg p.o. q.d. FOLLOW UP PLANS: 1. The patient is to follow up with his primary medical doctor and call [**Telephone/Fax (1) 9921**] for an appointment within one week after discharge from the hospital. He is to follow up with his nephrologist within one week of discharge from the hospital. [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**] Dictated By:[**Last Name (NamePattern1) 585**] MEDQUIST36 D: [**2131-5-1**] 14:41 T: [**2131-5-1**] 14:59 JOB#: [**Job Number 9922**] Name: [**Known lastname 9918**], [**Known firstname **] Unit No: [**Numeric Identifier 9919**] Admission Date: [**2131-4-21**] Discharge Date: [**2131-5-8**] Date of Birth: [**2087-2-12**] Sex: M Service: ADDENDUM: [**2131-5-2**], through [**2131-5-8**]. The patient was discharged to [**Hospital3 5558**] [**Hospital6 **]. HOSPITAL COURSE: The patient has continued to be stable for the past week. His hematocrit has been stable at the 28.0 to 30.0 range, and he has had no further evidence of bleeding from the gastrointestinal tract. Anticoagulants and antiplatelet therapies are being held given the risk of gastrointestinal bleeding. If there is no evidence of gastrointestinal bleeding in the next several weeks, the possibility of restarting Aspirin therapy and anticoagulation should be readdressed. This has been communicated to the family members. The patient continues to be in chronic atrial fibrillation with adequate rate control. If the patient's hematocrit remains stable without evidence of gastrointestinal bleeding, the question of anticoagulation should be readdressed as noted above. The patient continues on Vancomycin for Methicillin resistant Staphylococcus aureus sacral decubitus ulcer to complete at least a four week course. He also continues on Zosyn for gram negative bacteremia. The patient has remained afebrile. The patient has been followed by the renal team for end stage renal disease and has been receiving hemodialysis. He was dialyzed fully on [**2131-5-7**], and for two hours on [**2131-5-8**], to transition to a Tuesday, Thursday, and Saturday dialysis schedule since this is what was available at the rehabilitation. He continues to receive Epogen and phosphate binders. FOLLOW-UP: The patient is to follow-up with his primary medical doctor, [**Telephone/Fax (1) 9923**], upon discharge and is to call for appointment. Discharge medications and diagnoses are as noted in the previously dictated discharge summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 36**], M.D. [**MD Number(1) 9924**] Dictated By:[**Last Name (NamePattern1) 2685**] MEDQUIST36 D: [**2131-5-15**] 19:00 T: [**2131-5-15**] 19:10 JOB#: [**Job Number 9925**]

[ "578.9", "403.91", "276.5", "707.0", "790.7", "428.0", "V45.81", "V58.61", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.95", "86.22", "99.04", "45.13", "45.23", "38.93", "00.14" ]

icd9pcs

[ [ [] ] ]

14676, 14769

3008, 3086

14792, 16162

3113, 3492

16180, 18089

3515, 4942

327, 2191

2214, 2898

2915, 2991

19,223

189,320

50420

Discharge summary

report

Admission Date: [**2197-8-18**] Discharge Date: [**2197-9-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Open appendectomy. History of Present Illness: 83 y.o. F POD3 s/p open appy, now in afib with RVR since [**8-19**]. Dilt given IV and then gtt, along with IV lopressor. Rate went from 190s to 120s-130s and she was transferred to [**Hospital Ward Name 121**] 3 today ([**8-21**]) for further management. . During evaluation, patient began to complain of chest pain, given NTG X2. BP dropped to 70s syst but came up w/in 10 minutes with 250 NS bolus. Pt stated that her CP got a little better with NTG but began to feel light-headed when her blood pressure dropped. ECT without change from prior. Given Morphine 0.5 mg po IV X1 with some relief and will cycle CE. Past Medical History: Breast CA. s/p L mastectomy with [**Doctor First Name **] dissection [**11/2187**] Hyperlipidemia Hypothyriodism s/p RCA angioplasty in [**2192**] osteopenia Hypercholesterolemia Social History: no tob/ occ etoh/ no rec drugs, lives with son Family History: Mother with MI at 59 Physical Exam: On transfer to the ICU on [**8-29**]. Vitals: T: 96.8 P: 130 BP: 114/73 R: 18 SaO2: 95% on 4L NC General: Awake, alert, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Bibasilary crackles Cardiac: irreg irreg, tachy Abdomen: soft, minimally distended, normoactive bowel sounds, RLQ surgical incision c/d/i Extremities: trace pretibial edema, non-pitting, 2+ DP pulses b/l. Lymphatics: No cervical, supraclavicular LAD Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Pertinent Results: [**2197-8-18**] 08:04PM POTASSIUM-4.4 [**2197-8-18**] 08:04PM MAGNESIUM-1.6 [**2197-8-18**] 08:04PM HCT-38.0 [**2197-8-18**] 10:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.046* [**2197-8-18**] 10:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2197-8-18**] 10:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-19**] [**2197-8-18**] 10:30AM URINE GRANULAR-0-2 [**2197-8-18**] 10:30AM URINE MUCOUS-RARE [**2197-8-18**] 08:40AM GLUCOSE-118* UREA N-22* CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16 [**2197-8-18**] 08:40AM WBC-12.7*# RBC-4.50 HGB-13.3 HCT-40.1 MCV-89 MCH-29.5 MCHC-33.1 RDW-14.3 [**2197-8-18**] 08:40AM NEUTS-85.0* BANDS-0 LYMPHS-10.9* MONOS-2.3 EOS-1.0 BASOS-0.7 [**2197-8-18**] 08:40AM PLT SMR-NORMAL PLT COUNT-247 . [**8-18**] CXR IMPRESSION: AP chest compared to [**2191-9-25**] and [**2195-5-21**]: Particular interstitial abnormality in both lungs, most marked in the perihilar left lung has progressed since [**5-20**] consistent with pulmonary fibrosis. A small component of edema could be present. The heart is top normal size. There is no pleural effusion. . [**8-18**] CT Abd IMPRESSION: 1. Uncomplicated acute appendicitis. 2. Right lung base nodular density, new compared to [**2195-5-3**]. Recommend dedicated chest CT for further evaluation. . [**8-21**] ECHO Conclusions: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg). The right ventricular cavity is mildly dilated. Free wall motion could not be adequately seen. 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. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small, circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Mild mitral regurgitation. Preserved global and regional left ventricular systolic function. Mild right ventricular cavity enlargement. Small circumferential pericardial effusion. Mild pulmonary artery systolic hypertension. Is there a clinical history to suggest a primary pulmonary process (e.g, pulmonary embolism, phenomonia, etc. Based on [**2188**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . ECHO [**8-23**]: MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.0 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.4 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 1.4 cm Left Ventricle - Fractional Shortening: 0.59 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Mitral Valve - E Wave Deceleration Time: 206 msec TR Gradient (+ RA = PASP): 16 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV cavity. Focal apical hypokinesis of RV free wall. RV function depressed. Abnormal diastolic septal motion/position consistent with RV volume overload. AORTA: Normal aortic root diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Mild (1+) MR. TRICUSPID VALVE: Moderate to severe [3+] TR. Normal PA systolic pressure. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Conclusions: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.The right ventricular cavity is mildly dilated. There is focal hypokinesis of the apical free wall of the right ventricle. Right ventricular systolic function appears depressed. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5.Normal mitral valve leaflets. Mild (1+) mitral regurgitation is seen. 6.Moderate to severe [3+] tricuspid regurgitation is seen. 7.The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Compared with the findings of the prior study (images reviewed) of[**2197-8-21**], the pericardial effusion has resolved. The PA pressures are now less. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2197-8-23**] 13:42. CTA Chest [**8-29**]: CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: The heart and great vessels opacify well. There is no evidence of aortic aneurysm, dissection or pulmonary embolism. There is a small pericardial effusion. Coronary artery calcifications are noted. There is no pathologic mediastinal, hilar or axillary lymphadenopathy. There are bilateral moderate-to-large pleural effusions with associated compressive atelectasis of most of the lower lobes. The upper lobes are aerated. A tiny right lower lobe pulmonary nodule is unchanged compared to [**2194-3-6**] and is therefore not concerning. There is no pneumothorax. Limited evaluation of the upper abdomen demonstrates no significant abnormality. BONE WINDOWS: There are extensive degenerative changes of the thoracic spine but no suspicious lytic or sclerotic osseous lesion is identified. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate-to-large bilateral pleural effusions with associated atelectasis of lower lobes. 3. Small pericardial effusion. [**9-7**] PT 26.1* PTT 34.7 INR 2.7* Brief Hospital Course: The patient was admitted on [**8-18**] with abdominal pain, which was diagnosed on CT scan as acute appendicitis. She had an open appendectomy on [**8-18**] during which she received 900 cc crystalloid and had minimal blood loss (20 cc). She had a normal post-op course until [**8-20**], when she developed atrial fibrillation, with heart rate in the 170s-190s, and was started on a diltiazem drip. Cardiology was consulted, and coumadin therapy initiated with heparin drip. Diltiazem drip and amiodarone PO were used for rate control to HR in 100s. The patient converted to sinus rhythm intermittently but was not sustained. Patient was generally asymptomatic but did complain of chest pain, pleuritic in nature. She was ruled out for cardiac event with cardiac enzymes cycling and no major changes noted on EKG. Thyroid function tests were normal. On CXR and clinically the patient developed fluid overload which was thought to be a result of atrial fibrillation and atelectasis. She had one temperature of 100.4 on [**8-21**], but was otherwise afebrile with a modestly elevated WBC and suspicion for pneumonia was not high enough to start antibiotics. She required nasal cannula oxygen on progressively increasing levels. Between [**8-20**] and [**8-23**], she generally remained tachycardic on diltiazem drip and her amiodarone dose was increased to assist in rate control. On [**8-23**], her hypoxia worsened and she had she was transferred to the ICU for closer monitoring. Her labs included ABGs 7.43/38/55 on 5L and 7.46/38/81 on 100% NRB, HR 128, BP 103/72, RR 20. Her CXR showed volume overload. She had abdominal pain and only small flatus post procedure, and abdominal radiograph showed dilated colon. Her abdominal exam was benign at this time. An echocardiogram demonstrated right heart strain. Over the next several days her hypoxia improved so that she required on 3L NC, and she was transferred out of the ICU. Amiodarone was continued for her atrial fibrillation, as well as diltiazem and metoprolol for rate control. She continued to improve until [**8-29**], when she converted to normal sinus rhythm and was bradycardic. Her rate control medications were held, and later in the day she went back to atrial fibrillation with RVR, rate in the 150s and SBP in 100s. CT scan was performed at this time which showed large bilateral pleural effusions and no pulmonary embolism. She was transferred to the ICU for diuresis of pleural effusions, rate control, and respiratory therapy for hypoxia. Her vitals on transfer were temp 98.2, pulse 117 on diltiazem drip, and oxygen saturation of 95% on non-rebreather mask. Her problems in the ICU were managed as follows: Hypoxemia: The patient's hypoxemia was felt to be due to a combination of volume overload with large pleural effusions, atelectasis, and diastolic dysfunction exacerbated by atrial fibrillation leading to pulmonary congestion. The patient was diuresed with IV lasix and was negative 1-1.5 L every day while in the ICU. She received supplemental oxygen with nasal cannula and non-rebreather mask and required a Bi-PAP ventilation mask for one night. Her oxygen saturation improved with diuresis. At the time of discharge, she had oxygen saturation of 94% on room air. Leading up to discharge, she had even fluid balance for three days without daily lasix, and thus was not discharged on a diuretic. . Afib: Amiodarone was continued at loading dose of 400 mg [**Hospital1 **] while in the ICU. She was discharged on a dose of 400 mg QD. Diltiazem was found to be unsuccessful in controlling her rate. Metoprolol was titrated up to 50 PO TID, which maintained her in sinus rhythm with a sinus brady rate in 40s-50s. On discharge, she was transitioned to Toprol and was discharged on a slightly lower equivalent dose of 100 mg due to concern for bradycardia. . Anticoagulation: The patient's coumadin was held for several days due to supratherapeutic INR levels. She was discharged on coumadin 2 mg with an INR in the therapeutic range. It was understood that this dose would likely need to be adjusted in the future. . UTI: The patient was found to have a UTI on [**9-1**] with E.Coli that was resistant to quinolones. She was given IV ceftriaxone starting on [**9-3**] and was transitioned to cefpodoxime on discharge to be taken until [**9-9**] to complete course. . CAD: The patient will be followed by a cardiologist as an outpatient. She had some downsloping ST segments while in atrial fibrillation. She ruled out for ischemic event with cardiac enzyme testing. Cardiac risk stratification could be pursued as an outpatient. Patient is being discharged on aspirin and a beta blocker. . # Hypothyroid: The patient was continued on her normal dose of synthroid. . # Hyperlipidemia: The patient was continued on 10 mg atorvastatin. . #Dispo: The patient required long term rehabilitation and was transferred to a rehab facility on discharge. Medications on Admission: lopressor 25'', ASA 325', lipitor 10', synthroid 88mcg' Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*120 Tablet(s)* Refills:*1* 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: 1-2 Tablets PO once a day: Take 2 tabs po daily for 1 week, then 1 tab po daily thereafter. . Disp:*35 Tablet(s)* Refills:*2* 11. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO once for 1 doses: Give evening of [**9-7**] to make 100mg of metoprolol for today, then start Toprol XL [**9-8**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Appendicitis Congestive Heart Failure with diastolic dysfunction Pleural effusions Pulmonary edema Atrial Fibrillation Urinary Tract infection Discharge Condition: stable Discharge Instructions: You may resume your regular medications. Take all new medications as directed: Toprol XL 100mg daily starting [**9-8**]. Please have pt take one dose of metoprolol 50mg tonight ([**9-7**]) at 8 p.m. Amiodarone 400mg daily for one week, then 200mg daily. Warfarin 2mg nightly Cefpodoxime - for 2 more days only * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain * Dizziness * Palpitations Followup Instructions: Call PCP for [**Name9 (PRE) 702**] regarding right lung base nodule. Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**] Date/Time:[**2197-9-26**] 1:15. Please call and make an appointment with Dr. [**Last Name (STitle) **] (cardiology) [**Telephone/Fax (1) 6937**] in the next 2-3 weeks. You must have your INR checked within 3 days of leaving the hospital. Your INR results should be faxed to your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1924**], and your coumadin levels should be adjusted accordingly. Completed by:[**2197-9-7**]

[ "799.02", "599.0", "272.4", "V10.3", "286.9", "041.4", "412", "997.1", "540.9", "244.9", "511.9", "427.31", "V45.82", "428.30", "997.4", "428.0", "285.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "93.90", "47.09" ]

icd9pcs

[ [ [] ] ]

14980, 15065

8568, 13492

275, 296

15252, 15261

2027, 8545

15806, 16508

1227, 1249

13599, 14957

15086, 15231

13518, 13576

15285, 15783

1912, 2008

1264, 1816

221, 237

324, 944

1831, 1895

966, 1147

1163, 1211

66,496

157,049

42220

Discharge summary

report

Admission Date: [**2190-9-28**] Discharge Date: [**2190-10-6**] Date of Birth: [**2136-11-24**] Sex: M Service: SURGERY Allergies: Codeine / Oxycodone Attending:[**First Name3 (LF) 473**] Chief Complaint: Metastatic neuroendocrine tumor Major Surgical or Invasive Procedure: [**2190-9-28**]: 1. Subtotal pancreatectomy with splenectomy. 2. Antrectomy with gastrojejunostomy. 3. Partial omentectomy. 4. Open cholecystectomy. 5. Segment III mass resection 6. Segment II-III mass resection, segment III hamartoma resection. History of Present Illness: The patient is a 53-year-old gentleman presented to the [**Hospital 7912**] in [**Month (only) 205**] with left-sided abdominal pain and chest pain. He had a CT scan of his abdomen that revealed a mass measuring approximately 7 cm x 7 cm x 8 cm as well as several liver masses consistent with metastases. In mid [**Month (only) 205**], he underwent a CT-guided biopsy showing neuroendocrine tumor and these were also seen on a PET scan identifying the mass in the pancreas and lymphatic involvement of the celiac trunk as well as FDG uptake in several of the liver lesions. These liver lesions have also shown the presence of octreotide uptake. The patient was evaluated by Dr. [**Last Name (STitle) 468**] (Pancreaticobiliary Surgery), Dr. [**Last Name (STitle) **] (Hepatobiliary Surgery), and Dr. [**Last Name (STitle) **] (HemOnc) on [**2190-9-8**] to determine whether or not the pancreatic tumor and liver metastasis can be removed surgically. After thorough evaluation, the patient was scheduled for elective resection on [**2190-9-28**]. Past Medical History: PMH: hypertension, depression (currently untreated), hemorrhoids, and a single kidney since birth. PSH: tonsillectomy at age 5 but no other surgeries. Social History: His social history is notable for about a 30 pack-year smoking history. He started smoking at age 13 and quite at age 47. He smoked 1/2-1 packs per day. He denies alcohol or drug use. He previously has worked with glue and acetone at his job working with granite counter tops. He also had asbestos exposure in his early years working in a car garage. He is married and has 6 children, 3 with his current wife. Family History: His family history is remarkable for his father who had colon cancer in his 60 which was surgically treated. His is currently alive and healthy. He has 5 siblings and no other family history of malignancy. Physical Exam: On Discharge: VS: 97.7, 75, 140/84, 16, 95% RA GEN: Somewhat anxious, but in NAD HEENT: NC/AT, PERRL, Neck supple CV: RRR, no m/r/g Lungs: CTAB Abd: Bilateral subcostal incision open to air with steri strips and c/d/i. LLQ JP site with occlusive dressing and c/d/i. Extr: Warm, no c/c/e Pertinent Results: [**2190-10-6**] 06:15AM BLOOD WBC-14.7* RBC-3.25* Hgb-9.6* Hct-27.5* MCV-85 MCH-29.6 MCHC-34.9 RDW-14.5 Plt Ct-643* [**2190-10-5**] 06:40AM BLOOD Glucose-146* UreaN-15 Creat-1.1 Na-140 K-3.6 Cl-102 HCO3-28 AnGap-14 [**2190-10-5**] 06:40AM BLOOD ALT-54* AST-28 AlkPhos-74 TotBili-0.5 [**2190-10-5**] 06:40AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 [**2190-10-5**] 06:05PM ASCITES Amylase-22 Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 91523**],[**Known firstname 20**] [**2136-11-24**] 53 Male [**-1/3805**] [**Numeric Identifier 91524**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 88622**]/dif SPECIMEN SUBMITTED: omentum and spleen, Body and tail of pancreas, antrum, pancreatic tumor, gall bladder, Segment three resection, Segment three hamartoma, Segment two and three. Procedure date Tissue received Report Date Diagnosed by [**2190-9-28**] [**2190-9-28**] [**2190-10-1**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl Previous biopsies: [**-1/3089**] Slides referred for consultation. DIAGNOSIS: 1. Omentum and spleen, splenectomy and omentectomy (AF-AM): a. Spleen with congestion. b. Omentum, no diagnostic abnormalities recognized. c. No tumor seen. 2. Body and tail of pancreas, pancreatectomy (J-P): Atrophy of exocrine pancreatic acini with no tumor seen. 3. Antrum, distal gastrectomy (Q-V): Unremarkable stomach with antral mucosa; no tumor seen. 4. Pancreas, tumor, resection (W-AE): a. Neuroendocrine carcinoma; see synoptic report. b. One of six lymph nodes positive for metastatic carcinoma ([**1-21**]). 5. Gallbladder, cholecystectomy (AN-AO): No diagnostic abnormalities recognized. 6. Liver, segment 3, partial hepatectomy (A-C): a. Metastatic neuroendocrine carcinoma. b. Mild steatosis in benign liver. c. No increased fibrosis or iron deposition on special stains; reticulin stain evaluated. d. Focal organized infarction. e. Resection margin free of tumor. 7. Liver, segment 3, partial hepatectomy (D): a. Metastatic neuroendocrine carcinoma. b. Resection margin free of tumor. 8. Liver, segments 2&3, partial hepatectomy (E-I): a. Metastatic neuroendocrine carcinoma. b. Mild steatosis in benign liver. c. No increased fibrosis or iron deposition on special stains; reticulin stain evaluated. d. Resection margin free of tumor. Pancreas (Endocrine): Resection Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [**2188**] MACROSCOPIC Specimen Type: Partial resection, pancreatic body and tail, partial resection, pancreatic head. Other organs/Tissues Received: Spleen, gallbladder, gastric antrum, and liver segments. Tumor Site: Pancreatic head. Tumor focality: Unifocal. Tumor Size Greatest dimension: 9.5 cm. Additional dimensions: 8.5 cm x 7.0 cm. MICROSCOPIC Functionality type: Pancreatic endocrine tumor, functional status unknown. WHO Classification: Well-differentiated endocrine carcinoma (Gross local invasion and or metastases. Generally shows one or more of the following features: >= 2cm, angioinvasion, perineural invasion, 2 to 10 mitoses per 10 HPF). Mitotic activity: Less than 2 mitoses/10 High Power Fields. Tumor necrosis: Not identified. MICROSCOPIC TUMOR OF EXTENSION Margins: Margin(s) involved by tumor: Proximal pancreatic margin. Primary Tumor: Tumor invades adjacent tissue/organs: Peripancreatic soft tissues. Primary Tumor (pT): pT3: Tumor extends beyond the pancreas, but without involvement of the celiac axis or superior mesenteric artery. Regional Lymph Nodes (pN): pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 6. Number involved: 1. Distant metastasis (pM): pM1: Distant metastasis, site(s)): Liver. Lymphatic/vascular Invasion: Present. Perineural invasion: Absent. Additional Pathologic Findings: Chronic pancreatitis. [**2190-9-28**] LIVER US: 1. Extensive metastatic disease in segments IV through VIII as described. [**2190-9-29**] EKG: Sinus tachycardia. There may be ST segment elevation in the inferior leads but without reciprocal changes. There is early R wave progression across the precordial leads. Since the previous tracing of [**2190-9-22**] the rate is markedly increased. The axis is more vertical. Early precordial T wave amplitude is less prominent. ST segment elevations, particularly in leads II and aVF, are somewhat concerning for inferior myocardial infarction. Brief Hospital Course: The patient with the history of biopsy proven metastatic neuroendocrine carcinoma was admitted to the HPB Surgical Service for possible resection of the tumor. On [**2190-9-28**], the patient underwent subtotal pancreatectomy with splenectomy, antrectomy with gastrojejunostomy, partial omentectomy, open cholecystectomy and segment III mass resection, segment II-III mass resection, segment III hamartoma resection, which went well without complication (reader referred to the Operative Note for details). Intraoperatively, the patient received 2 units of RBC and 2 units of FFP for EBL 1100, he was hemodynamically stable. Post operatively, the patient was extubated and transferred in SICU for observation. Neuro: The patient received Bupivacaine via epidural catheter and Dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. The patient has an allergy to Codeine and his oral pain medication was changed to achieve optimal pain control. He was discharged home on PO Ultram and Tylenol. Anxiety: The patient has had experienced anxiety attacks during hospitalization. They thought to be secondary to his diagnosis, treatment continuation and possible outcomes. The patient was given small doses of benzodiazepines and was discharge home with prescription for Ativan. The patient was instructed to f/u with PCP for anxiety evaluation and needs to continue Ativan. CV: The patient had an episode of tachycardia post operatively, secondary to pain/anxiety. He was restarted on his home dose of antianxiety medication with good effect. HR downwarded to normal rate. The patient remained stable from a cardiovascular standpoint during his hospitalization. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. JP amylase was sent on POD # 7 and came back low (22). Diet was advanced to regular on POD # 8. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Wound was evaluated daily and no signs or symptoms of infection were noticed. Endocrine: The patient's blood sugar was monitored throughout his stay and was slightly above the normal limits. The patient was given insulin sliding scale during hospital stay. Glucometer and insulin teaching were done prior discharge. The patient was instructed to follow up with his PCP to continue monitor his blood sugar and further treatment plans. VNA was instructed to reinforce insulin/glucometer use. Hematology: The patient had a base line HCT level of 43.7 preop. His HCT dropped to 29.8 intraoperatively and patient received transfusion 2 units of RBC. Postoperatively HCT was checked daily and on POD # 4 was low at 20.6. The patient was transfused with one unit of RBC, second unit was given on POD # 7 (HCT 23.4). After last transfusion, the patient HCT level improved, no additional transfusion were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diabetic diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: alprazolam.5' prn insomnia, lisinopril 10', prochlorperazine maleate 10''' prn nausea, ranitidine 150', zolpidem 5' prn insomnia Discharge Medications: 1. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 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. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] [**Location (un) 5087**] VNA Discharge Diagnosis: 1. Metastatic neuroendocrine tumor 2. Anemia 3. Anxiety 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 [**5-25**] 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 continue to check you blood sugar with Glucometer as instructed. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2835**] Date/Time:[**2190-11-1**] 10:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] . Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**2-18**] weeks after discharge to continue monitor your blood sugar. Call [**Telephone/Fax (1) 90556**] to schedule a follow up appointment with Dr. [**Last Name (STitle) **]. Completed by:[**2190-10-6**]

[ "V15.82", "401.9", "427.89", "E935.8", "209.71", "209.72", "V16.0", "300.00", "292.12", "787.02", "719.41", "285.9", "311", "753.0", "209.25", "759.6" ]

icd9cm

[ [ [] ] ]

[ "41.5", "54.4", "03.90", "50.22", "43.7", "52.53", "51.22" ]

icd9pcs

[ [ [] ] ]

12469, 12545

7542, 11400

311, 559

12645, 12645

2796, 7519

13975, 14445

2263, 2473

11579, 12446

12566, 12624

11426, 11556

12796, 13447

13462, 13952

2488, 2488

2502, 2777

240, 273

587, 1638

12660, 12772

1660, 1813

1829, 2247

20,140

145,664

24091

Discharge summary

report

Admission Date: [**2117-6-7**] Discharge Date: [**2117-6-18**] Date of Birth: [**2059-1-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: Infection and gangrene of right above knee stump Major Surgical or Invasive Procedure: Revision of right above the knee amputation stump History of Present Illness: The patient is a 58 year old male who previously had an above the knee amputation in [**2116-6-11**] who presented on [**2117-6-7**] with a right stump gangrenous infection. After having his prosthesis, the patient reportedly was doing well in rehab until he began noticing his stump turning black 4 months ago. The patient had recently been discharged from [**Hospital1 18**] on [**2117-5-20**] following a complicated SICU course in which he suffered from MRSA pneumonia and VRE urinary tract infection. He then followed up with Dr. [**Last Name (STitle) **] on [**2117-6-1**] for hit right stup gangrene and was instructed to return to the hospital on [**6-7**] for IV antibiotics prior to scheduled surgery on [**6-8**]. Past Medical History: PVD s/p multiple failed femoral distal bypass Diabetes mellitus CAD s/p CABG [**2102**] s/p ex lap [**3-16**] Social History: 60 pack year smoker Family History: Father died of an MI at 62 Physical Exam: Gen: cachectic, no acute distress Lungs: clear to ascultation bilaterally, with decreased breath sounds at the bases Heart: regular rate and rhythum, normal S1S2 Abdomen: soft, nontender, nondistended Neuro: alert and oriented X 3 Pulses: left lower extremity 2+ femoral, popliteal, dorsalis pedis, and posterior tibial. Right lower extremity: 1+ femoral Extremities: Right lower extremity stump is black for 10 inches long with surrounding tender ulcerated edges Pertinent Results: [**2117-6-17**] 07:22AM BLOOD WBC-5.6 RBC-3.32* Hgb-10.0* Hct-30.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-16.0* Plt Ct-196 [**2117-6-17**] 07:22AM BLOOD Plt Ct-196 [**2117-6-13**] 04:00AM BLOOD PT-14.1* PTT-41.4* INR(PT)-1.3 [**2117-6-17**] 07:22AM BLOOD Glucose-112* UreaN-6 Creat-0.4* Na-135 K-3.5 Cl-105 HCO3-28 AnGap-6* [**2117-6-17**] 07:22AM BLOOD Calcium-7.2* Phos-3.1 Mg-1.7 Brief Hospital Course: The patient was admitted on [**2117-6-7**] with a gangrenous right stump and started on IV vancomycin, levofloxacin, and Flagyl preoperatively. On [**6-8**], the patient underwent a revision of his above knee amputation with no complications and was subsequently admitted to the PACU. On [**6-10**] the patient was transferred to the floor, doing well. Later that evening, the patient was admitted to the ICU for decreased urine output and hypotension (78/52) and a central venous line was placed. After a 1L bolus of NS, his BP went to 88/54 and he was mentating well. On [**6-11**], the patient was confirmed to be C. difficile positive. Tube feeds were begun. Pain management was consulted and saw the patient. On [**6-12**], the patient was determined to be healthy enough to leave the ICU for the VICU. On [**6-15**], levofloxacin was discontinued. On [**6-16**], a PICC line was placed in preparation for IV vancomycin to be administered at rehab and the patient's tracheostomy was decannulated. [**2117-6-18**] d/c to rehab stable condition Medications on Admission: vitamin c, aspirin, atorvastatin, plavix, lovenox, gabapentin, ipratropium, lansoprazole, lorazapam, lidoderm patch, lopressor, oxycontin, MVI, ambien, acetaminophen, albuterol, hydrocodone Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Lansoprazole Oral 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 10. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*42 Tablet(s)* Refills:*0* 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*14 Tablet(s)* Refills:*0* 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours). Disp:*28 grams* Refills:*2* 14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: Gangrene and infection of right AKA stump Discharge Condition: Good Discharge Instructions: Please take all medications as directed. Please stay on vancomycin for 2 weeks. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 2 weeks Completed by:[**2117-6-18**]

[ "730.07", "707.03", "008.45", "496", "250.00", "V45.81", "414.00", "997.62", "799.4", "440.24" ]

icd9cm

[ [ [] ] ]

[ "96.6", "84.3", "38.93" ]

icd9pcs

[ [ [] ] ]

5016, 5084

2290, 3347

362, 414

5170, 5176

1887, 2267

5305, 5392

1358, 1386

3587, 4993

5105, 5149

3373, 3564

5200, 5282

1401, 1868

274, 324

442, 1172

1194, 1305

1321, 1342

2,090

146,557

53418

Discharge summary

report

Admission Date: [**2137-12-3**] Discharge Date: [**2137-12-14**] Date of Birth: [**2061-4-8**] Sex: M Service: MEDICINE Allergies: Amiodarone / Monosodium Glutamate Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: respiratory disress and hypotension Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 656**] is a 76yo gentleman who had recent redo repair of thoracic aortic dissection with a course complicated by staph bacteremia and post operative seizures who was transferred from [**Hospital 100**] Rehab with respiratory distress and hypotension. . He had been making good progress at rehab, and had been more alert and was moving his hands and sitting in a chair. Yesterday, he became more drowsy and developed a fever to 102.4, and zosyn was started. He was given a dose of zosyn. Overnight, he had a large bowel movement and then shortly after he became tachypneic (40-50s) and his oxygen saturation dropped to 88% on FiO2 of 35%. He was given 1mg of ativan and 40mg IV lasix, and he made 200cc of urine over the next 3 hours. His oxygen sats improved with increasing his FiO2 to 100%. There was minimal output from his cholecystostomy tube. He was sent to the [**Hospital1 18**] ED for further care. . In the ED, his initial vital signs were significant for BP of 60/p, which improved to 112/51 on recheck, HR 99 with a temp of 104 and RR of 37. His eyes were open. Glucose was 116. His pressure then drifted down to 71/37 despite receiving four liters of NS. Peripheral dopamine was started, and he was noted to be alert to verbal commands. A femoral line was placed (given b/l UE DVTs) and pressors were changed from dopamine to norepinephrine. Of note his HR climbed to 150s while on dopamine. . His labs were significant for a respiratory alkalosis, lactate of 2.2, WBC 8.1, Hct 31.8, troponin of 0.1 with a normal CK, AP 174 with normal other LFTs, Cr of 1.5 up from 1.0 and INR of 2.4. Blood cultures were sent. A CT torso was performed which showed LLL collapse and tree and [**Male First Name (un) 239**] opacification of the right lung fields with no intraabdominal pathology and no PE. He received 325mg per GJ tube, vancomycin 1gm IV, and 600mg of tylenol PR. CT surgery was consulted and recommended admission to the [**Hospital Unit Name 153**]. On transfer to the floor his vital signs were HR 115, BP 112/53 RR 36, 100% on FiO2 of 100%, T 101.5 with norepinephrine at 0.9mcg/kg/min. . Per nursing report, his IV infiltrated with contrast during the CT torso and plastics placed a dressing over his right arm. . Unable to obtain review of systems secondary to mental status. Past Medical History: Type A aortic dissection in [**2132**] s/p replacement aortic arch, resuspension of aortic valve, coronary artery bypass graft x1 s/p coil embolization of his left internal iliac aneurysm [**2136**] CTA in [**2137-9-3**] showed increase in size of aorta to 6.3cm, hence [**Year (4 digits) 1834**] planned redo repair in [**2137-10-3**] with replacement of ascending aorta and arch with graft - developed seizures post-op, neurology felt this was sign of anoxic cerebral insult - found to have E faecalis bacteremia - LLL PNA with Cx growing serratia and E Coli - left chest tube placed for pleural effusion - right IJ thrombosis found during line placement - hematuria felt to be due to Foley trauma while on coumadin; required CBI and followed by urology - had trach and GJ tube [**10/2137**] - [**Year (4 digits) 1834**] work-up with bronch for possible TBM, which was negative - slow neurologic improvement, at time of discharge: "he was able to follow commands- he was able to open his eyes, grasp my fingers, and stick out his tongue. He was not moving his limbs other than moving his toes and fingers and was not antigravity, he was areflexic" - dc'd to rehab [**11-11**] on trach collar with CPAP Readmitted [**Date range (1) 104398**] with fever and seizures - coag negative staph bacteremia from PICC line - found to have Cholecystitis but not felt to be operative candidate, so had percutaneous choleycystostomy tube - left subclavian DVT noted [**11-22**] - dc'd back to rehab with plan for 6 weeks of vancomycin and return in [**1-4**] months for cholecystectomy pAFib s/p ablation [**7-/2137**], on coumadin s/p PPM for tachy-brady syndrome HTN Hyperlipidemia PVD Anemia, felt to be due to chronic disease h/o CHF with preserved EF Diverticulosis Benign prostatic hyperplasia Spinal Stenosis Social History: Was living at [**Hospital **] rehab. Prior smoker, but quit. Married, wife is his HCP. Family History: NC Physical Exam: 99.5 115/48 107 15 96% on AC 450/18 100% with PEEP 5 GENERAL: Ill-appearing man lying in bed with mouth open, trach in place, not responding to verbal stimuli and minimally responsive to tactile stimuli HEENT: Eyes closed. Pupils are small but equal b/l and both reactive to light. Does not track movements or sounds. No icterus. Mucous membranes are moist. CARDIAC: Irregularly irregular and tachycardic, no murmurs or rubs LUNGS: Moving air well anteriorly with some coarse breath sounds; left base has somewhat bronchial breath sounds. ABDOMEN: Obese but soft, does not wince even with deep palpation, per chole tube in place with small amount of bilious drainage. EXTREMITIES: Warm. ++right>left UE edema, but no LE edema. Peripheral pulses are intact b/l. Right arm is wrapped and splinted. SKIN: Diaphoretic, scabs and tears in skin, especially in LUE. Powder in left groin. NEURO: Resists eyes being opened but otherwise does not react to examiner. No tremors or myoclonus observed. LINES: left PICC, left 20g, right femoral. 250cc concentrated yellow urine in Foley. Pertinent Results: . LABS: at discharge: 8.0>9.4/27.7<314 N58.4, L29.5, M7.2, E4.4, B0.5 INR 3.3 134/4.2/95/33/33/1.8<81 Ca 8.6, Mg 2.4, Phos 4.1 ALT 23, AST 32, AlkPhos 122, TB 0.5, lipase 51, amylase 61 INR 4.0 Vanc trough 28.1 Phenytoin level 6.2 . [**12-11**] PTH: 34 . [**12-11**] ABG: 7.48/42/119 . [**12-4**] lactate 2.2, decreased to 0.9 with IVF . UA [**12-3**], 5, 8 with RBC (most 170 on [**12-7**]), 15 WBC on [**12-7**], none with epis . [**12-11**] blood pending [**12-10**] sputum GNR GRAM STAIN (Final [**2137-12-10**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2137-12-12**]): Commensal Respiratory Flora Absent. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. GRAM NEGATIVE ROD(S). MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD #3. SPARSE GROWTH. . [**12-10**] femoral catheter neg [**12-10**] blood pending [**12-10**] urine neg [**12-8**] blood pending [**12-7**] urine neg [**12-7**] cdiff neg 12/2 blood neg [**12-3**] bile neg [**12-3**] PICC neg [**12-3**] cdiff neg [**12-3**] resp viral ctx neg [**12-3**] blood neg [**12-3**] urine neg . multiple sputum samples were sent during course of stay however were insufficient. . STUDIES: PICC placement [**2137-12-10**]: 1. Evidence of occlusion involving the bilateral subclavian veins with no central access available for catheter placement. 2. 20 cm PICC placed via right basilic access with the tip located in the mid axillary line. Please note that this is not a central venous catheter given occlusion of the right subclavian vein. . CXR [**12-3**]: Left basilar consolidation, likely reflecting lower lobe collapse and left pleural effusion, similar to the comparison study. . CT Torso [**12-3**] : CT CHEST WITH AND WITHOUT CONTRAST: The pulmonary arterial system is well opacified and there is no embolic filling defect. A tracheostomy tube is visualized in good position. Lungs are notable for intralobular septal thickening and scattered areas of ground-glass density. A left pleural effusion is slightly larger than on the comparison study. There is no right pleural effusion. Interpretation of fine detail is slightly obscured by respiratory motion. Nevertheless, there are areas of poorly marginated nodular type of opacity, which is new from the comparison study (3A:39), as well as areas of tree-in-[**Male First Name (un) 239**] type opacities, also progressed from the previous study and together suggestive of infection. Note is made of bibasilar atelectasis as well as a consolidation seen along the medial basal aspect of the right lower lobe. The left lower lobe is notable for collapse with similar findings seen in the lingula. . There is no pericardial effusion. The heart is notable for atherosclerotic calcification of the coronary arteries and a dual lead pacing device. The patient is status post replacement of the ascending aorta with an interposition graft as well as replacement of the aortic arch. A large amount of fluid in the pericardial recesses is unchanged. A descending thoracic aortic dissection persists. There is no mediastinal or axillary lymphadenopathy. CT ABDOMEN WITH CONTRAST: The stomach contains a percutaneous gastrojejunostomy tube, which appears to be appropriately positioned. The spleen, splenule, pancreas and adrenal glands are unremarkable. The liver is notable for diffuse periportal edema. Hypodensity in the left lobe (3B:A3) is too small to characterize and unchanged. Near the edge of the liver in the right lobe is a 15 x 9 mm hyperdense lesion (3B:A2), which was not definitively seen on previous studies. A percutaneous cholecystostomy tube is seen in place. The kidneys enhance and excrete contrast in a symmetric fashion. There is no free gas or free fluid in the abdomen. There is no retroperitoneal or mesenteric lymphadenopathy. An aortic dissection is visualized, similar to that seen on previous studies. The true lumen appears to supply the celiac trunk, superior mesenteric artery and right renal artery while the left renal artery originates from the false lumen. This section extends into both common iliac arteries and also into the proximal portion of the left external iliac artery. CT PELVIS WITH CONTRAST: The urinary bladder contains Foley catheter and a small amount of gas. A metallic wire in the rectum may represent a temperature probe. Otherwise, the colon is predominantly decompressed and is unremarkable. The prostate is enlarged measuring 72 x 64 mm in cross-sectional area. The seminal vesicles are unremarkable. There is no free gas or fluid in the pelvis. There is no pelvic or inguinal lymphadenopathy. Trace amount of gas in the right common femoral vein as a consequence of the injection. There is a fat-containing left inguinal hernia. Numerous coils are redemonstrated in the region of the left internal iliac artery. The colon is notable for diverticulosis, with no evidence to suggest acute diverticulitis. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion. Degenerative changes are seen throughout the spine and involving both sacroiliac joints. The patient is status post median sternotomy. An old rib fracture deformity is seen in the right fourth rib posteriorly as well as in the right first rib posteriorly. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Post-surgical changes of the aorta and extensive aortic dissection, as described above, and overall minimally changed. 3. Large left pleural effusion with associated collapse of the left lower lobe. The lungs also reveal scattered consolidations as described above and poorly marginated nodular type opacities which are new and short interval and likely also infectious. 4. Suggestion of hypervolemia with intralobular septal thickening in the lungs as well as periportal edema. 5. Diverticulosis. 6. Hepatic hyperdensity in the right lobe as above. A similar hyperdensity was seen in [**2136-8-3**]. Considerations include a hemangioma, or possible AV-malformation (?previous biopsy site). This could be assesed further with ultrasound. . EEG [**12-4**]: This telemetry captured no pushbutton activations and no ictal or interictal epileptiform activity. The background activity was slow with additional bursts of generalized slowing suggestive of a moderate encephalopathy involving both cortical and subcortical structures. Additional triphasic waves are part of the mentioned encephalopathy. Although there were no areas of prominent focal slowing seen in this recording, subtle asymmetries may be difficult to discern in a generally slow recording. TEE [**11-19**]: No valvular vegetations or masses. No vegetations on the RA/RV pacing wire. An aortic dissection flap is seen in the descending aorta to the level of the aortic arch, consistent with the patient's known history. Brief Hospital Course: 76yo gentleman who is s/p redo replacement aortic arch with presumed anoxic brain injury and post-op bacteremia as well as cholecystitis s/p cholecystosomy admitted for sepsis. . # Respiratory Failure: At first, likely secondary to infectious process. Empiric therapy for HAP with Vanc/Cipro (Vanc D1 [**11-14**], Cipro [**12-4**]); Vanc should be continued until [**2137-12-26**] and Cipro until [**2138-1-1**]. Vancomycin was held on the day of discharge because of an elevated vancomycin level to 28.1. A Vancomycin level should be checked in the AM, and vancomycin dose adjusted accordingly. Patient was initially also treated with Cefepime, but this was soon stopped. His ventilator settings were gradually weaned to pressure support, and at discharge he seemed to be at baseline with occassional periods off of the ventilator on trache mask (up to two hours). Barriers to extubation at discharge included muscle weakness and pulmonary edema. He was tolerating a lasix drip, however was still net positive 7 liters from admission due to fluid resuscitation for sepsis. We elected to keep patient off of lasix drip on day of discharge because Cr was elevated, but think that the patient is total body volume overloaded and would benefit from further diuresis. He has been intermittently hypotensive during bolus diuresis, and lasix drip has been well-tolerated and can resume in order to keep patient net even or slightly negative on a daily basis. . # Sepsis: Found to have serratia bacteremia on OSH culture and then had sputum with GNR on [**12-10**]. Possible sources include GU or GI. LFTs were normal apart from alk phos, so cholecystitis less likely. Could also be due to pneumonia or due to PICC line infection, so PICC line was removed and replaced with a midline. Patient was seen by the infectious disease team who agreed with plan and suggested to start Meropenem if patient decompensated. . # Acute renal failure: Felt to be a combination of ATN and hypovolemia given small amount of granular casts. Patient's electrolytes were checked and repleted daily while on the lasix drip. Foley catheter was changed twice over the admission, most recent being approximately 1 week prior to discharge. Patient often complained of discomfort related to the foley site though it was felt to be necessary due to BPH and hematuria. At the time of discharge, patient's Creatinine was trending up, and this was felt to be most likely secondary to intravascular depletion from diuresis (although he remains total body volume overloaded). Consequently, diuresis was held on the day of discharge as mentioned above, but Cr should be checked regularly and diuresis resumed when Cr trending down. . # Fever: Patient spiked fevers during admission, and as a result his femoral line (placed during admission) was pullled on [**12-10**]. Other possible sources of infection included pulmonary and GU, as well as a possible infected pulmonary effusion. The ICU team considered performing a CT-guided thoracentesis, but his fevers resoved after pulling out the femoral line and a thoracentesis was not pursued. . # Altered mental status and h/o Seizures and Likely Anoxic Cerebral Injury: At admission, patient was evaluated by neurology who felt no current evidence of seizure activity but he does have a history of non-convulsive status epilepticus. EEG neg for seizure so likely due to hypotension, possibly oversedation from anti-epileptic medications. His MS improved quickly during his hospital course. During his admission his Phenobarbital was stopped on [**12-8**] and his Keppra and Dilantin were continued with adjustment of Dilantin level to between [**6-11**] corrected for albumin. Coumadin titration is likely changed dilantin levels, and his dilantin level should be checked every few days going forward. . # Hypercalcemia: Resolved during admission and was likely secondary to renal failure. PTH was in Normal range of 34. . # Hematuria and BPH: Was described at rehab [**12-2**] Patient was followed by urology during recent hospital stay and was started on flomax. Continued to have some hematuria during this hospitalization, has 3 way foley and undergoing bladder irrigation. Likely due to anticoagulation in the setting of foley placements. Resolved several days before discharge so a urology consult was not done. . # Atrial Fibrillation and UE DVTs: INR was supratherapeutic to at 4.0 on the day of discharge. His PM coumadin should be held and INR checked in the AM, and dose adjusted accordingly. (Coumadin and Phenobarbital interact and it will likely be difficult to achieve optimal therapeutic levels of the two medications; they should be monitored closely). The patient was bridged with Heparin for 48 hours after achieving a therapeutic INR. Goal INR is [**2-5**]. His Metoprolol was continued. We considered stopping dronederone as it was not keeping him in sinus, however did not hear back from his cardiologist so it was continued. . # Anemia: Hct remained relatively stable, though patient did require 1U PRBC during admission. Note that patient required multiple transfusions during recent hospital stay and he has guaiac positive stool as well as recent hematuria. H2B was continued. . # Recent Cholecystitis: Was not felt to be the etiology of his sepsis per surgery. Dr. [**Last Name (STitle) **] (who initially placed the tube), felt that it should be kept in place for now, and the patient should follow up with Dr. [**Last Name (STitle) **] in early [**Month (only) 404**]. . # S/p Aortic arch repair/dissection/CABG: No acute issues. CT surgery consulted in the ED. Recently had TEE that did not show vegetations on grafts or pacemaker leads, and as patient improved, further echo was not done. Simvastatin and ASA were continued. . # h/o diastolic heart failure: Patient was maintained on prn Lasix and then a Lasix drip given episodes of hypotension. . # Elevated troponin and EKG changes: Suspect patient was somewhat ischemic in setting of hypotension and tachycardia at admission. ASA was continued and repeat CEs remained stable with troponin of .11 and CKs did not increase. . # Infiltrated IV site: Patient had an infiltrated IV site at admission. It was monitored by plastic surgery who felt that it was not compartment syndrome. Pain improved over time though the right arm continued to be ecchymotic and edematous at discharge. Was treated with hot compresses, with some improvement. . # CODE STATUS: Full, discussed with HCP Medications on Admission: MEDICATIONS (per recent DC summary): ASA 81mg daily Warfarin ?mg prn INR 2.5-3.0 (received 7.5mg [**11-25**]) Vancomycin 1g IV Q24H through [**12-16**] Zosyn started [**12-2**] Dronedarone 400 mg [**Hospital1 **] Dilantin-125 100mg PO TID Phenobarbital 30mg PO TID Levetiracetam 1000 mg [**Hospital1 **] Metoprolol Tartrate 50 mg TID Furosemide 40 mg [**Hospital1 **] Simvastatin 10 mg daily Terazosin 1 mg HS Polyvinyl Alcohol-Povidone 1.4-0.6 % drops Q6H Ranitidine 150mg daily Chlorhexidine Gluconate 0.12 % 15ml [**Hospital1 **] Ipratropium-Albuterol 6-8 Puffs Q4H prn wheeze Bisacodyl 10 mg prn Constipation. Acetaminophen 650mg Q4H prn pain ALLERGIES: Amiodorone, MSG Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: adjust according to INR. 3. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO twice a day: Please give at least 1 hour before or after meals. Please give at 6am and 10pm. 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Outpatient Lab Work INR/PT every other day until INR at goal of [**2-5**] on continued basis. Electrolytes including creatinine, potassium, magnesium 2 days after discharge and therafer until creatinine improved and potassium and magnesium not requiring repletion. Please also check Keppra and Dilantin levels weekly. 8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for constipation. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 16. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed) as needed for foley. 17. 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. 18. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours): Please give until [**2138-1-1**]. 19. 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. 20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 22. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous once a day: Please give until [**2137-12-26**]. 23. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 24. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 25. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 26. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2H PRN () as needed for pain: Do not give if RR<12 or if in pain. 27. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day: Please give at 2pm. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: Bacteremia Respiratory failure Acute Renal Failure Diastolic CHF Atrial fibrillation Pleural effusion Secondary Diagnoses: Cholecystitis Aortic dissection s/p graft repair Tachy-brady syndrome s/p pacemaker Hypertension Hyperlipidemia Peripheral Vascular Disease Anemia, felt to be due to chronic disease Diverticulosis Benign prostatic hyperplasia Spinal Stenosis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Lethargic but arousable Activity Status: Out of Bed with assistance to chair or wheelchair Hemodynamically stable Ventilator dependent but able to tolerate trach collar for short periods of time (up to several hours) Discharge Instructions: You were admitted to the hospital for respiratory distress and low blood pressure thought to be related to an infection in your blood. You were treated with IV fluids and antibiotics and you gradually improved. Additionally, you had a decline in your renal function during the course of your hospitalization, likely related to receiving contrast for a CT scan at admission to the hospital and then receiving medications (Lasix) to help remove the IV fluids. We expect that your kidney function will improve over the next several weeks. At a previous hospitalization, you have a percutaneous cholecystostomy tube placed to drain your gall bladder. Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] during your stay, who recommended that you keep the tube at this time, but you should follow up with Dr. [**Last Name (STitle) **] in early [**Month (only) 404**]. You were continued on Coumadin and should have your INR checked and your Coumadin dose adjusted accordingly after discharge. Dilantin can also increase your INR so it is important to have this checked every 2-3 days after discharge. Your Dilantin level has also been changing as we have adjusted your coumadin. Your goal Dilantin level is [**6-11**], once corrected for low albumin. Dilantin levels should be checked every few days. We made several changes to your medications: Stopped phenobarbital Continued vancomycin - please continue until [**2137-12-26**] Started Ciprofloxacin - please continue until [**2138-1-1**] Please take all medications as prescribed. Followup Instructions: You have the following apopintment scheduled: Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2138-3-7**] 10:00 You also have an appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 851**] of Neurology on [**2138-1-7**] at 9:30am. Please come to the [**Location (un) **] of the [**Hospital Ward Name 860**] Building. For questions, please call ([**Telephone/Fax (1) 26609**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

23227, 23293

12849, 19366

337, 343

23722, 23722

5815, 5823

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4675, 4679

20092, 23204

23314, 23436

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29,617

108,558

34406

Discharge summary

report

Admission Date: [**2101-6-10**] Discharge Date: [**2101-6-16**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Admitted after fall in bathroom with rib fractures and hemothorax. Major Surgical or Invasive Procedure: [**6-10**]: Blood transfusions, vitamin K and FFP, chest tube insertion, epidural catheter placement. History of Present Illness: 86 year old male was evaluated at an outside hospital after a fall in the bathroom at his rehab facility and was discharged back to rehab that same day. Hematocrit check at rehab was 18, so pt returned to outside hospital, got 1 unit packed RBCs, vitamin k, and ffp and was transferred to [**Hospital1 18**]. Past Medical History: ?CHF, Atrial fibrillation with pacemaker, DM, HTN, chronic UTI/chronic renal failure Social History: Was recuperating at [**Hospital 5503**] Health Care Center at time of admission. Son [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 79118**]) lives in area. Family History: Non-contributory Physical Exam: Afebrile, vital signs stable. Gen: No distress, alert and oriented x3 CV: RRR Resp: Bibasilar crackles Abd: Soft/non-tender/non-distended. +bowel sounds Ext: Warm and well perfused. Pertinent Results: [**2101-6-10**] 07:15PM URINE RBC-21-50* WBC->1000 BACTERIA-MANY YEAST-NONE EPI-0 [**2101-6-10**] 07:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0 LEUK-MOD [**2101-6-10**] 07:15PM PT-23.0* PTT-33.1 INR(PT)-2.2* [**2101-6-10**] 07:15PM WBC-18.5* RBC-2.74* HGB-6.9* HCT-21.6* MCV-79* MCH-25.2* MCHC-31.9 RDW-17.5* [**2101-6-15**] 06:10AM HCT 34.0* [**2101-6-12**] 03:20AM Gluc 108* BUN 61* Creatinine 1.5* Sodium 134 Potassium 5.2* Chloride 106 HCO3 20* Anion Gap 13 [**6-10**] EKG: Sinus tachycardia. Left bundle-branch block. [**6-10**] CXR: Extensive right-sided rib fractures multiple in more than one place highly suggestive of a flail chest. There is also a posteriorly layering pneumothorax. [**6-15**] CXR: Interval removal of right-sided chest tube with development of small apical pneumothorax. No significant residual effusion. The heart remains mildly enlarged without evidence for overhydration. There is also a hazy area of opacity in the left upper lobe, which could be resolving contusion injury; however, this should be followed to resolution. No change to previously seen rib fractures. [**6-16**] CXR: Stable small apical pneumothorax. F/u right lower lobe opacity (likely pulmonary contusion) with future films. Brief Hospital Course: He was admitted to the Trauma service with right sided rib [**5-4**] fractures, a hematocrit of 21.6 and INR 2.2. A chest tube was placed and returned 800cc of blood from the thorax. He was initially admitted to the trauma ICU for monitoring. His hematocrit improved after transfer of 4 units RBCs, vit k, and ffp. On [**6-11**], urinalysis revealed a UTI, for which he was treated with 3 days of ciprofloxacin. His hematocrit subsequently remained stable and gradually increased to 34.0 on [**6-15**]. Because of his rib fractures the Acute Pain service was consulted for epidural analgesia. The epidural catheter was placed and remained for several days. He was later transitioned to oral narcotics and the epidural was removed. His pain adequately controlled on Tylenol, Tramadol, and Oxycodone prn. He is on a bowel regimen. Pt was previously anticoagulated for atrial fibrillation. Because of his recent fall and hemothorax and increased risk of similar subsequent events given pt's age and relative instability, would recommend not restarting Coumadin for anticoagulation in spite of pt'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] score of 4. Physical therapy was consulted and have recommended rehab after acute hospital stay. Medications on Admission: Coumadin, Digoxin 0.125 mg QD, Accupril 40 mg QD, Humalog 15 u TID, Lantus 20 U QHS, Glucophage 1000 mg [**Hospital1 **], Colace 100 [**Hospital1 **], Atenolol 25 mg QD, Lasix 40 QD Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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 for constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 11. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Insulin NPH & Regular Human Subcutaneous Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Health Care Center Discharge Diagnosis: Right rib [**5-4**] fractures and hemothorax secondary to fall from standing. Discharge Condition: Stable, meeting discharge criteria, afebrile, vital signs stable, eating regular diet, pain controlled on oral meds, indwelling foley. Discharge Instructions: It is important that you continue to cough, deep breathe and use the incentive spirometer every hour that you are awake to prevent pneumonia that is often a complication associated with rib fractures. Followup Instructions: Call Dr.[**Name (NI) 18535**] office to schedule a follow up appointment in 2 weeks at ([**Telephone/Fax (1) 36338**]. Follow up with a urologist to evaluate your urinary retention and history of urinary tract infections after discharge from rehab. Follow up with your PCP after discharge from rehab.

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icd9cm

[ [ [] ] ]

[ "34.04", "03.90", "99.04" ]

icd9pcs

[ [ [] ] ]

5215, 5280

2639, 3897

327, 430

5402, 5539

1311, 2616

5788, 6092

1076, 1094

4129, 5192

5301, 5381

3923, 4106

5563, 5765

1109, 1292

221, 289

458, 768

790, 877

893, 1060

17,579

126,237

43555

Discharge summary

report

Admission Date: [**2159-8-12**] Discharge Date: [**2159-8-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: sepsis, hypotension, fever Major Surgical or Invasive Procedure: placement of right IJ line, arterial line History of Present Illness: 83yoW with h/o HTN, recent hip [**Hospital 24785**] transferred from [**Hospital 100**] Rehab with fever and hypotension. She has been at [**Hospital 100**] Rehab since [**5-/2159**] for treatment of osteomyelitis with vancomycin and levofloxacin. She also recently completed a 14 day course of Flagyl for c. difficile infection. At around 2AM today she was noted to be more confused with T 101 HR 100 BP 60s/palp RR 24 93%RA, and transferred to [**Hospital1 18**] ED. In ED patient noted to be febrile with T 101, tachypneic, hypotensive BP 60s/palp. She was given 5L iv fluid, and treated with doses of Zosyn and Flagyl. CVP improved from 5 to 10; SvO2 85%; lactate 4.4 improved to 3.7. She was started on levophed for continued BP support. CXR demonstrates LLL PNA and effusion, and retrocardiac density. Past Medical History: Hypertension s/p left hip ORIF x2, c/b presumed osteomyelititis breast cancer s/p left mastectomy [**2128**] s/p bilateral cataract extraction deafness Social History: patient is widowed, previously living on her own prior to hip fracture. Son [**Name (NI) **] [**Name (NI) 174**] lives in [**Location 1411**] and has power of attorney. Another son lives in [**Name (NI) 4565**]. previously drank 1glass wine/month. no tob, illicits. Family History: mother d. 50s of hepatic ca brother d. 50s of renal failure sister d. 50s of breast ca Physical Exam: T 98.8 HR 94 BP 89/41 RR 18 100% 2Lnc GEN: awake, alert, thin appearing, NAD HEENT: pinpoint pupils, reactive, anicteric, thick white/cream tongue plaque CV: RRR, no mrg, nml s1s2 Resp: CTAB anteriorly with expiratory wheeze, LLL coarseness heard laterally Abd: +BS, soft, ttp LLQ, no rebouding/guarding, ND, no HSM Ext: 2+ DP pulses, LLE laterally rotated, 1+ nonpitting edema Neuro: alert, oriented to person, states she is in X-ray. CN II-XII intact, strength decreased B LE, intact 4+/5 BUE Pertinent Results: CXR: LLL pna and effusion Abd CT: noncontrast, study pending ECG: rate 110, NSR w/ PACs, nml axis and intervals, TWI I, II, aVL, V2, T-wave flat V1, V3-4 [**2159-8-12**] 10:50AM LACTATE-7.5* [**2159-8-12**] 10:04AM LACTATE-6.1* [**2159-8-12**] 10:04AM HGB-12.8 calcHCT-38 O2 SAT-86 [**2159-8-12**] 09:55AM WBC-76.1*# RBC-4.02* HGB-12.2 HCT-38.6 MCV-96 MCH-30.3 MCHC-31.6 RDW-15.8* [**2159-8-12**] 09:55AM PLT COUNT-125* [**2159-8-12**] 08:47AM LACTATE-4.8* [**2159-8-12**] 07:30AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.023 [**2159-8-12**] 07:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD [**2159-8-12**] 07:30AM URINE RBC-[**6-8**]* WBC-[**11-18**]* BACTERIA-MOD YEAST-MOD EPI-21-50 [**2159-8-12**] 06:43AM LACTATE-3.7* [**2159-8-12**] 04:21AM LACTATE-4.4* [**2159-8-12**] 04:18AM PT-16.2* PTT-36.7* INR(PT)-1.7 Brief Hospital Course: 83yo woman with history of hypertension, osteomyelitis transferred from NH with hypotension, fever, in sepsis. She was treated with 9L iv fluids and started on levophed for blood pressure support. A right IJ and A-line were placed. CVPs and SvO2s were monitored. CXR demonstrated a LLL pneumonia and effusion. She received doses of Flagyl and Zosyn in the ED. She was preparing for an abdominal CT scan to evaluate for acute abdominal pathology when her blood pressure began to decline. She was brought to the MICU where BP and SvO2 continued to decline with MAPs in the 50s. Vasopressin and dobutamine were added, and iv fluids were continued in pressure bags. We were preparing to treat with Xygris and start neosynephrine when she became more hypotensive and tachycardic. Her pressure was unsustainable, and she went into PEA arrest. Per confirmation with her son, [**Name (NI) **] [**Name (NI) 174**], her code status was DNR/DNI. She expired at 11:09AM. The patient's son was notified. The medical examiner was notified and waived the case. Post-[**Last Name (un) **] examination was declined. Medications on Admission: Trazadone 50mg qHS Levofloxacin 500mg po daily ([**2160-1-31**]) Vancomycin 1000mg [**Hospital1 **] iv (stop [**2159-8-19**]) Coumdain 1mg qHS Tylenol 650mg Q8hrs Fosamax 70mg qweekly Calcium/Vit D Colace 100mg [**Hospital1 **] FeSO4 325mg [**Hospital1 **] Fluconazole 100mg daily Folate 1mg daily Toprol XL 50mg daily Remeron 30mg qHS MVI daily Oxycodone 5mg [**Hospital1 **] Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

[ "785.52", "584.9", "458.9", "780.6", "038.3", "276.2", "995.92" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

4805, 4814

3232, 4345

288, 331

4866, 4876

2283, 3209

4933, 4944

1654, 1742

4772, 4782

4835, 4845

4371, 4749

4900, 4910

1757, 2264

222, 250

359, 1176

1198, 1351

1367, 1638

14,973

190,490

45725

Discharge summary

report

Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-14**] Date of Birth: Sex: Service: NEUROOLOGY HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old woman with advanced dementia with coronary artery disease, atrial fibrillation, hypertension, who presents after being found unresponsive. At baseline, she requires assistance with feeding and bathing. She says only one or two words. She walks in her home with a cane. Today, she took a nap around 2:00 p.m. Her husband tried to wake her but couldn't and thought that her breathing was irregular. He called 9-1-1 and she was taken to [**Hospital3 **] Emergency Room where she was intubated and sedated. PAST MEDICAL HISTORY: 1. Atrial fibrillation, INR 3.7 last Thursday. 2. Hypertension, long-standing. 3. CAD, status post CABG. 4. Dementia, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. ADMISSION MEDICATIONS: 1. Trazodone. 2. Coumadin. 3. Aspirin. 4. Lopressor. 5. Procardia. 6. Microzide. 7. Avapro. 8. Wellbutrin. 9. Vitamin E. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: She lives with her husband, as described above. Her daughter is a nurse and health care proxy. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood pressure 200/80, heart rate 65. She appeared comfortable. The oropharynx was clear. No carotid bruits. No JVD. No thyromegaly. Cardiac: Notable for a regular rate and rhythm. Chest: Clear. Abdomen: Benign. Extremities: She had no clubbing, cyanosis or edema. Neurologic: She was intubated and sedated, not responding to voice or sternal rub. She was moving the right leg spontaneously but not the other extremities. Her dolls eye was positive in a horizontal direction. Pupils were reactive with positive corneal reflexes. Face was symmetric with a positive gag. She had increased tone in the left arm and leg. Hyperreflexic in the left arm and leg with an extensor plantar response on the right, 2+ reflexes with plantar response that was flexor. She grimaces to pain and attempts to withdrawal all four extremities. LABORATORY/RADIOLOGIC DATA: White count 11, hematocrit 37, platelets 294,000. Sodium 137, potassium 4.3, BUN 20, creatinine 1.4, INR 3.2. She had a CT which showed an old left cerebellar stroke and some asymmetry in the right anterior cerebral artery territory. HOSPITAL COURSE: The patient is a 78-year-old woman who was found unresponsive and went into respiratory distress. As part of her workup, she had a head CT showing evidence of a possible right anterior cerebral artery stroke. She was intubated on arrival to the Emergency Room. She was admitted to the Neurointensive Care Unit. Initially, her blood pressure was allowed to autoregulate. She eventually was started on a labetalol drip for her blood pressure. She had episodes of seizures during admission treated with Ativan. She reverted on Dilantin. She was transfused to keep her hematocrit elevated. She was started on levofloxacin for pneumonia. She continued to have fevers initially. She was on anticoagulation for prosthetic heart valve. Over time, she continued to have leukocytosis and fever. She was started on vancomycin which was then discontinued after no significant improvement in her care. They decided to make her DNR/DNI. The patient began to have movement of the right side spontaneously, however, she continued to have decerebrate-like posturing on the left. Eventually, she was successfully extubated and she was discharged to home with hospice care. DISCHARGE DIAGNOSIS: 1. Right anterior cerebral artery stroke. 2. Seizures. 3. Pneumonia. 4. Dementia. 5. Coronary artery disease. 6. Atrial fibrillation. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279 Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2183-7-9**] 04:00 T: [**2183-7-9**] 17:41 JOB#: [**Job Number 97443**]

[ "427.31", "V45.81", "401.9", "434.91", "414.01", "518.82", "599.0", "294.8", "780.39" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3625, 3997

2434, 3604

958, 1143

1293, 2416

729, 935

1160, 1278

7,924

107,787

45015+45048

Discharge summary

report+report

Admission Date: [**2120-11-19**] Discharge Date: [**2094-2-8**] Date of Birth: [**2044-8-23**] Sex: F Service: [**Doctor Last Name 1181**] MEDICINE CHIEF COMPLAINT: Shortness of breath and dyspnea. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman who was recently discharged from the [**Hospital1 346**], where she was evaluated for multiple medical problems listed separately in the past medical history, who was transferred from [**Location (un) 2716**] Point because of increasing dyspnea, shortness of breath, and cough for one day. The patient has chronic fevers. She denied a battery of constitutional symptoms including headache, fever, chills, nausea, vomiting, diarrhea, dysuria. PAST MEDICAL HISTORY: 1. Breast cancer metastatic to [**Location (un) 500**] and spleen. 2. Fever of unknown origin likely due to malignancy or adrenal insufficiency. 3. Left lower lobe collapse. 4. Congestive heart failure with diastolic dysfunction and preserved ejection fraction. 5. Atrial fibrillation. 6. Adrenal insufficiency status post bilateral adrenalectomy. 7. Melanoma status post excisional biopsy. 8. Meningioma status post resection. 9. Thyroid nodules of unclear origin. 10. Inappropriate antidiuretic hormone release previously. 11. External hemorrhoids. ALLERGIES: Opiates of unclear reaction as well as to tape, where she develops a rash. MEDICATIONS ON PRESENTATION: 1. Mirtazapine 50 mg in the evening. 2. Tranxene 7.5 mg daily. 3. Lorazepam 0.25 mg daily. 4. Colace 100 mg twice daily. 5. Fludrocortisone 0.1 mg daily. 6. Hydrocortisone 30 mg in the morning and 20 mg in the evening. 7. Pantoprazole 40 mg daily. 8. Arimidex 4 mg daily. 9. Metoprolol 62.5 mg daily. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs: Temperature 98.4, heart rate 101 and irregular, blood pressure of 164/67, and oxygen saturation is 89% on room air, and 98% on 4 liters nasal cannula. General: This is a chronically ill appearing elderly-pale woman, who did not cooperate with the entire examination. HEENT: Normocephalic. There is a well-healed scar from her meningeal resection, she has anicteric sclerae and pale conjunctivae. Pupils are equal, round, and reactive to light. Extraocular movements are intact without nystagmus. The throat was clear. Neck: Supple, thyroid not palpable, the jugular veins are flat. There is no carotid bruit. Nodes: There is no cervical, supraclavicular, axillary, or inguinal adenopathy. Lungs: She had poor effort, decreased excursion, and decreased breath sounds at the based. She had slight wheezing and crackles diffusely. Heart: Irregular, tachycardic, normal S1, S2, no extra sounds. Abdomen: She had normal bowel sounds, soft, nontender, and nondistended. Spleen tip was palpable. The liver was not palpable. Extremities: The patient had +2 lower extremity edema to her mid calf. Vascular: The radial, carotid, and dorsalis pedis pulses were +2 bilaterally. LABORATORY EVALUATION ON PRESENTATION: White blood cell count 47.4, hematocrit 26.0, platelets 209. Chemistry panel was normal. Electrocardiogram revealed multifocal atrial tachycardia at 95 beats per minute, there was no interval change from a previous electrocardiograms. HOSPITAL COURSE: 1. Cardiac: Over the course of the patient's long hospital stay, her dose of metoprolol was sequentially increased from 62.5 mg twice daily to ultimately 75 mg every eight hours for rate control. In consultation with the Cardiology service, the patient was also given an ACE inhibitor. She required periodic diuresis with furosemide, approximately every four days she received furosemide for volume overload. Her heart rate and blood pressure were well controlled on this regimen. Patient underwent repeat surface echocardiography which revealed increased pulmonary hypertension, unchanged ejection fraction. 2. Endocrine: The patient's requirement for hydrocortisone replacement fluctuated during the course of the hospital stay in consultation with the Endocrine service, an attempt was made to lower her hydrocortisone replacement, however, her white blood cell count climbed to over 70 when decreasing the dose of Hydrocortisone to 25 mg every 12 hours. She ultimately required several stress doses up to 100 mg every eight hours. Her fingersticks were always within the normal range despite several conventional serum glucose values below 40, this was attributed to pseudohypoglycemia caused by high white blood cell count. The patient underwent ultrasonography of the thyroid gland, which revealed nodules unchanged from previous evaluation. Given the multiple comorbidities of this patient, the Endocrine service did not recommend further evaluation at this time. 3. Psychiatric: The patient had several episodes of confusion, paranoid delusions, and visual hallucinations. In consultation with the Psychiatric Service, she was given a trial of Risperidone, however, the patient was overly sedated on this medication, and was eventually withdrawn. The patient underwent further computer tomography of the head revealing no new mass lesions during two or three episodes of unresponsiveness. 4. Hematology: As reviewed in previous summary, the patient is now transfusion dependent. He received a transfusion of [**12-12**] pack units approximately every 3-4 days while in the hospital to maintain a hematocrit of approximately 38%. She also required periodic diuresis with blood transfusions, no fevers or adverse reactions occurred during transfusion. 5. Oncology: As reviewed in previous summaries, the patient underwent [**Month/Day (2) 500**] marrow biopsy on her last admission. Her cytogenetic evaluation revealed possible early myelodysplastic syndrome or AML given that there were two cells bearing the lesion that .................... chromosome. The Oncology service was consulted, and they deemed that the patient does not have either myelodysplastic syndrome or AML. The patient underwent splenic biopsy in the Interventional Radiology suite twice. The first time the pathology specimen revealed collection of megakaryocytes, though was not diagnostic. The second time, a large amount of necrotic debris, macrophages was recovered as well as neutrophils. This was deemed to be consistent with infection. 6. Infectious Disease: Patient's fevers over the first half of her hospital course abated, however, she did have persistent white blood cell elevation attributed to malignancy and adrenal insufficiency. Her large left pleural effusion as well as her cerebrospinal fluids were sampled, neither which shown to have an infection. However, on [**2120-12-17**], the patient became hypotensive. Urinalysis revealed Enterococcal urinary tract infection. She was transferred to the Intensive Care Unit for sepsis. She was placed on Vancomycin intravenously. After two days, her blood pressure stabilized, and she was returned to the General Medical Floor. The remainder of this hospital summary will be dictated separately. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern4) 96234**] MEDQUIST36 D: [**2120-12-19**] 11:04 T: [**2120-12-19**] 11:03 JOB#: [**Job Number **] Admission Date: [**2120-11-19**] Discharge Date: [**2120-12-21**] Date of Birth: [**2044-8-23**] Sex: F Service: [**Doctor Last Name **] ADDENDUM: The admission for this Discharge Summary was [**2120-11-19**]. The first portion of this summary was transcribed on [**2120-12-19**]. Please insert the following paragraph at the very end of the main text of the Discharge Summary: The patient was transferred to the medical floor (as stated above). While her blood pressure had increased to above 100 systolic, she remained largely unresponsive. Her family (in consultation with Dr. [**Last Name (STitle) **] decided that they wished to pursue comfort measures only. All medications except benzodiazepines and opiates were withdrawn. The patient was made as comfortable as possible by titrating lorazepam and hydromorphone. On [**2120-12-21**], at 2:30 a.m., the patient expired. Her sons [**Name2 (NI) 3708**] and [**Name (NI) **]) were present. Dr. [**Last Name (STitle) **] was notified as well. DISCHARGE DIAGNOSIS: Enterococcal sepsis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2120-12-21**] 03:03 T: [**2120-12-21**] 03:02 RP: [**2120-12-23**] kbh JOB#: [**Job Number 96233**]

[ "198.5", "511.9", "599.0", "198.3", "038.8", "255.4", "428.30", "427.31", "197.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "34.91", "41.32", "03.31" ]

icd9pcs

[ [ [] ] ]

8350, 8665

3253, 8328

187, 221

250, 730

752, 3236

26,774

142,618

51200

Discharge summary

report

Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-15**] Date of Birth: [**2059-10-2**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 3984**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Intubation Central line placement History of Present Illness: 82M PMH CAD, PAD, RAS, CHF (EF 20%), recently admitted [**Date range (3) 106247**] with new diagnosis metastatic SCLC s/p radiation x 4 sessions, Cycle 1 Carboplatin and Etoposide, Pleurx catheter placement now p/w septic shock. Patient transferred from [**Hospital **] Rehab the day of admission with increased work of breathing and respiratory distress. . In the ED, T: 105.0 BP: 85/50 HR: 140 (atrial fibrillation) RR: 16 SaO2: 100% NRB. Patient in respiratory distress. - Chest x-ray showed multifocal PNA - Difficult intubation - Vancomycin/zosyn/azithromycin administered - Dexamethasone 10 mg IV x 1 - 18g x 2, 22g PIV - no central line placed for thrombocytopenia - NS x 6 L - Peripheral neosynephrine/levophed - Platelets 2 units Past Medical History: - Small cell lung cancer, recently diagnosed [**4-/2142**] s/p Cycle 1 Carboplatin and Etoposide and radiation therapy x 4 sessions - Hypertension - Hyperlipidemia - Coronary artery disease with occlusion of RCA, LCx, and noncritical disease of the LAD - Hypertensive/ischemic cardiomyopathy with ejection fraction of 15%-20% in [**1-/2141**] - Peripheral vascular arterial disease status post an abdominal aortic aneurysm with aortobifemoral bypass with acute occlusion in the right common RCA status post PTCA initially by Dr. [**Last Name (STitle) **] and status post right PTCA by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], good result - Status post right total hip arthroplasty - Status post right carotid endarterectomy - Status post right total hip arthroplasty - Status post cholecystectomy as noted - Chronic renal failure (baseline creatinine 1.4-1.7) - Status post cataract surgery Social History: Transferred from [**Hospital **] Rehab. Married. History of EtOH and tobacco abuse per records. Family History: Non-contributory. Physical Exam: VS: T: 101.7 HR: 121 BP: 107/60 RR: 34 SaO2: 89% on PS 20/10 100%FiO2 GEN: Respiratory distress HEENT: PERRLA, ETT in place CV: Tachycardic, regular, nl s1, s2, no m/r/g PULM: Coarse breath sounds anteriorly ABD: Soft, NT, ND, + BS, no HSM EXT: Mottled, Dopplerable pulses NEURO: Sedated, non-specific movements, does not follow commands Pertinent Results: [**2142-5-15**] 04:30PM WBC-0.1*# RBC-3.31* HGB-10.0* HCT-28.7* MCV-87 MCH-30.3 MCHC-35.0 RDW-13.7 [**2142-5-15**] 04:30PM GRAN CT-20* [**2142-5-15**] 04:30PM PLT COUNT-12*# [**2142-5-15**] 04:30PM PT-14.4* PTT-31.9 INR(PT)-1.3* [**2142-5-15**] 04:30PM GLUCOSE-127* UREA N-51* CREAT-2.5*# SODIUM-141 POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-15* ANION GAP-19 [**2142-5-15**] 04:30PM ALT(SGPT)-37 AST(SGOT)-47* CK(CPK)-210* ALK PHOS-154* TOT BILI-1.3 [**2142-5-15**] 04:30PM CALCIUM-7.8* PHOSPHATE-2.5* MAGNESIUM-1.8 URIC ACID-3.6 [**2142-5-15**] 04:30PM CORTISOL-121.8* [**2142-5-15**] 04:30PM cTropnT-0.12* [**2142-5-15**] 04:30PM CK-MB-5 [**2142-5-15**] 04:45PM LACTATE-3.0* [**2142-5-15**] 09:08PM WBC-0.2*# RBC-2.75* HGB-7.9* HCT-25.3* MCV-92 MCH-28.9 MCHC-31.4# RDW-13.6 [**2142-5-15**] 10:04PM GLUCOSE-126* UREA N-43* CREAT-2.4* SODIUM-141 POTASSIUM-5.5* CHLORIDE-119* [**2142-5-15**] 10:04PM PHOSPHATE-4.4# MAGNESIUM-1.6 [**2142-5-15**] 10:16PM LACTATE-3.5* [**2142-5-15**] 10:16PM TYPE-ART TEMP-36.1 PO2-65* PCO2-64* PH-6.93* TOTAL CO2-15* BASE XS--21 . CHEST (PORTABLE AP) [**2142-5-15**] 4:12 PM IMPRESSION: 1. New airspace opacity involving the right lower lobe concerning for pneumonia. 2. Interval decrease in size of left-sided pleural effusion with likely improved aeration left lung with left pleural drainage catheter. Underlying large left hilar mass partially visualized and better evaluated on prior cross- sectional imaging. . CHEST (PORTABLE AP) [**2142-5-15**] 5:16 PM IMPRESSION: Interval placement of ET tube and NG tube. Multiple air-space opacities within the right lung indicating multifocal pneumonia. Brief Hospital Course: Mr. [**Known lastname **] presented to the ED with respiratory distress and hypotension. He was intubated soon after presentation. Laboratories were significant for neutropenia with ANC 20, thrombocytopenia to 12, bicarbonate 15, and acute on chronic renal failure with creatinine 2.5. Chest x-ray showed multifocal pneumonia. He was given doses of vancomycin, Zosyn, and azithromycin. He was given dexamethasone 10 mg IV. He was given six liters normal saline without blood pressure response and started on peripheral Levophed and Neosynephrine. He was admitted to the MICU 20:30 on maximum doses of Levophed and Neosynephrine. A right femoral central line was placed and Vasopressin was added, in addition to four liters of normal saline without blood pressure response. Arterial line was placed and ABG at 22:16 on the respirator 6.93/64/65. Persistent and progressive refractory hypotension continued, followed by further clinical decline, and the patient expired 22:43. The family was notified and declined autopsy. Medications on Admission: Latanoprost 0.005 % 1 drop OD QHS Lipitor 40 mg DAILY Senna 8.6 mg [**Hospital1 **]:PRN constipation Aspirin 325 mg DAILY Allopurinol 300 mg DAILY Tylenol 325-650 mg Q6H:PRN pain Megestrol 400 mg DAILY Metoprolol 25 mg [**Hospital1 **] Colace 100 mg TID Bisacodyl 10 mg DAILY:PRN constipation Albuterol 90 mcg INH Ipratropium Bromide 0.02 % INH Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure Septic shock Small cell lung cancer Discharge Condition: Expired Discharge Instructions: x Followup Instructions: x [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "038.9", "518.81", "427.31", "995.92", "197.2", "162.9", "428.0", "584.9", "276.2", "486", "425.4", "284.1", "785.52", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "96.04", "00.17", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

5720, 5729

4264, 5295

306, 341

5828, 5837

2578, 4241

5887, 6017

2186, 2205

5691, 5697

5750, 5807

5321, 5668

5861, 5864

2220, 2559

247, 268

369, 1110

1132, 2055

2071, 2170

15,218

159,946

28225

Discharge summary

report

Admission Date: [**2126-10-31**] Discharge Date: [**2126-11-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: Chest pain transfer from OSH for elective cath of known CAD Major Surgical or Invasive Procedure: Cardiac Catheterization and PCI History of Present Illness: HPI: 83m with htn, dm2, cad, chf, cva, gib is transferred from [**Hospital3 17921**] Center in [**Location (un) 5450**], NH for consideration of difficult catheterization. He presented to CMC on [**2126-10-22**] after 2-3 days of increasing weakness and progessive rest angina. His angina first began in [**4-/2126**] when he had an NSTEMI. Following this, he noted intermittent mild chest pain, almost always at rest, that generally went away on its own and only rarely required nitroglycerin. He would have this once every few weeks. 2 days before his CMC admission, he began to have his typical anginal pain at rest that required ntg to relieve it occuring 6-7 times per day; just before going to the hospital, he began to notice that the ntg was becoming less effective. When he got to CMC, an ECG showed lateral ST-depressions and a Tn of 0.45, and he was diagnosed with an NSTEMI; a CXR showed pulmomary edema. He was started on asa, clopidogrel, beta-blocker, and a heparin drip. During this process, he became acutely dyspneic and was felt to be in acute pulmonary edema. He was transferred to the ICU, never intubated, and managed medically with improvement in sx and oxygen saturations; at this point he also declared his desire to be DNR/DNI. Digoxin was begun for transient episodes of atrial fibrillation. His medical management of NSTEMI continued, and an echo showed an ef of 35-40%, mod-severe ao stenosis, MR. [**First Name (Titles) **] [**Last Name (Titles) **] was obtained who felt that based on his [**4-/2126**] catheterization, he'd require CABG, which the patient declined. His heparin was stopped on [**10-28**] as he was no longer in pain and had an unexplained hct drop, which subsequently stabilized with no source found. On [**10-31**], he was ambulating with PT without dyspnea or chest pain and was transferred to [**Hospital1 18**] for consideration of intervention. . Cardiac cath was performed on [**11-1**] that revealed a known 95% calcified stenosis near the origin of large D1 that underwent POBA. The proximal LCX lesion from [**4-/2126**] progressed to 90% stenosis and underwent PCI with BMS resulting in a 10% residual stenosis. While undergoing intervention, patient's blood pressure dropped into the 50's systolic everytime the balloon was inflated. Past Medical History: PMH: -HTN -DM2: Dx [**2121**], on oral meds, no retinopathy, neuropathy, nephropathy he knows of -Hypercholesterolemia -CVA [**2101**] and [**2113**] -CAD: Cath in [**4-/2126**] with severe 3VD, NSTEMI in [**4-/2126**] and [**10/2126**] -CHF: EF 35-40% -Afib: New at prior admission -Aortic stenosis -Mitral regurg -Tricuspid regurg -Pulmonary HTN -GIB [**4-/2126**], ? from PUD per pt -Rectal cancer s/p resection and xrt [**2105**] -Glaucoma -Depression . PSH: -Colon resection with colostomy -L TKR -CCY Social History: SocHx: A former federal judge who grew up in this area, he currently is retired and lives with his wife. [**Name (NI) **] is fairly indepedent in ADL's, though has had some difficulty dressing himself due to his CVA. He never smoked but does have an exposure hx from family members. [**Name (NI) **] used to drink a moderate amount but none in two years. Family History: FHx: Father died of emphysema. Mother died of old age in 90's. Brother died of prostate cancer in his 60's. Physical Exam: PE: t 98.9, bp 103/57, hr 84, rr 18, spo2 97%ra gen- pleasant, chronically-ill appearing, fair function, non-tox, nad heent- anicteric, op clear with mmm neck- thick, difficult to assess jvd, no thyromegaly cv- rrr, s1s2, [**3-18**] harsh rusb systol murmur pul- moves air well, minimal rales bibasilar abd- soft, nt, nd, ostomy in place and empty, scars in ruq, no hsm back- no cva/vert tenderness, no sacral edema extrm- no cyanosis/edema, warm/dry nails- minimal clubbing, no pitting/color changes/indentations neuro- a&ox3, no focal cn deficits, decr str in rue and rle Pertinent Results: Cardiac cath report [**2126-11-1**] PTCA COMMENTS: Following review of the diagnostic angiograms, the LAD and circumflex were identified as PCI targets. A repeat left coronary angiogram confirmed the findings from the prior diagnostic angiography. We planned to treat the LAD lesion followed by the LCX stenosis using an XBLAD 3.5 guide and CPTXS wire. Due to a history of bleeding with heparin, we chose to use Angiomax prophylactically. The guide support was excellent. The LAD lesion was crossed with minor difficulty using the CPTXS wire and positioned in the distal LAD. The stenosis was dilated with a 2.5mm and a 3.0mm balloon with very good angioplasty results. Due to the heavy calcium burden and hypotension with each inflation (SBP 60-70mmHg), we chose not to deploy a stent at this site. Our attention was next directed to the circumflex which proved to be somewhat more tolerant to balloon inflation with less hypotension. The lesion was predilated with a 2.5mm and 3.0mm balloon and then stented with a 3.0x12mm Driver stent deployed at 18atm with excellent results. The mid portion of the stent was then postdilated with a 3.0mm noncompliant balloon with excellent final results. No residual stenosis. Final angiography of the left coronary artery revealed no dissection at the PCI sites and normal (TIMI 3) flow. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 0 minutes. Arterial time = 0 hour 50 minutes. Fluoro time = 14.6 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 120 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: ANGIOMAX IV Cardiac Cath Supplies Used: .014 [**Company **], CHOICE PT XS, 300CM 2.5 GUIDANT, VOYAGER 12 3.0 GUIDANT, VOYAGER 12 3.0 [**Company **], NC RANGER, 9MM 7F CORDIS, XBLAD 3.5 200CC MALLINCRODT, OPTIRAY 200CC 3.0 [**Company **], DRIVER, 12 - ALLEGIANCE, CUSTOM STERILE PACK - GUIDANT, PRIORITY PACK 20/30 COMMENTS: Successful PCI of the LAD and circumflex as described in the PTCA portion of this report. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PCI of the mid LAD and proximal circumflex with balloon angioplasty and bare metal stenting, respectively. . . [**2126-11-1**] 06:15AM BLOOD WBC-7.4 RBC-2.87* Hgb-8.9* Hct-26.6* MCV-93 MCH-30.9 MCHC-33.4 RDW-17.4* Plt Ct-349 [**2126-11-4**] 06:33AM BLOOD WBC-7.3 RBC-3.62* Hgb-10.7* Hct-33.6* MCV-93 MCH-29.7 MCHC-31.9 RDW-18.1* Plt Ct-467* . [**2126-11-1**] 06:15AM BLOOD Glucose-100 UreaN-20 Creat-0.9 Na-145 K-4.5 Cl-108 HCO3-30 AnGap-12 [**2126-11-4**] 06:33AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-141 K-3.8 Cl-106 HCO3-27 AnGap-12 . [**2126-11-2**] 05:27AM BLOOD CK(CPK)-59 [**2126-11-2**] 05:27AM BLOOD CK-MB-4 cTropnT-0.74* [**2126-11-3**] 05:50AM BLOOD CK(CPK)-46 [**2126-11-3**] 05:50AM BLOOD CK-MB-NotDone cTropnT-0.63* . [**2126-11-1**] 06:15AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.4 Iron-57 [**2126-11-1**] 06:15AM BLOOD calTIBC-255* VitB12-705 Folate-19.0 Ferritn-82 TRF-196* . [**2126-11-2**] 05:27AM BLOOD Digoxin-1.1 Brief Hospital Course: 83m with htn, dm2, hyperlipidemia, cad, chf who CMC admitted on [**10-22**] for an NSTEMI with a course complicated by acute pulmonary edema, afib, and hypotension and who was transferred to [**Hospital1 18**] for cardiac intervention. . #CAD -- Mr. [**Known lastname 25443**] arrived symptom free, and overnight was maintained on a sound medical regimen, including aspirin, clopidogrel, atorvastatin, and metoprolol. He remained symptom free over the first night. The next morning he went to cardiac cath where he was noted to have 95% LAD and 90% LCX lesions. He received a cypher stent to the LCX lesion and balloon angiplasty to the LAD lesion; this decison was primarily made based on hypotension (down to the 60's systolic) that occured each time the balloon was inflated. He was transferred to the CCU post-intervention where he was monitored for 24 hours and transfused 2units of RBCs for a hct of 26.6 (had been slowly trending down at CMC). After the procedure he noted feeling much better, with more energy, and this persisted throughout the remainder of the admission. He continued to feel well and ambulated with PT without lightheadedness, pain, or dyspnea. . #CHF -- Throughout the admission, he appeared euvolemic to minimally hypovolemic. His daily weights and ins/outs were followed. He was kept on a two gram sodium diet. Towards the end of his course he received around 750cc NS it it was felt he dehydrated with good increase in his urine output. His o2 sats were in the mid to high 90's on room air throughout the admission. He was maintained on digoxin with normal levels. . #Atrial fibrillation -- He remained in sinus rhythm for the entire admission. He was maintained on metoprolol and digoxin. Given his prior GIB and the requisite post-PCI anticoagulation, it was decided not to start warfarin. . #History of GI bleed -- No evidence of bleeding while at CMC or at [**Hospital1 18**]. His hct was stable, and there was neither melena nor hematochezia in his ostomy bag. He is discharged on pantoprazole for prophylaxis. . #Anemia -- Mildly macrocytic, it was felt likely related to chronic disease. This was borne out by anemia studies showing anemia of inflammation and normal b12 and folate. . #DM2 -- He was maintained on glyburide and RISS with a diabetic diet. . #Code -- DNR/DNI, confirmed by patient. . #Disposition -- He is being sent to rehab for help with general deconditioning. Medications on Admission: -Clopidogrel 75mg daily -ASA 81mg daily -Lovastatin 60mg daily -Ezetimibe 10mg daily -Digoxin 0.25mg daily -Pantoprazole 40mg [**Hospital1 **] -Wellbutrin XL 150mg daily -Venlafaxine SR 150mg daily -Buspirone 60mg daily -Tamsulosin 0.8mg daily -Vit D 600mg daily -Xalatan 1% daily -Glyburide 1.5mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO HS (at bedtime). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Glyburide 1.25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Insulin Regular Human 100 unit/mL Solution Sig: Sliding scale units Injection four times a day: Standard sliding scale. 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 15. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Buspirone 15 mg Tablet Sig: 2am and 1pm Tablets PO twice a day: 30mg in AM; 15mg in PM. Discharge Disposition: Extended Care Facility: catholic [**Hospital **] medical center Discharge Diagnosis: Coronary artery disease Secondary: -HTN -DM2: Dx [**2121**], on oral meds, no retinopathy, neuropathy, nephropathy he knows of -Hypercholesterolemia -CVA [**2101**] and [**2113**] -CAD: Cath in [**4-/2126**] with severe 3VD, NSTEMI in [**4-/2126**] and [**10/2126**] -CHF: EF 35-40% -Afib: New at prior admission -Aortic stenosis -Mitral regurg -Tricuspid regurg -Pulmonary HTN -GIB [**4-/2126**], ? from PUD per pt -Rectal cancer s/p resection and xrt [**2105**] -Glaucoma -Depression Discharge Condition: Good, with improved symptoms Discharge Instructions: You underwent an elective cardiac catheterization for severe coronary artery disease. You received a stent to your left circumflex artery and balloon angioplasty to your left anterior descending artery. Because of this intervention and your heart condition, you will need to be diligent about taking your prescribed medications and attending appropriate follow up care. You should also not do any heavy lifting for a couple weeks to allow your cath site and heart to heal. You can expect some bruising around your cath site, but if your cath site becomes painful or begins to ooze blood, please call your cardiologist. You should also call your doctor or come directly to the ER if you experience CP, SOB, diaphoresis or lightheadedness. . You have been started on a medication called Plavix (clopidogrel) and must take this medication everyday. Do NOT stop this medication for any reason without first discussing it with your cardiologist. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 13318**], a cardiologist, on Tuesday, [**11-26**] at 2:45; call [**Telephone/Fax (1) **] for questions. . You will be called by Dr.[**Name (NI) 68558**] office for an appointment; if you do not hear from them, call [**Telephone/Fax (1) 68559**].

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icd9cm

[ [ [] ] ]

[ "36.06", "00.66", "00.45", "00.41", "88.56" ]

icd9pcs

[ [ [] ] ]

11793, 11859

7487, 9919

324, 358

12389, 12420

4323, 5667

13414, 13718

3603, 3713

10274, 11770

11880, 12368

9945, 10251

6478, 7464

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3728, 4304

5686, 6461

225, 286

386, 2684

2706, 3215

3231, 3587

7,275

188,260

43652

Discharge summary

report

Admission Date: [**2134-11-1**] Discharge Date: [**2134-11-3**] Date of Birth: [**2078-11-11**] Sex: M Service: MED Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[**First Name3 (LF) 14037**] Chief Complaint: SOB, Altered mental status s/p HD Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: HPI: This is a 56M w/ PMH sig for ESRD on HD, Diastolic CHF, HTN, A-fib s/p ablation [**8-14**] who now p/w progressively increasing SOB since last night. Last HD was [**10-29**] without complications, and pt was in his USOH until last night when he suddenly developed SOB - worse w/ lying down, improved w/ standing. In addition, he experienced assoc NP[**MD Number(3) **], crampy/dull/nonradiating/constant mid-lower back pain, and the sensation that his heart was racing. He states that his palpitations were similar to those he experienced before his ablation procedure but that he never had any assoc SOB in the past. He denies having any recent fevers, chills, sick contacts, URI [**Name2 (NI) 21010**], chest pain, diaphoresis, N/V, leg pain or swelling, travel, or numbness or tingling in his extremities. He states that he has been taking all his prescribed medications religiously without any recent changes to his regimen. He also admits to increased salt in his diet, including chinese food [**4-15**] days PTA. On return to ED from HD pt had delta MS (alert, less oriented, not sure of location or how he got ther). Received ativan 1 mg for agitation. Oxygenation better (97% on 3L nc). Breathing comfortably, no CP, no dyspnea. Remained on nitro gtt but it was not titrated to normotension; SBP remained 200s. Past Medical History: 1. End-stage renal disease secondary to idiopathic glomerulonephritis on hemodialysis [**Month/Day (3) 766**], Wednesday, Friday, status post failed renal transplant x2. 2. Seizure disorder. 3. Hypertension. 4. Hepatitis C virus. 5. Recurrent cellulitis. 6. Peripheral vascular disease with 70% left ileac, 50% right ileac by catheterization [**11-13**]. 7. Hyperparathyroidism status post parathyroidectomy. 8. Diastolic CHF 9. Supraventricular tachycardia/AVNRT status post ablation [**8-14**]. 10. Clean coronary arteries by cardiac catheterization [**6-14**]. 11. Restless leg syndrome. Social History: shares apartment with brother but mostly lives on own tobacco 1ppd no etoh Family History: not obtained Physical Exam: 97.0, 211/118, 73, 16 , 97% 3Lnc Gen intermittent falling asleep to riled up yelling and irrational, AOx1-AOx3 depending on time of evaluation HEENT PERRL, supple neck, no jvd PULM crackles bibasilar with [**Month (only) **] breath sounds at bases CVS RRR No m/r/g, R chest tunnel line pulsatile Ext cachectic, weak, no asterixis Neuro CN2-12 intact, strength 4/5 diffusely, 3+ UE DTRs/ 2+ [**Name2 (NI) **] DTRs, cerebellum intact, gait deferred [**3-15**] confusion, MSE intermittent AOx3 (world spelling backwards, and quarters in $1.75 approp) to AOx1 (no world, no quarters) in matter of moments Pertinent Results: [**2134-11-1**] 10:30AM NEUTS-79.1* LYMPHS-14.2* MONOS-5.8 EOS-0.3 BASOS-0.6 [**2134-11-1**] 10:30AM WBC-10.2# RBC-3.95* HGB-11.5* HCT-34.5* MCV-87 MCH-29.2 MCHC-33.5 RDW-16.6* [**2134-11-1**] 10:30AM cTropnT-0.08* [**2134-11-1**] 10:30AM ALT(SGPT)-21 AST(SGOT)-35 CK(CPK)-49 TOT BILI-0.9 [**2134-11-1**] 10:30AM GLUCOSE-87 UREA N-37* CREAT-7.6*# SODIUM-143 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-30* ANION GAP-20 [**2134-11-1**] 01:00PM TSH-2.5 [**2134-11-1**] 01:00PM GLUCOSE-81 UREA N-38* CREAT-7.7* SODIUM-142 POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-21* [**2134-11-1**] 01:00PM CALCIUM-9.7 PHOSPHATE-5.8* MAGNESIUM-2.0 [**2134-11-1**] 09:35PM CALCIUM-9.3 PHOSPHATE-3.3# MAGNESIUM-1.6 [**2134-11-1**] 09:35PM CK-MB-NotDone cTropnT-0.12* Brief Hospital Course: Pt admitted to MICU for evaluation of HTNive urgency with acute change in mental status after hemodialysis. Pt re-examined in MICU, noted to be intermittently irrational and confrontational to sleepy and unable to answer any previously correctly answered questions appropriately- change within moments. Question of subtle rhythmic leg movement vs restless leg movement. THroughout first hospital night, pt was weaned off of nitroglycerin gtt but refused to take home BP meds, maintained SBP between 140s to 160s. In AM of HD2, pt remained stable in confrontational state, no [**Doctor Last Name 688**]. Seen and examined with PCP and MICU team; PCP states that this has been pts new baseline recently, but that the [**Doctor Last Name 688**] episode is new since last week when he recieved a phone call from pts brother about a similar episode. EEG negative for epileptiform activity, although pt does have increased discharges in right frontal lobe. Pt recieved hemodialysis daily for 3 days (ED, MICU day 1, MICU day 2). Pt with stable vital signs and returning to baseline mental status, tolerating POS, and ambulating without difficulty. Pt discharged for close followup with PCP Dr [**Last Name (STitle) 5762**], likely that pt had presented with a CHF/ HTNive episode from fluid overload requiring HD and a recurrent metabolic encephalopathy from osmotic shifts [**3-15**] hemodialysis. Medications on Admission: Metoprolol XL 150 mg PO QD Calcium Acetate 667 mg PO TID W/MEALS plus [**3-17**] with snacks Lamotrigine 100 mg PO LUNCH, 200 mg QHS Nifedipine CR 90 mg PO QD Pantoprazole 40 mg PO Q24H Levetiracetam 250 mg PO BID Prednisone 2.5 mg PO QD Lisinopril 40 mg PO QD Discharge Medications: Metoprolol XL 150 mg PO QD Calcium Acetate 667 mg PO TID W/MEALS plus [**3-17**] with snacks Lamotrigine 100 mg PO LUNCH, 200 mg QHS Nifedipine CR 90 mg PO QD Pantoprazole 40 mg PO Q24H Levetiracetam 250 mg PO BID Prednisone 2.5 mg PO QD Lisinopril 40 mg PO QD Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Congestive Heart Failure Metabolic encephalopathy Discharge Condition: stable Discharge Instructions: Return to Emergency Department or to your PCP for shortness of breath, chest pain, dizziness or lightheadedness, confusion or any other concerns. Followup Instructions: Follow up with your Primary Care Provider Dr [**Last Name (STitle) 5762**] within one week, call for an appointment. Continue your hemodialysis schedule as usual, defer to Renal team for any changes. Please follow up with your primary neurologist within one week, call for an appointment.

[ "443.9", "428.0", "424.0", "403.91", "070.54", "428.23", "397.0", "345.90" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5881, 5887

3884, 5283

347, 361

6001, 6009

3094, 3861

6203, 6496

2444, 2458

5595, 5858

5908, 5980

5309, 5572

6033, 6180

2473, 3075

274, 309

389, 1721

1743, 2336

2352, 2428

73,055

137,944

45588

Discharge summary

report

Admission Date: [**2185-10-12**] Discharge Date: [**2185-10-26**] Date of Birth: [**2099-11-15**] Sex: F Service: MEDICINE Allergies: Accupril / Heparin Agents Attending:[**First Name3 (LF) 1943**] Chief Complaint: Hip fracture Major Surgical or Invasive Procedure: Left hemiarthroplasty Upper endoscopy (EGD) x2 Central venous catheter placement History of Present Illness: Ms. [**Known lastname 1557**] is an 85 year-old woman with ESRD on HD, PAD s/p RLE stent on Plavix, HTN, DM2 admitted with left femoral neck fracture after mechanical fall on [**2185-10-11**], now POD4 s/p left hip hemiarthroplasty. On the day of mechanical fall, the patient had just returned home from rehab, following a recent admission to the MICU for flash pulmonary edema [**Date range (1) 57958**]/[**2185**]. She denied any lightheadedness, dizziness, headache, visual changes before and after the fall. She was brought to the [**Hospital1 18**] ED, and CT showed signal irregularity in the area of the left femoral neck fracture, concerning for pathologic lesion. She was initially medically optimized and then underwent left hip hemiarthroplasty, and an area of ??????unusual-looking collapsed comminuted fracture?????? was biopsied, pathology results pending. The patient was recovering well following her operation and her diet was advanced, but she had a sensation of food becoming stuck in her chest and small episodes of non-bilious, non-bloody emesis nearly every time she tried to eat. She denies any associated nausea, odynophagia, abdominal pain, or diarrhea. She had been having normal BMs but noted that she had dark red blood per rectum x2. She denies any associated pain, urgency, or diarrhea, and reports the BMs felt normal to her but looked bloody. She feels more fatigued today and has had minimal ambulation due to left hip pain. She denies lightheadedness, dizzinesss, chest pain, or dyspnea. She has had a ~10-lb weight loss over the past 3 months, which she attributes to dialysis and dietary modifications. Her last EGD in [**7-/2183**] showed chronic antral gastritis with intestinal metaplasia and esophageal ring at GEJ with small hiatal hernia. She reports having a colonoscopy at an unknown OSH ~2 years ago, and her last colonoscopy at [**Hospital1 18**] in [**9-/2179**] showed sigmoid diverticulosis. The patient denies any previous hematemesis, hematochezia, or melena. She takes ASA 81mg Daily and Plavix 75mg Daily at home, and denies use of NSAIDs or other anticoagulants at home. She was started on ASA, Plavix, and Heparin 5000 units subcutaneous on admission, and also Coumadin 5mg Daily on [**2185-10-15**] for DVT ppx. Coumadin and Heparin were discontinued when her Hct decreased from 25.3 to 20.6 and she was noted to have supratherapeutic INR 3.8, which peaked to 6.5. Hct rose to 22.5 with 1u PRBC, then 22.9 with another 1u PRBC. ASA and Plavix were following dark red, foul-smelling BMs and continued Hct drop, now at 19.2 despite 4 units PRBC today. In all, the patient received 4units PRBC, 2units FFP, and Vitamin K 5mg x1; 2units PRBC on [**10-17**]; 1units PRBC on [**10-15**]; and 2units PRBC on [**10-13**]. The patient is also complaining of substernal chest pressure, and denies pain or tightness. Past Medical History: - Diabetes mellitus II - on oral hypoglycemics only - Hypertension - Anxiety - Autonomic dysfunction (orthostatic hypotension) - Hyperlipidemia - Obesity - Right distal fibular fracture [**8-7**] - L1 thru L4 compression fractures - Peripheral neuropathy - PAD with stent right leg - ESRD on dialysis -- Dr. [**Last Name (STitle) 1366**] Social History: She lives alone in [**Location (un) 55**]. She quit smoking over 40 years ago (prior 1 ppd for about 10 years). No alcohol or illicit drug use. She is retired. Family History: DM - sister, father, and multiple other family members HTN - multiple family members Father died of MI at 66 Physical Exam: VS: 96.7 183/67 86 20 99% on RA GENERAL: Elderly woman in mild distress, appropriate.. HEENT: Normocephalic, atraumatic. No conjunctival pallor or scleral icterus. HEART: RRR, normal S1/S2. 3/6 systolic murmur at RUSB and [**2-6**] blowing systolic murmur at mitral position. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Prominent abdominal bruit. EXTREMITIES: Left leg shortened and externally rotated, with severe pain on passive and active motion. NEURO: limited due to patient discomfort and bedrest, but grossly non-focal. VS: 97.4 87 170/64 18 96% 2L NC GENERAL: Elderly woman in NAD, denies pain HEENT: nc/at. No scleral icterus. HEART: RRR, normal S1/S2. 3/6 systolic murmur throughout precordium LUNGS: CTAB, mild scattered expiratory wheezes ABDOMEN: Soft/NT/ND, no rebound/guarding. EXTREMITIES: no edema, in pneumoboots Pertinent Results: ADMISSION LABS: [**2185-10-11**] 09:39PM BLOOD WBC-4.9 RBC-2.75* Hgb-9.0* Hct-27.7* MCV-101* MCH-32.8* MCHC-32.6 RDW-16.6* Plt Ct-223 [**2185-10-12**] 10:50AM BLOOD WBC-5.3 RBC-2.68* Hgb-8.9* Hct-27.2* MCV-102* MCH-33.0* MCHC-32.6 RDW-16.7* Plt Ct-216 DC LABS: [**2185-10-26**] 06:20AM BLOOD WBC-7.0 RBC-3.54* Hgb-10.8* Hct-33.4* MCV-94 MCH-30.6 MCHC-32.4 RDW-16.2* Plt Ct-142* HELICOBACTER PYLORI ANTIBODY TEST (Final [**2185-10-24**]): EQUIVOCAL BY EIA EGD [**2185-10-18**]: A 1cm red spot with oozing blood was seen in the second portion of the duodenum. (injection, endoclip) Erythema, congestion and friability in the whole stomach compatible with erosive gastritis Erosions in the antrum and pylorus Ulcers in the antrum Esophagitis in the lower third of the esophagus Otherwise normal EGD to third part of the duodenum EGD [**2185-10-21**]: Ulcers in the lower third of the esophagus Small hiatal hernia Friability, congestion and erythema in the whole stomach compatible with gastritis An active site of bleeding was seen in the duodenal bulb. (endoclip) The area in the proximal second part of the duodenum that had previously been clipped no longer had clips placed. An ulcerated lesion was seen which was not actively bleeding. An area adjacent to it was erythematous but after washing revealed eroded mucosa without evidence of active or recent bleeding. (endoclip) Otherwise normal EGD to third part of the duodenum PENDING: - FEMORAL NECK BONE BIOPSY [**2185-10-14**] Brief Hospital Course: 85 year-old woman was admitted after a fall which resulted in left hip fracture s/p left hemiarthroplasty on [**2185-10-14**]. She was started on warfarin for post-orthopedic surgery anticoagulation. She subsequently developed an acute drop in hematocrit and had melena and was transferred to the ICU. She required multiple PRBC (13 units) and FFP (7 units). EGD performed twice for continuing HCT drop and found severe esophagitis with esophageal, antral, and duodenal ulcers. HCT remained stable after the 2nd EGD on [**2185-10-21**]. The patient's H.pylori antibody test was equivocal, but given the severity of her ulcer disease, it was decided that she may benefit from H.pylori eradication therapy. She was transferred to rehab after 5 days of HCT stable at 33-35. PROBLEM LIST # L hip fracture: Pt was admitted with L hip fracture, concerning for pathologic fracture. She went to OR on [**2185-10-14**] and had L hemiarthroplasty. She was started on coumadin as prophylactic anticoagulation and developed drop in hct with melena (further outlined below). After her GI bleed issue resolved, she began working with physical therapy in house and did well. Pneumoboots were used as her DVT prophylaxis. Her pain was well controlled with around the clock tylenol. She is being discharged to rehab. # Large upper GI bleed: She was started on prophylactic coumadin after her L hemiarthroplasty and developed drop in hct with melena. She was transferred to MICU for monitoring. She underwent EGD that showed gastric ulcer which were injected and endoclipped, and also showed esophagitis. Post EGD, her hct continued to trend down from 28 -> 24 and pt had continued melena. For continued melena and hct drop, she underwent repeat EGD that showed active bleeding site in duodenal bulb which was also clipped. Previous D2 lesion endoclip had fallen off, so it was re-clipped. She still had diffuse gastritis with ulcers in lower 1/3 esophagus. She was transfused 13 units of RBCs in total and her hct nadired at 19. Her hct remained stable after 2nd EGD, and she was transferred out to the floor. She continued to have some dark stools but her hct remained ~33. She was started on empiric treatment for h. pylori with PPI, clarithromycin and amoxicillin on [**2185-10-26**] given her large duodenal ulcers seen on her second EGD. She was also started on sucralfate. Her last 3 hcts were: 35 -> 34.9 -> 33.4 # Demand Ischemia: In the setting of acute anemia and large GI bleed, she developed chest pain with EKG changes. CE trended up MB 2->22; CK 201->301; Troponin 0.02->0.39. Heparin gtt was held in setting of GIB. She had an echo that showed "Hyperdynamic LV systolic function. The apex may be hypokinetic. Mild to moderate mitral regurgitation. Severe pulmonary hypertension." Her chest pain and EKG changes resolved with transfusion. # HTN: After her GI bleed, she was restarted on metoprolol 50 mg [**Hospital1 **] (home dose). Her systolic blood pressure remained stably elevated in 150-160s, with occasional increase to 180s, but patient remained asymptomatic. Her metoprolol were not uptitrated as an inpatient given her recent large GI bleed, but can be uptitrated as an outpatient when she has been stable for longer. # ESRD/HD: renal was consulted on admission given patient's dialysis and she received dialysis throughout her hospitalization. Patient generally tolerated her dialysis well, but did develop one episode of hypotension during dialysis on [**10-25**] with some shortness of breath. Her BP came up on its own and her breathing improved as well. Patient was felt to be volume up from her dry weight, so she received an extra session of dialysis before being discharged to rehab and tolerated it well. Her electrolytes were monitored and repleted as needed. # Peripheral vascular disease/CAD: after she developed her GI bleed, her plavix and aspirin were stopped. Consideration of restarting aspirin should be held until patient has her follow up appointment/EGD with GI and healing of her bleeding ulcers are documented. Patient has a follow up appointment with GI in 2 wks. Atorvastatin was continued. # Diabetes: Her actos were held in house and patient was covered with sliding scale insulin. Her actos were restarted at discharge. # Wheezing: Patient developed some shortness of breath and wheezing during dialysis on [**10-25**]. She was ordered albuterol nebs as needed for her wheezing and shortness of breath but did not require any. She is being discharged on albuterol nebs on as needed bases, but this can be discontinued if her respiratory status remains stable. She has no known diagnosis of asthma or COPD. # Thrombocytopenia: patient developed thrombocytopenia to 60s during her active GI bleed. Unclear if this was due to dilutional effect in the setting of massive pRBC transfusion and likely consumption of platelets during active bleeding. Heparin antibody studies were sent and were positive, so heparin products were discontinued. Her thrombocytopenia resolved before heparin products were stopped. Transitional Issues: [ ] Pathology from L hip fracture still pending [ ] Aspirin and plavix were discontinued in the hospital. Would consider restarting aspirin if GI follow up/repeat EGD shows healed ulcers (pt has GI follow up appt in 2 wks) Medications on Admission: 1. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 7. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 8. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 7. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. clarithromycin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. 12. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 14 days. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/shortness of breath. 14. DVT prophylaxis Sequential Compression Stockings. Apply to both legs. 15. Blood Pressure If systolic blood pressure over 190, [**Name8 (MD) 138**] MD. Please consider uptitrating metoprolol for blood pressure control 16. Outpatient Lab Work Check CBC on [**2185-10-27**], [**2185-10-29**], [**2185-11-1**], during hemodialysis Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] [**Doctor Last Name **] hospital Discharge Diagnosis: PRIMARY DIAGNOSES: - Left hip fracture status post left hemiarthroplasty (hip replacement) - Upper gastrointestinal bleed - Esophageal, gastric, and duodenal ulcers - End stage renal disease on hemodialysis 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 after falling and sustaining a left hip fracture. You underwent hip surgery on [**10-14**]. After the surgery, your red blood cell count began to fall and you had some bleeding from your GI tract. Because of the bleeding, you were transferred to the ICU for stabilization and endoscopy. The endoscopy showed a bleeding duodenal ulcer as well as stomach ulcers and inflammation of the lining. The bleeding stopped and you were transferred back to the floor. On the floor, your blood counts remained stable. You had a small amount of residual bleeding. Your BP was controlled. You maintained your dialysis schedule and discharged to rehab. Please call Dr.[**Name (NI) 2935**] office and schedule a follow up appointment with him when you are done with rehab. Please STOP taking these medications: Aspirin and plavix These NEW medications were started for you: - pantoprazole 40 mg by mouth twice daily to reduce acid - tylenol 1 gram by mouth every 8 hours for pain - sucralfate 1 gram by mouth every 6 hours for your stomach - clarithromycin 250 mg by mouth twice daily for 14 days (first day [**2185-10-26**] --> last day [**2185-11-9**]) - amoxicillin 500 mg by mouth every day for 14 days (first day [**2185-10-26**] --> last day [**2185-11-9**]) - albuterol nebulizer as needed for wheezing and shortness of breath Complete Medication List: Nephrocap 1 mg Capsule: One (1) Cap DAILY metoprolol tartrate 25 mg Tablet: One (1) Tablet 2 times a day venlafaxine 75 mg Capsule: One (1) Capsule Daily atorvastatin 40 mg Tablet: One (1) Tablet Daily pantoprazole 40 mg Tablet: One (1) Tablet every 12 hours acetaminophen 500 mg Tablet: Two (2) Tablet every 8 hours pioglitazone 30 mg Tablet: One (1) Tablet once a day. sevelamer carbonate 800 mg Tablet: One (1) Tablet three times a day. Vitamin C 1,000 mg Tablet: One (1) Tablet once a day. sucralfate 1 gram Tablet: One (1) Tablet 4 times a day clarithromycin 250 mg Tablet: One (1) Tablet every 12 hours for 14 days (first day [**2185-10-26**] -> last day [**2185-11-9**]) amoxicillin 250 mg Capsule: Two (2) Capsule every 24 hours for 14 days (first day [**2185-10-26**] -> last day [**2185-11-9**]) albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization: One (1) Inhalation every 6 hours as needed for wheezing/shortness of breath. Followup Instructions: Please follow-up in 2 weeks at the [**Hospital 9696**] clinic at [**Hospital 61**] Hospital [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Center, [**Location (un) 551**]. Please call [**Telephone/Fax (1) 1228**] for an appointment. F/U with surgical biopsy results while at clinic visit. Please also call Dr.[**Name (NI) 2935**] office and follow up with him when you are done with rehab. You have an appointment with GI doctors [**Last Name (NamePattern4) **]: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2185-11-16**] at 2:00 PM With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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31571

Discharge summary

report

Admission Date: [**2181-9-8**] Discharge Date: [**2181-9-25**] Date of Birth: [**2117-12-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: cardiogenic shock s/p STEMI, cardiac arrest Major Surgical or Invasive Procedure: TandemHeart placement Intubation History of Present Illness: 63yo male transferred from OSH intubated s/p VF/VT arrest. Pt was admitted through the OSH ED accompanied by friend with whom he had been drinking heavily. He was s/p fall and had facial/body lacerations. Pt moving all limbs and alert/responsive on physical exam. Vitals on ED intake: T98.1 HR68 BP130/94 RR20 SatO2 100/RA. He was also c/o severe [**9-21**] chest pain that was described "like my GERD". He was given nitro w/o effect and GI regimen. Pt coded at 0950 went into VF/VT arrest and defibrillated. He became bradycardic and was paced for 2-3min before resuming NSR. Beside TTE showed anterior hypokinesis and large LV thrombus. He was given Heparin 5300u, ASA, ativan, fentanyl, atropine, and amiodarone 150mg bolus. Pt became hypotensive, paced, no defib and started on Dopamine drip. He was intubated w/o complication and airlifted to [**Hospital1 18**] for further management. In flight began cooling with fluids. Labs on transfer: K=3.5, Bun:Cr 17:0.8, WBC =13, Hct=47, Plt=193, Ptt=23, INR=0.9, EtOH=146. LFT, lipase wnl. No ABGs. . Pt admitted directly to cardiac cath lab, intubated, and unsedated. He was femoral cath'd and stent was placed in the proximal LAD. He went into vfib multiple times (>8), underwent CPR, defibrillation. He was started on max pressors: levophed and dopamine. IABP was placed. He was given amiodarone and started on amio drip, bicarb, epinephrine, lidocaine and potassium. OGT was placed. Subclavian line placed. Given Heparin 4000u. Tandem heart placed and pressors were withdrawn with good BP response. Good UO to IV lasix given in lab. Pt was sedated and paralyzed. Begin arctic sun cooling in cath lab. Labs in cath: multiple ABGs showed lactic acidosis likely [**2-13**] lack of perfusion during episodes of vfib. Respiratory acidosis corrected on vent settings VT = 550, RR=20. ABG s/p placement tandem heart showed increase in pO2 52->275. . On the floor pt continued on TandemHeart and Arctic Sun cooling. Hemodynamics monitored. Pt with hypokalemia, hypocalcemia requiring sliding scale repletion. Past Medical History: Anxiety attacks GERD SEIZURES HTN . Social History: Married, wife [**Name (NI) **]. -[**Name2 (NI) 1139**] history: unknown -ETOH: recent heavy use -Illicit drugs: unknown Family History: pt unable to provide Physical Exam: Exam on Admission GENERAL: Caucasian male, intubated and sedated, arctic sun cooling pads in place HEENT: multiple abrasions over face; PERRL NECK: cervical collar CARDIAC: no S1/S2 (TandemHeart), sounds obscured by vent LUNGS: ventilated; upper anterior lungs auscultated only given arctic sun pad; clear to auscultation ABDOMEN: unable to assess given pads EXTREMITIES: R thumb displaced and pale, cool extremities, cap refill 2sec, +L femoral line; +R femoral TandemHeart catheter SKIN: multiple abrasions on face, chest, extremities/hands PULSES: no pulses palpated . Exam on day of Discharge: Temp Max: 99.0 Temp current: 97.8 HR: 75-77 RR: 18-20 BP: 113-118/55-62 O2 Sat: 100% RA 24 hour I= 320 O= 1745 8 hour I= 360 O= Weight: none FS: none Tele: 70's SR, no VEA Gen: A/O x3, appears nervous, conversant, making jokes. HEENT: supple, no JVD CV: RRR, 2/6 systolic murmur at left upper sternal border, no radiation. RESP: CTAB post ABD: soft, pos BS, BM today EXTR: no edema. [**Month (only) **] sensation in plantar aspect of right foot from arch to toes, also in left hand from palm to fingers with some tingling. Right thumb with mild swelling and bruising, good ROM, now has splint. Right groin site without ecchymosis or hematoma. NEURO: Alert, oriented. Using walker to ambulate. Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Skin: rash right lower back almost gone, no open areas. Access: Midline. Tubes: none Pertinent Results: [**2181-9-8**] 03:41PM BLOOD WBC-19.9* RBC-4.98 Hgb-14.9 Hct-43.4 MCV-87 MCH-29.8 MCHC-34.2 RDW-13.7 Plt Ct-224 [**2181-9-8**] 11:12PM BLOOD WBC-21.5* RBC-4.95 Hgb-15.0 Hct-42.6 MCV-86 MCH-30.3 MCHC-35.3* RDW-13.8 Plt Ct-196 [**2181-9-9**] 02:28AM BLOOD WBC-17.5* RBC-4.58* Hgb-13.9* Hct-39.2* MCV-86 MCH-30.4 MCHC-35.6* RDW-13.9 Plt Ct-157 [**2181-9-9**] 06:07AM BLOOD WBC-15.6* RBC-4.33* Hgb-13.0* Hct-36.9* MCV-85 MCH-30.0 MCHC-35.1* RDW-13.9 Plt Ct-135* [**2181-9-9**] 09:53AM BLOOD WBC-17.6* RBC-4.35* Hgb-12.9* Hct-38.4* MCV-88 MCH-29.5 MCHC-33.5 RDW-13.7 Plt Ct-175 [**2181-9-9**] 08:25PM BLOOD WBC-19.2* RBC-3.93* Hgb-11.9* Hct-33.9* MCV-86 MCH-30.2 MCHC-35.1* RDW-14.1 Plt Ct-144* [**2181-9-10**] 12:54AM BLOOD WBC-19.7* RBC-3.83* Hgb-11.5* Hct-33.1* MCV-86 MCH-30.0 MCHC-34.8 RDW-14.0 Plt Ct-119* [**2181-9-10**] 03:55AM BLOOD WBC-18.9* RBC-3.59* Hgb-11.0* Hct-30.8* MCV-86 MCH-30.6 MCHC-35.7* RDW-14.1 Plt Ct-108* [**2181-9-10**] 07:39AM BLOOD WBC-18.3* RBC-3.75* Hgb-11.3* Hct-32.5* MCV-87 MCH-30.2 MCHC-34.8 RDW-14.1 Plt Ct-116* [**2181-9-10**] 07:56PM BLOOD WBC-12.7* RBC-3.47* Hgb-10.1* Hct-30.4* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.8 Plt Ct-104* [**2181-9-11**] 03:58AM BLOOD WBC-12.2* RBC-3.36* Hgb-10.1* Hct-29.0* MCV-86 MCH-29.9 MCHC-34.7 RDW-14.9 Plt Ct-98* [**2181-9-11**] 12:51PM BLOOD WBC-13.6* RBC-3.34* Hgb-10.0* Hct-29.5* MCV-88 MCH-29.9 MCHC-33.9 RDW-14.7 Plt Ct-108* [**2181-9-11**] 08:12PM BLOOD WBC-12.0* RBC-3.17* Hgb-9.5* Hct-27.5* MCV-87 MCH-30.0 MCHC-34.6 RDW-14.7 Plt Ct-111* [**2181-9-12**] 04:12AM BLOOD WBC-13.2* RBC-3.23* Hgb-9.8* Hct-27.9* MCV-87 MCH-30.3 MCHC-35.0 RDW-14.7 Plt Ct-114* . [**2181-9-8**] 03:41PM BLOOD PT-17.1* PTT-150* INR(PT)-1.5* [**2181-9-9**] 02:28AM BLOOD PT-13.6* PTT->150* INR(PT)-1.2* [**2181-9-9**] 09:53AM BLOOD PT-12.7 PTT-85.4* INR(PT)-1.1 [**2181-9-9**] 04:49PM BLOOD PT-13.0 PTT-90.5* INR(PT)-1.1 [**2181-9-10**] 04:23PM BLOOD PT-12.9 PTT-73.1* INR(PT)-1.1 [**2181-9-11**] 03:58AM BLOOD PT-12.3 PTT-31.5 INR(PT)-1.0 [**2181-9-11**] 12:51PM BLOOD PT-12.9 PTT-43.7* INR(PT)-1.1 [**2181-9-11**] 08:12PM BLOOD PT-13.0 PTT-68.3* INR(PT)-1.1 [**2181-9-12**] 04:12AM BLOOD PT-13.2 PTT-67.5* INR(PT)-1.1 . [**2181-9-8**] 03:41PM BLOOD Glucose-259* UreaN-19 Creat-1.1 Na-141 K-4.1 Cl-108 HCO3-17* AnGap-20 [**2181-9-8**] 10:00PM BLOOD Glucose-165* UreaN-17 Creat-1.0 Na-146* K-3.0* Cl-112* HCO3-21* AnGap-16 [**2181-9-9**] 02:28AM BLOOD Glucose-176* UreaN-18 Creat-0.9 Na-138 K-4.0 Cl-110* HCO3-19* AnGap-13 [**2181-9-9**] 06:07AM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-143 K-4.3 Cl-115* HCO3-21* AnGap-11 [**2181-9-9**] 09:53AM BLOOD Glucose-110* UreaN-17 Creat-0.5 Na-146* K-4.3 Cl-114* HCO3-23 AnGap-13 [**2181-9-9**] 01:00PM BLOOD Glucose-176* UreaN-16 Creat-0.8 Na-141 K-4.4 Cl-111* HCO3-24 AnGap-10 [**2181-9-9**] 04:49PM BLOOD Glucose-139* UreaN-17 Creat-0.8 Na-143 K-4.3 Cl-113* HCO3-22 AnGap-12 [**2181-9-10**] 04:23PM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-144 K-4.0 Cl-113* HCO3-26 AnGap-9 [**2181-9-10**] 07:56PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-142 K-4.1 Cl-114* HCO3-22 AnGap-10 [**2181-9-10**] 07:56PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-142 K-4.1 Cl-114* HCO3-22 AnGap-10 [**2181-9-11**] 03:58AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-142 K-3.7 Cl-112* HCO3-24 AnGap-10 [**2181-9-11**] 12:51PM BLOOD Glucose-103* UreaN-21* Creat-1.0 Na-144 K-3.8 Cl-112* HCO3-28 AnGap-8 [**2181-9-12**] 04:12AM BLOOD Glucose-121* UreaN-24* Creat-0.5 Na-148* K-4.1 Cl-114* HCO3-25 AnGap-13 . [**2181-9-8**] 03:41PM BLOOD CK(CPK)-746* [**2181-9-8**] 10:00PM BLOOD ALT-535* AST-755* LD(LDH)-1067* AlkPhos-62 [**2181-9-10**] 12:54AM BLOOD LD(LDH)-1181* [**2181-9-10**] 03:55AM BLOOD ALT-315* AST-377* LD(LDH)-1122* AlkPhos-49 [**2181-9-11**] 03:58AM BLOOD ALT-225* AST-308* LD(LDH)-1093* AlkPhos-45 [**2181-9-12**] 04:12AM BLOOD ALT-164* AST-190* LD(LDH)-893* AlkPhos-35* [**2181-9-8**] 03:41PM BLOOD CK-MB-51* MB Indx-6.8* cTropnT-0.91* [**2181-9-9**] 06:07AM BLOOD CK-MB-495* MB Indx-37.0* cTropnT-3.51* [**2181-9-9**] 09:53AM BLOOD CK-MB-GREATER TH cTropnT-4.65* . [**2181-9-8**] 03:41PM BLOOD Calcium-6.3* Phos-1.7* Mg-1.9 [**2181-9-9**] 02:28AM BLOOD Calcium-7.6* Phos-1.1* Mg-2.8* [**2181-9-9**] 09:53AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.2 Cholest-146 [**2181-9-10**] 07:39AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.8 [**2181-9-12**] 04:12AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.2 . [**2181-9-9**] 09:53AM BLOOD Triglyc-93 HDL-51 CHOL/HD-2.9 LDLcalc-76 . [**2181-9-8**] 11:45AM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5 FiO2-100 pO2-67* pCO2-55* pH-7.13* calTCO2-19* Base XS--11 AADO2-616 REQ O2-97 -ASSIST/CON Intubat-INTUBATED [**2181-9-8**] 12:03PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5 pO2-65* pCO2-47* pH-7.40 calTCO2-30 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2181-9-8**] 12:20PM BLOOD Type-ART Rates-20/ Tidal V-550 PEEP-12 pO2-87 pCO2-46* pH-7.16* calTCO2-17* Base XS--12 Intubat-INTUBATED [**2181-9-8**] 12:42PM BLOOD Type-ART pO2-52* pCO2-58* pH-7.13* calTCO2-20* Base XS--10 [**2181-9-8**] 01:07PM BLOOD Type-ART Rates-20/ Tidal V-550 PEEP-7 FiO2-100 pO2-275* pCO2-43 pH-7.20* calTCO2-18* Base XS--10 AADO2-420 REQ O2-70 -ASSIST/CON Intubat-INTUBATED . [**2181-9-8**] 04:34PM BLOOD Type-ART Temp-34 pO2-274* pCO2-29* pH-7.33* calTCO2-16* Base XS--9 Intubat-INTUBATED Vent-CONTROLLED [**2181-9-8**] 05:46PM BLOOD Type-ART Temp-34 pO2-80* pCO2-32* pH-7.36 calTCO2-19* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [**2181-9-8**] 11:25PM BLOOD Type-ART pO2-113* pCO2-31* pH-7.40 calTCO2-20* Base XS--3 [**2181-9-9**] 01:05AM BLOOD Type-ART Temp-33.8 Rates-24/ Tidal V-500 PEEP-12 FiO2-50 pO2-123* pCO2-28* pH-7.44 calTCO2-20* Base XS--3 Intubat-INTUBATED . [**2181-9-8**] 11:45AM BLOOD Lactate-7.1* [**2181-9-8**] 12:03PM BLOOD Glucose-213* Lactate-6.6* Na-140 K-2.7* Cl-100 [**2181-9-8**] 12:20PM BLOOD Glucose-305* Lactate-8.0* Na-142 K-2.3* Cl-106 [**2181-9-8**] 12:42PM BLOOD Glucose-272* Lactate-7.8* Na-133* K-2.5* Cl-98* [**2181-9-8**] 01:07PM BLOOD K-3.2* [**2181-9-8**] 04:34PM BLOOD Glucose-206* Lactate-7.3* K-3.8 [**2181-9-8**] 05:46PM BLOOD Glucose-182* Lactate-6.2* K-3.2* [**2181-9-8**] 08:29PM BLOOD Lactate-2.1* [**2181-9-8**] 11:25PM BLOOD Glucose-166* Lactate-3.7* K-3.2* . ECG Study Date of [**2181-9-8**] 10:43:50 PM Sinus rhythm followed by ectopic ventricular beats and possible accelerated idioventricular rhythm with retrograde atrial activation. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 0 130 426/464 0 -85 90 . Cardiac Cath Study Date of [**2181-9-8**] COMMENTS: 1. Selective coronary angiography in this right-dominant system demonstrated one-vessel disease. The LAD had a proximal thrombotic occlusion and a 70% stenosis in its middle segment. The RCA and LCX had mild disease. 2. Limited resting hemodynamics revealed an LA pressure of 60 mm Hg and systemic hypotension in the setting of maximal pressor supoport. 3. Emergent successful PTCA/stent of the LAD subtotal occlusion in cardiogenic shock with a MINI VISION Rx 2.5x23mm bare-metal stent (BMS). Final angiography had showed adequate result with improved coronary flow and no angiographically apparent dissecton. An 8Fr 40cc IABP advanced into position via R femoral artery with dual chamber pacing support via L femoral vein. Despite these interventions, patient continued to remain hemodynamically unstable. TandemHeart was prepared and primed per protocols. A left atrial cannula via R femoral vein advanced into position (at 52 cm) and a 17 Fr arterial cannula advanced into position via left femoral artery (at transition). TandemHeart left atrial to femoral artery extracorporeal circuit completed for percutaneous ventricular assist device support with hemodynamics improved but still guarded prognosis after multiple v-fib arrest requiring CPR and shocks (15-20 defibrillations). (see PTCA comments for details). FINAL DIAGNOSIS: 1. One-vessel coronary disease. 2. Cardiogenic shock. 3. Successful PTCA/stenting of the LAD subtotal occlusion with a MINI VISION Rx 2.5x23mm bare-metal stent (BMS). Patient in cardiogenic shock not improved with R 8Fr IABP support and dual chamber pacing. TandemHeart prepared per protocols. A left atrial cannula advanced via R femoral vein (at 52 cm) after successful transseptal puncture completed and a 17 Fr arterial cannula (placed at transition) advanced via L femoral artery access. This completed the TandemHeart left atrial to femoral artery extracorporeal circuit for percutaneous ventricular assist device support. (see PTCA comments for details) 4. ASA indefinitely, clopidogrel 75 mg daily 5. Vasopressin and dopamine vasopressor support 6. Serial ECG and cardiac isoenzymes 7. Echocardiogram in AM 8. Guarded prognosis . THUMB (AP & LATERAL) RIGHT PORT Study Date of [**2181-9-8**] 5:53 PM FINDINGS: No previous images. There is a fracture of the volar aspect of the base of the distal phalanx of the thumb with substantial dorsal dislocation. . FINGER(S),2+VIEWS RIGHT PORT Study Date of [**2181-9-9**] FINDINGS: Frontal and oblique views show relocation of the previous dislocation. A lateral view is suggested to determine whether the lucency on the palmar surface of the distal phalanx seen on the previous examination represents a true fracture. . Portable TTE (Complete) Done [**2181-9-10**] at 11:38:50 AM Conclusions The left atrium and right atrium are normal in cavity size. A catheter is seen crossing the right atrium and entering the mid-left atrium. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the anterior septum, and anterior walls, and distal inferior wall and apex. The remaining segments contract normally (LVEF = 25-30 %). There was minimal/no change in the dysfunctional segments with decrease in tandem heart support level, but the normal segments become more dynamic No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). The leaflets appear to open. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The severity does not change with decrease in tandem heart support. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. CLINICAL IMPLICATIONS: Based on [**2178**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . Cardiac Cath Study Date of [**2181-9-11**] FINAL DIAGNOSIS: 1. Successful removal of tandem heart cannulas with perclose to arterial sites, and manual pressure to venous sites. 2. This patient will receive IV antibiotic therapy. 3. Heparin is to be resumed in 6 hours. . Portable TTE (Complete) Done [**2181-9-20**] at 12:31:12 PM Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed (ejection fraction 40 percent) secondary to extensive apical hypokinesis. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). 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. 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. Compared with the findings of the prior study (images reviewed) of [**2181-9-10**], the left ventricular ejection fraction is increased. . MRA BRAIN W/O CONTRAST Study Date of [**2181-9-23**] 4:38 PM FINDINGS: There is no intracranial hemorrhage or acute infarct. The small low-density areas seen on the CT correspond to multiple tiny CSF spaces in the subcortical and deep white matter of left posterior parietal lobe. Appearances are consistent with Virchow [**Doctor First Name **] spaces. There are multiple small foci of T2 and FLAIR hyperintensities in the subcortical white matter of both cerebral hemispheres in keeping with chric microangiopathic small vessel disease. The diffusion imaging shows no restricted areas to suggest infarction. The ventricle dimensions and sulcal configuration are within normal limits. There is no intracranial mass, mass effect or midline shift. The visualized paranasal sinuses and orbits show no abnormality. MRA: There are no flow-limiting stenosis, vascular occlusions, aneurysms in this non-contrast MRA study. Both ACA, MCA, PCA, AICA and PICA are visualized. The anterior communicating and right posterior communicating arteries are visualized. The left posterior communicating artery is poorly visualized. IMPRESSION: 1. Multiple small CSF spaces in the left posterior parietal lobe suggestive of prominent Virchow [**Doctor First Name **] spaces. Recommend attention on follow up imaging. 2. Multiple subcortical T2 and FLAIR hyperintensities in keeping with chric microangiopathic small vessel disease. 3. No acute infarct or intracranial hemorrhage. . ECG Study Date of [**2181-9-24**] 8:52:34 AM The rhythm is probably sinus but consider also ectopic atrial rhythm. Anterior wall myocardial infarction of indeterminate age but may be acute/recent/in evolution. The QTc interval appears prolonged but is difficult to measure. Since the previous tracing of [**2181-9-23**] there is no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 64 150 100 482/489 -2 61 98 . Brief Hospital Course: Mr. [**Known lastname **] is a 63yo male with GERD, anxiety attacks who was admitted to OSH s/p fall, EtOH binge, and complaints of chest pain. Patient was transferred from OSH intubated and on pressors for VT/VF arrest [**9-8**] am. He was taken directly to the cath lab for stent to proximal LAD, TandemHeart placement, and Arctic Sun cooling protocol for cardiac arrest s/p STEMI and cardiogenic shock. . s/p STEMI: Patient presented to OSH with STEMI and had confirmed elevated cardiac biomarkers. Cardiac history was unknown. S/p BMS placed in prox LAD in cath lab here [**9-8**]. He was started on Heparin gtt, clopidogrel 600mg loading dose, and then 75mg daily. He was cooled per Arctic Sun protocol for neuroprotection. There was some question of possible LV thrombus on TTE at outside hospital, though TTE here on [**9-10**] showed no signs of thrombus. Patient was continued on heparin drip throughout CCU course in setting of akinetic apex and risk for LV thrombus formation; he was transitioned to warfarin. He was bridged appropriately and his INR was therapeutic on discharge. . Cardiogenic shock: Pt s/p large STEMI confirmed anterior hypokinesis and LV thrombus on OSH bedside TTE, LVEF 20%. Pt was airlifted from OSH and taken immediately to cardiac catheterization, BMS placed in prox LAD. He had multiple runs of Vfib at both facilities, s/p CPR, defibrillation and pressor support. Pt placed on TandemHeart in cath lab with improvement of oxygenation and urine output. Patient had been started on dopamine, vasopressin, and levophed in the cath lab; the levophed was quickly weaned off prior to transfer to the CCU. He was continued on pressor support on arrival to the CCU and weaned off vasopressin overnight. He was also started on Arctic Sun protocol s/p arrest. On [**9-11**], Tandemheart catheter was noted to have shifted slightly from left atrium into right atrium with no significant change in oxygenation. Flow rate on percutaneous LVAD was turned down, which patient appeared to tolerate well, so patient was taken to cath lab for removal of Tandemheart. Dopamine was weaned off successfully and his pressures were maintained. For the remainder of his admission, there was no issue with hypotension. He became hypertensive with agitation while he was delirious immediately following extubation. His pressures were stable and were able to tolerate adding metoprolol xl and lisinopril. . Vfib arrest: Pt had multiple runs of Vfib at both outside hospital and here, s/p CPR, defibrillation and pressor support in the cath lab. He was given antiarrhythmic medications including initiation of amiodarone drip in cath lab. He was monitored on telemetry. He was started on cooling per Arctic Sun protocol s/p arrest for neuroprotection. He did not have any further ventricular arrhythmias while in house. . Respiratory Failure: Patient was intubated on transfer from OSH. Likely hypoxemic resp failure given FiO2 100% and low O2 saturation; [**2-13**] volume overload after STEMI and vfib arrest. Pt diuresed significantly after 100mg IV lasix in cath lab. After several days when hemodynamic stability was achieved, he was started on a furosemide drip which improved his oxygenation on the ventilator. He was also found to have an acinetobacter pneumonia with thick sputum and intermittent mucus plugging. Initial attempts at extubation were unsuccessful in the setting of extreme agitation when sedation wore off; patient could not tolerate spontaneous breathing trials either due to anxiety. A trial of precedex was not effective in sedating patient. On [**9-17**], he was extubated successfully after weaned off propofol. He was quickly transitioned from shovel mask to nasal cannula and then to room air. He maintened good oxygenation and did not need any additional supplemental oxygenation while in house. . Altered Mental Status: He was delirious after extubation with significant agitation and dillusions. He was actively hallucinating about various things over the course the week after extubation. He was never violent. He was cognizent of his family. He was given Zyprexa for acute agitation and psychiatry was consulted along with behavioral neurology. He was placed on standing Zyprexa QHS with extra prn doses made available for acute agitation. After approximately 5 days of agitation, he cleared. He was oriented to person, place, date, and to situation. He had good insight into his condition and why he was in the hospital. He also had insight into the fact that he was not mentally at baseline yet. The Zyprexa was discontinued once the delirium and agitation resolved. On discharge he was mentally appropriate. . s/p fall: Likely [**2-13**] EtOH intake and cardiogenic shock in setting of concurrent MI. Head CT could not be done initially because patient was unstable but eventually showed no acute bleed; it did show an "ill-defined hypodensity in the left parieto-occipital region at the border zone of the left MCA and PCA suggestive of subacute to chronic infarct," unchanged from previous MRI from [**2176**] that wife had brought in from an outside hospital. . R Thumb fracture: Likely incurred after fall (pt with facial and chest lacerations). Appears displaced. Ortho was consulted on day of admission and his thumb was reduced with good result on f/u post-reduction films. Thumb was placed in a splint for three weeks, and was recommended followup with orthopedics in 2 months. However once the patient was awake, his thumb dislocation is a chronic problem that happens relatively frequently. . Seizure Disorder: Per wife, patient has temporal lobe epilepsy. He was continued on home levetiracetam 500mg [**Hospital1 **]. . GERD: Pt uses PPI at home, but started on plavix therapy in setting of recent MI. Started on famotidine IV renally dosed . Patient was seen by physical therapy and was discharged to a rehabilitation facility specializing in neurologic rehabilitation. . He was full code for this admission. Medications on Admission: Duloxetine 60mg cap [**Hospital1 **] levetiracetam 500mg [**Hospital1 **] HCTZ 25mg daily Metop succinate 50mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take every day with aspirin for at least one month, do not stop taking unless Dr. [**Last Name (STitle) 171**] says it is OK. 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO DAILY (Daily) as needed for constipation. 7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for Fever. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to rash on right lower back. 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): give with meals. 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: goal INR 2.0-3.0. 16. Outpatient Lab Work please check INR on Thursday [**9-27**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Myocardial infarction Ventricular fibrillation Right thumb dislocation Acitinobacter Pneumonia Acute Systolic Dysfunction, EF now 40% Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital because you had a heart attack and suffered a serious heart arrhthmia called ventricular fibrillation. You required CPR and defibrillation to restart your heart. You were transferred from an outside hospital to [**Hospital1 18**] for management of your condition. You were taken to cardiac catheterization and were resuscitated multiple times for the arrhythmia involving medications, CPR, and defibrillation. You were placed on an external pumping device to keep your blood circulating while your heart was initially very weak called a TandemHeart. Given the severity of your heart attack you were also placed in a hypothermic state to protect your brain and heart in the acute state of your illness. You developed a pneumonia while on the mechanical ventilator which was treated with antibiotics. You were also found to be somewhat delirious for several days, but improved greatly with time. . The following changes were made to your medications: - Start aspirin and Plavix to prevent the stent in your heart from clotting off. It is very important that you take this every day for at least one month and possibly longer. Do not stop taking unless Dr. [**Last Name (STitle) 171**] tells you to. - Decrease the Toprol to 25 mg daily - Start Atorvastatin to prevent blockages in your coronary arteries - Start Lisinopril to lower your blood pressure and help your heart recover from the heart attack. - Stop taking HCTZ - Start taking Thiamine and Folic acid to correct nutritional deficiencies - Start senna to prevent constipation - Start Tylenol for any fevers or pain - Start Calcium with meals as your Calcium level has been low - Start Amiodarone to prevent the atrial fibrillation from returning. - Start Clotrimazole cream to treat the rash on your back - Start Warfarin to prevent blood clots from your atrial fibrillation . Weight yourself every day and call Dr. [**Last Name (STitle) 18542**] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Followup Instructions: Please be sure to keep your followup appointments. . Gastorenterology: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 74235**] MD Address: [**Location (un) **] [**Apartment Address(1) 8537**] [**Location (un) **] [**Numeric Identifier 74236**] Phone: [**Telephone/Fax (1) 74237**] Specialty: GE - Gastroenterology Date/time: Wed [**10-3**] at 2:30pm. Fax: [**Telephone/Fax (1) 74238**] . Department: CARDIAC SERVICES When: WEDNESDAY [**2181-10-24**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD and [**First Name4 (NamePattern1) 751**] [**Last Name (NamePattern1) 16157**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Neurology: [**Last Name (LF) **], [**Name6 (MD) **] P, MD Department:Neurology Division:Behavioral Neurology Unit Operating Unit:[**Hospital1 18**] Office Phone:([**Telephone/Fax (1) 1703**] Office Fax:([**Telephone/Fax (1) 9382**] Patient Location:[**Hospital Ward Name 860**] 253 Date/Time: Thursday [**11-8**] at 2:00pm. . Electrophysiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**11-30**] at 1:20pm Completed by:[**2181-9-26**]

[ "427.5", "293.0", "276.2", "427.1", "997.31", "570", "518.81", "428.0", "300.00", "E849.8", "414.01", "785.51", "816.02", "345.40", "427.31", "E888.9", "346.90", "401.9", "305.01", "410.11", "530.81", "041.7", "428.21" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.62", "97.44", "38.93", "37.68", "36.06", "00.45", "79.04", "37.22", "96.72", "00.40", "99.60", "00.66", "37.61", "88.56", "99.61" ]

icd9pcs

[ [ [] ] ]

25757, 25804

18082, 21950

359, 394

25982, 25982

4167, 12016

28238, 29518

2695, 2717

24257, 25734

25825, 25961

24115, 24234

15002, 18059

26165, 28215

2732, 4148

14705, 14985

276, 321

423, 2480

25997, 26141

2502, 2539

2555, 2678

53,632

129,390

41641+58467

Discharge summary

report+addendum

Admission Date: [**2162-8-25**] Discharge Date: [**2162-8-26**] Date of Birth: [**2100-8-18**] Sex: F Service: NEUROSURGERY Allergies: lisinopril / [**Doctor First Name **] / Mucinex Attending:[**First Name3 (LF) 78**] Chief Complaint: Elective admission for coiling Major Surgical or Invasive Procedure: [**2162-8-25**]: Cerebral angiogram with recoiling of the L ICA/MCA junction aneurysm History of Present Illness: 62F elective admission for coiling of the L ICA/MCA junction Aneurysm. Past Medical History: - HTN - MDD - Insomnia - s/p coiling of L ICA/MCA junction aneurysm [**9-/2161**] Social History: non-contributory Family History: non-contributory Physical Exam: Upon discharge: Nonfocal exam, angio site soft with no hematoma, + pulses Brief Hospital Course: 62F who presented for an elective recoiling of a L ICA/MCA junction aneurysm. The procedure was complicated by difficulty in obtaining IV access for the procedure thus requiring anesthesia to obtain access via a mammary vessel. Post-angio she was admitted to the ICU for observation. She was started on a Heparin drip at 800 units/hr overnight and ASA was restarted. There were no complications and she remained stable. Her Heparin drip was discontinued in the AM. Her foley was removed and she was OOB without complication. She was discharged home on [**8-26**]. Medications on Admission: wellbutrin 150mg daily, clonidine 0.1 mg [**Hospital1 **], amlodipine 5 mg daily, clonazepam 0.5mg 1-2 tabs Qhs Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. CloniDINE 0.1 mg PO BID 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Clonazepam 0.5 mg PO QHS:PRN sleep 6. Acetaminophen 325-650 mg PO Q6H:PRN pain 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Cerebral aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Medications: ?????? Take Aspirin 325mg (enteric coated) 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 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 What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks, you will not need any imaging. Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2162-8-26**] Name: [**Known lastname 2152**],[**Known firstname **] Unit No: [**Numeric Identifier 14308**] Admission Date: [**2162-8-25**] Discharge Date: [**2162-8-26**] Date of Birth: [**2100-8-18**] Sex: F Service: NEUROSURGERY Allergies: lisinopril / [**Doctor First Name 1866**] / Mucinex Attending:[**First Name3 (LF) 40**] Addendum: Patient vomited x1 at discharge, patient insisted on going home, she denies feeling ill and believed it was due to drinking warm gingerale and old pasta. Repeat BP 160/88 and nonfocal. Dr [**First Name (STitle) **] aware. Patient will go home and communicated understanding of when to come back to the ER. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2162-8-26**]

[ "437.3", "787.02", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.72", "88.41" ]

icd9pcs

[ [ [] ] ]

5074, 5215

817, 1384

341, 429

1993, 1993

4165, 5051

686, 704

1547, 1902

1952, 1972

1410, 1524

2144, 3223

3249, 4142

719, 719

271, 303

735, 794

457, 529

2008, 2120

551, 636

652, 670

5,866

122,438

4478

Discharge summary

report

Admission Date: [**2142-11-6**] Discharge Date: [**2142-11-14**] Date of Birth: [**2077-11-16**] Sex: F Service: SURGERY Allergies: Tegaderm Hp Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: s/p right sigmoid resection, primary anastomosis, hemicolectomy mucus fistula, ileostomy Major Surgical or Invasive Procedure: Ileostomy takedown History of Present Illness: Had post-op constipation s/p B/L knee replacement ([**2142-8-6**]). Had perf 2ndary to ischemic distension of cecum. [**2142-8-18**] had sigmoid resection and primary anastomosis, right hemicolectomy, mucous fistula, and ileostomy. Colonoscopy [**10-23**] - mild edema at sigmoid [**Last Name (un) 1236**]. Past Medical History: HYPOTHYROID HYPERCHOLESTEMIA GERD S/P BILATERAL KNEE REPLACEMENT Sjogren's RA Social History: quit tob 19 years ago, no etOH, no drugs Family History: nc Physical Exam: AAOx3 NAD RRR CTAB pos BS, soft NT/ND, wound c/d/i, covered in sterie strips Pertinent Results: [**2142-11-10**] 05:00AM BLOOD WBC-7.7 RBC-3.27* Hgb-9.1* Hct-28.6* MCV-88 MCH-27.7 MCHC-31.7 RDW-16.2* Plt Ct-247 [**2142-11-9**] 02:20AM BLOOD WBC-9.7 RBC-3.01* Hgb-8.7* Hct-26.6* MCV-88 MCH-29.0 MCHC-32.8 RDW-16.7* Plt Ct-214 [**2142-11-8**] 01:40AM BLOOD WBC-11.4* RBC-3.28* Hgb-9.2* Hct-29.0* MCV-89 MCH-28.1 MCHC-31.7 RDW-16.6* Plt Ct-201 [**2142-11-13**] 09:30AM BLOOD Glucose-89 UreaN-6 Creat-0.6 Na-136 K-3.1* Cl-99 HCO3-30 AnGap-10 [**2142-11-10**] 05:00AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 [**2142-11-7**] 04:20AM BLOOD Glucose-113* UreaN-9 Creat-0.8 Na-140 K-3.1* Cl-104 HCO3-27 AnGap-12 [**2142-11-8**] 01:40AM BLOOD CK(CPK)-200* [**2142-11-7**] 03:00PM BLOOD CK(CPK)-234* [**2142-11-8**] 01:40AM BLOOD CK-MB-2 cTropnT-<0.01 [**2142-11-7**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 [**2142-11-13**] 09:30AM BLOOD Calcium-8.6 Phos-2.0* Mg-1.7 [**2142-11-11**] 06:00AM BLOOD Calcium-8.8 Phos-2.4* Mg-1.8 [**2142-11-10**] 05:00AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.5* [**2142-11-9**] 02:20AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.8 [**2142-11-8**] 01:40AM BLOOD Calcium-8.9 Phos-1.8* Mg-2.1 [**2142-11-7**] 04:20AM BLOOD Calcium-9.5 Phos-2.9 Mg-1.7 ABDOMEN (SUPINE & ERECT) [**2142-11-10**] 10:05 PM ABDOMEN (SUPINE & ERECT) Reason: r/o ileus or obstruction. [**Hospital 93**] MEDICAL CONDITION: 64 year old woman s/p ileostomy closure, POD 5, now with nausea. REASON FOR THIS EXAMINATION: r/o ileus or obstruction. ABDOMINAL X-RAY (SUPINE AND LEFT LATERAL DECUBITUS) CLINICAL DETAILS: Day 5 post-ileostomy closure. Evaluate for obstruction. FINDINGS: There are surgical clips along the left lateral abdomen and mid abdomen. There are a number of mildly dilated loops of small bowel noted in mid abdomen which measure up to 4 cm in diameter. No wall thickening. There is air distally within nondistended colon. These appearances are likely to represent post-operative ileus. No evidence of free intra-abdominal air on the lateral decubitus film. Brief Hospital Course: Patient underwent ex lap, LOA, ileostomy and MF takedown on [**2142-11-6**] without complications. She had post op hypotension and decreased urine output for which she was given fluid, her epidural was stopped and she was given a PCA, and she was given some pressors (Neo). HCT was stable. Central line was placed on POD1. She was tx from the PACU top the ICU for further observation. Neo was weaned down in ICU, she had fluid resuscitation, and her electorlytes were repleted as needed. She improved, passed flatus and she had her NGT removed and was tx to the floor on POD4. Her diet was advanced on the floor as tolerated - it she had to be slowed down because of nausea, her pain was well controlled, and she ambulated witht the help of PT and nursing staff. On POD7 foley was d/c'd. On POD8 she is in good condition for d/c to rehab. Medications on Admission: Atenolol Hydouril Tagamet Lipitor Levoxyl Neurontin Salagen Folic acid Percocet prn Calcium Lysine Vit C Mg Tylenol Discharge Medications: 1. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO Q6 (). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Ileostomy - needed to be taken down from previous surgery Discharge Condition: Good Discharge Instructions: If you have fever >101, severe pain, bleeding or discharge from wounds, persistent vomiting, inability to eat, chest pain, shortness of breath, or anything else that causes you concern, please call or return. Followup Instructions: Call Dr. [**Last Name (STitle) **] for an appointment ([**Telephone/Fax (1) 15665**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]

[ "710.2", "998.2", "272.0", "V55.2", "401.9", "276.52", "714.0", "568.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.59", "46.51", "46.73" ]

icd9pcs

[ [ [] ] ]

5010, 5099

3039, 3887

370, 391

5200, 5207

1020, 2322

5464, 5693

904, 908

4053, 4987

2359, 2425

5120, 5179

3913, 4030

5231, 5441

923, 1001

242, 332

2454, 3016

419, 729

751, 830

846, 888

32,278

113,783

32477

Discharge summary

report

Admission Date: [**2152-6-7**] Discharge Date: [**2152-6-23**] Date of Birth: [**2077-8-11**] Sex: M Service: CARDIOTHORACIC Allergies: Dilaudid Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2152-6-7**] Cardiac Catheterization [**2152-6-14**] Mitral Valve Repair(28mm Csgrove Annuloplasty Band) and Four Vessel Coronary Artery Bypass Grafting(Left internal mammary artery to left anterior descending, saphenous vein grafts to diagonal, ramus, and posterior descending artery). History of Present Illness: This is a 74 year old male with a six month history of worsening dyspnea on exertion. Several weeks prior to admission, he admitted to rapid decrease in exercise capacity. For several years, he had used two pillows for sleep. He has no history of chest pain or PND. On [**6-6**], he presented to his cardiologist with the above complaints. Office echocardiogram showed an LVEF of 15-20%. He was subsequently admitted to [**Hospital 6451**] with congestive heart failure. BNP on admission was 1400. He was diuresed with IV Lasix with improvement in his shortness of breath. He was stabilized on medical therapy and transferred to the [**Hospital1 18**] for further evaluation and treatment. Past Medical History: Congestive Heart Failure, Hypertension, Hyperlipidemia, Type II Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency, History of Atrial Fibrillation, GERD, History of Urinary Sludge, Prior Tonsillectomy, Hidradenitis Suppurative s/p Surgery Social History: 15 pack year history of tobacco. Quit smoking over 25 years ago. Admits to 3 ETOH drinks per month. Married, lives with spouse. Family History: Denies premature coronary disease. Physical Exam: PREOP EXAM - Vitals: 137/64, 79, 18, 95% RA General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm, normal s1s2, soft systolic murmur Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2152-6-7**] 10:20AM BLOOD WBC-6.8 RBC-3.99* Hgb-12.5* Hct-36.9* MCV-93 MCH-31.5 MCHC-34.0 RDW-14.6 Plt Ct-264 [**2152-6-7**] 10:20AM BLOOD PT-13.9* PTT-28.4 INR(PT)-1.2* [**2152-6-7**] 10:20AM BLOOD Glucose-147* UreaN-20 Creat-1.3* Na-140 K-3.6 Cl-105 HCO3-23 AnGap-16 [**2152-6-7**] 10:20AM BLOOD ALT-18 AST-19 AlkPhos-84 TotBili-0.9 [**2152-6-7**] 10:20AM BLOOD Albumin-4.3 Cholest-133 [**2152-6-7**] 10:20AM BLOOD %HbA1c-6.2* [**2152-6-7**] 10:20AM BLOOD Triglyc-115 HDL-31 CHOL/HD-4.3 LDLcalc-79 [**2152-6-7**] Cardiac Catheterization 1. Coronary angiography in this right-dominant system revealed three-vessel disease: --the LMCA had no angiographically apparent disease. --the LAD had diffuse 80% stenosis in its mid-portion. D1 was a very large vessel wrapping around the lateral wall, with an ostial 80% stenosis. --the LCX had an 80% proximal stenosis --the RCA was occluded in its mid-portion and fills by right-to-right and left-to-right collaterals. 2. Resting hemodynamics revealed elevated right- and left-sided filling pressures with RVEDP 10 mmHg and LVEDP 26 mmHg. There was moderate pulmonary arterial hypertension with PASP 59 mmHg. The cardiac output was low-normal with CI 2.1 L/min/m2. The PCWP was elevated at 26 mmHg. There was mild systemic arterial systolic hypertension with SBP 145 mmHg. There was no gradient across the aortic valve upon pullback of the angled pigtail catheter from LV to ascending aorta. [**2152-6-8**] Carotid Ultrasound: Bilateral less than 40% carotid stenosis. [**2152-6-8**] Echocardiogram: Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with near-akinesis of the inferior/inferolateral walls. There is moderate-to-severe hypokinesis of the remaining segments (LVEF = 20%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname **] was admitted under cardiology and [**Known lastname 1834**] cardiac catheterization which revealed severe three vessel coronary artery disease with moderate to severe pulmonary hypertension(see result section). Cardiac surgery was consulted and further evaluation was performed. Carotid ultrasound found no significant disease of the internal carotid arteries. Repeat echocardiogram was notable for an LVEF of 20% with mild mitral regurgitation(see result section). Post catheterization, he had a slight decline in renal function and his ACE inhibitor was discontinued. His preoperative creatinine peaked to 1.7. Creatinine just prior to surgery was 1.5. Preoperative course was also notable for bouts of paroxysmal atrial fibrillation/flutter for which he was maintained on intravenous Heparin. On [**6-14**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] coronary artery bypass grafting and a mitral valve repair by Dr. [**Last Name (STitle) **]. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. On postoperative day one, sedation was weaned and he was extubated. However, due to severe agitation and confusion associated with atrial fibrillation and low mixed venous saturations, he was electively reintubated. While intubated and sedated, cardioversion was performed but unsuccessful. He was also given several units of PRBCs. On postoperative day three, he self-extubated. He did not required reintubation but was initially maintained on 100% shovel mask. Despite medical therapy and multiple cardioversions, he continued to experience atrial fibrillation. Given atrial fibrillation, he was eventually started on Amiodarone and Warfarin. He temporarily required a Heparin bridge. Postoperative renal function remained relatively stable. His confusion and agitation gradually improved with use of haldol. On [**2152-6-20**], Mr. [**Known lastname **] was transferred to the step down unit for further recovery. He continued to be gently diuresed towards his preoperative weight. The physical therapy service worked with him daily to increase his strength and mobility. Keflex was started for mild incisional erythema. An ace inhibitor was started given his low preoperative ejection fraction. Mr. [**Known lastname **] continued to make steady progress and was discharged to Baypoint of [**Hospital1 1474**]. Dr. [**Name (NI) 38327**] coumadin clinic will assume management of his coumadin dosing after discharge from rehabilitation. His goal INR is 2.0-2.5. He will also follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (un) **]. Amiodarone will be tapered to 200mg once daily. Medications on Admission: Aspirin 325 qd, Zestril 20 qd, Toprol XL 50 qd, Lasix, KCL, Nexium 40 qd, Plavix Load of 600mg Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 5 days. 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 1 mg Tablet Sig: Adjust for goal INR 2.0-2.5 Tablets PO DAILY (Daily): Adjust dose for goal INR of 2.0-2.5. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 10 days: Take with lasix and stop when/if lasix stopped. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take amiodarone 400mg twice daily for 2 more days. Starting [**2152-6-26**], take 400mg once daily for 7 days and then decrease to 200mg once daily therafter until seen by Dr. [**Last Name (STitle) 7047**]. . 13. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Primary: Coronary Artery Disease, Mitral Regurgitation, Acute on Chronic Systolic Heart Failure - s/p CABG and MV Repair Secondary: Postoperative Atrial Fibrillation, Postoperative Agitation, Hypertension, Hyperlipidemia, Type II Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency 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) You are taking coumadin (a blood thinner) for atrial fibrillation. You goal INR is 2.0-2.5. You coumadin dosing will be managed by Dr. [**Last Name (STitle) 7047**] and you will need an appointment for blood draw (PT/INR) when discharged from rhab for coumadin management. [**Telephone/Fax (1) 8725**] 8) Take amiodarone 400mg twice daily for 2 more days. Starting [**2152-6-26**], take 400mg once daily for 7 days and then (Starting [**7-3**])decrease to 200mg once daily therafter until seen by Dr. [**Last Name (STitle) 7047**]. 9) Take lasix and potassium once daily for 10 days. Monitor electrolytes and replete as needed. Monitor daily weights. Preop weight 150lbs. You may need continued treatment with lasix but will be determined per cardiologist or rehab physician. 10) Take Keflex for 5 days for sternal wound erythema. 11) Monitor renal function (BUN/CREAT)given history of chronic renal insufficieny and currently on Ace and lasix. Preop Creat 1.3. [**6-23**] Creat 1.4. 12) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in [**5-13**] weeks, call [**Telephone/Fax (1) 170**] for appt Dr. [**Last Name (STitle) 7047**] in [**3-12**] weeks, call [**Telephone/Fax (1) 8725**] for appt Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 15369**] in [**3-12**] weeks, call [**Telephone/Fax (1) 6699**] for appt ****Coumadin management with Dr. [**Last Name (STitle) 7047**] via his coumadin clinic. They are aware of patient (contact[**Name (NI) **] [**2152-6-23**]). Please contact his office when discharged from rehab to schedule PT/INR draw and appointment for coumadin management.**** Completed by:[**2152-6-23**]

[ "530.81", "244.9", "293.0", "V15.82", "428.23", "584.9", "705.83", "403.90", "250.00", "414.01", "E878.8", "427.31", "416.8", "427.1", "V58.83", "428.0", "585.9", "V58.61", "424.0", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.15", "35.33", "99.04", "36.13", "39.61", "99.61", "37.23", "96.04", "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

9135, 9194

4550, 7284

294, 585

9539, 9548

2215, 4527

11278, 11908

1748, 1784

7429, 9112

9215, 9518

7310, 7406

9572, 11255

1799, 2196

235, 256

613, 1304

1326, 1587

1603, 1732

24,688

138,825

15117

Discharge summary

report

Admission Date: [**2103-11-9**] Discharge Date: [**2103-11-17**] Date of Birth: [**2048-2-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 21112**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: colonoscopy, capsule endoscopy History of Present Illness: 55m with CAD and ESRD ([**3-15**] fsgs) s/p LRT [**6-/2103**] presented to and OSH ED on [**11-8**] with bloody diarrhea, frequent episodes. His admission here thus far has been significant for two tagged RBC scans, two colonoscopies, EGD, Meckel's scan, and finally a capsule endoscopy, with the final conclusion being that the bleeding source was a number of sites in the jejunum, likely angioectasias that were persistently oozing. He has required frequent transfusions, about 18 to date with his last being the evening prior to transfer ([**11-14**]). Transplant surgery has been consulted for possible operative intervention, though nothing has been planned yet. When seen in the ICU, he said he felt completely fine, had no complaints. He had been up walking his room for most of the day with no lightheadedness, chest pain, or dyspnea. He had no abdominal pain or nausea. His last bowel movement was a few hours prior and was dark with a small amount of red blood. His hct's over the last 14 hours have trended 27 -> 33 -> 30 -> 29.4 without transfusion. . Past Medical History: PMH: -CAD: MI [**2098**], stented x 1 -ESRD [**3-15**] FSGS s/p LRT [**6-/2103**] . PSH: -CCY -Back [**Doctor First Name **] -R knee arthroscopic [**Doctor First Name **] Social History: married, lives with wife, retired for 5y; h/o tobacco, 1ppd x 40y, quit [**3-19**]; rare EtOH, 1 beer/month; denies drug use . Family History: FHx: per OMR, no h/o GI bleed in family, no GI cancers, no renal disease . Physical Exam: PE: t 99.9/99.9, bp 141/55, hr 92, rr 16, spo2 97%ra gen- pleasant, well appearing/functioning male, non-tox, nad heent- anicteric, op clear with mmm cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis/edema, warm/dry nails- no clubbing, no pitting/color changes/indentations neuro- a&ox3, no focal cn/motor deficits . Pertinent Results: [**2103-11-9**] 05:33PM CALCIUM-7.9* MAGNESIUM-1.8 [**2103-11-9**] 05:15AM GLUCOSE-132* UREA N-19 CREAT-1.1 SODIUM-141 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-24 ANION GAP-12 [**2103-11-9**] 05:15AM WBC-3.4* RBC-2.97*# HGB-8.6*# HCT-24.8*# MCV-84# MCH-28.9 MCHC-34.5 RDW-14.3 [**2103-11-9**] 05:15AM PT-10.3* PTT-18.5* INR(PT)-0.9 Brief Hospital Course: A/P: 55m with CAD, ESRD s/p xpl admitted with GIB- capsule endoscopy shows jejunal angioecatasias required multiple transfusions but has been stable since last night. . #GI bleed -- [**3-15**] jejunal AVM's per capsule study, HCT stable during and after capsule study, thus enteroscopy was not done- only indicated if pt actively bleeding; GI and Transplant surgery followed throughout hospital course, a central line was maintained for access; Pt transfused x 1 before discharge home, cleared by transplant surgery. . #CAD -- No active ischemia; held ASA due to bleed; continued atorvastatin throughout hospital stay. . #Renal xpl -- Cr stable throughout hospital course, renal transplant service followed throughout hospital stay; pt was maintained on immunosuppressives. . #Leukopenia -- ANC 1700. Likely [**3-15**] immunosuppressives. Pt remained afebrile throughout hospital course, no indication for ID workup during this admission, renal transplant service aware. . #Code -- full Medications on Admission: -ASA 325 mg qd -CellCept [**Pager number **] mg qam, 1000mg qpm -Bactrim SS qd -Lipitor 10mg qd -Rapamycin 2mg qd inpt -Mycophenolate Mofetil 1000 mg PO QPM -Mycophenolate Mofetil 500 mg PO QAM -Pantoprazole 40 mg IV Q12H -Atorvastatin 10 mg PO DAILY -Sirolimus 2 mg PO DAILY -Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: GIB Discharge Condition: stable Discharge Instructions: Please present to the hospital if you have bloody stool or black tarry stool, dizzyness/headache, chest pain/shortness of breath, fever/chills. Please follow up with your appointments and take your medications as directed. Followup Instructions: You have the following appointments:Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2104-8-11**] 11:00

[ "V45.82", "414.01", "285.8", "403.91", "285.1", "569.85", "412", "V42.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "99.15", "45.13", "99.05", "88.47", "99.04", "38.93", "45.19" ]

icd9pcs

[ [ [] ] ]

4614, 4620

2651, 3640

328, 361

4668, 4677

2290, 2628

4948, 5151

1812, 1889

4009, 4591

4641, 4647

3666, 3986

4701, 4925

1904, 2271

279, 290

389, 1455

1477, 1650

1667, 1796

19,851

113,286

44301

Discharge summary

report

Admission Date: [**2125-8-22**] Discharge Date: [**2125-8-31**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 783**] Chief Complaint: Gm + Bacteremia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 64 yo M with multiple medical problems including hep C, HIV, ESRD on HD who was recently hospitalized for MRSA bacteremia and was evaluated in the ED on [**8-21**]. He presented to HD febrile/tachy, he was dialized and subsequently sent to the ED on [**8-21**] with hallucinations. Blood cultures were drawn. Work-up was negative and he was sent back to [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **], NH on [**8-21**]. Pt called back on [**8-22**] to ED for further eval since for [**1-11**] positive blood cultures with gm + cocci in clusters. Pt with difficult access and indwelling cath/cuffed femoral line for several months. Past Medical History: 1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]. 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) ESRD on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000 5) Congestive heart failure: echocardiogram [**10/2123**] w/ EF 60%. 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) Hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative colonoscopies. 16) Anemia: [**2117**]. Started Epogen. 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-12**]. 22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal valve. Treated with thermal therapy. At that time was also offerred hormonal therapy, but this was deferred. 23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) MRSA- grew out from culture from L anterior chest wound, s/p I+D 25) Peripheral neuropathy: on a narcotics contract 26) Diastolic CHF: [**2-/2125**] TTE: LV cavity is unusually small. Hyperdynamic LV systolic fxn (EF >75%), trivial MR, trivial/physiologic pericardial effusion 27) Thrombosis of dialysis line, on chronic anti-coagulation 28) Emphysema Social History: History of tobacco abuse (quit 20 years ago), alcohol abuse (quit >20 years ago) and heroin and cocaine abuse (quit >20 years ago). Has a fiance who visits him frequently and is involved in his care. Recently lost his home after several hospitalizations and has been in an extended care facility for 5-6 months, but hopes to return home to his fiance. He has not been ambulating for approximately one year. He has a wheelchair and a walker, but reports that he is starting to ambulate slowly with assistance. Family History: Non-contributory. Physical Exam: -VS: 99.0 BP 105/40 HR 104 16 100% on 2LNC -GEN: awake, resting comfortably in bed, answering questions appropriately, eyes closed but opens when told to -HEENT: MMM, OP clear, no teeth upper/lower -CV: Reg Nml S1, S2, no m/r/g LUNGS: CTABL, No crackles or wheezing ABDOMEN: Soft ND/NT +BS EXT: Large left thigh mass encircling anterior left leg which is warm and tender. L PICC with dressing over line no evidence of oozing, L femoral line in place-no oozing, no peripheral edema; R chest area without open wound, no purulent discharge currently NEURO: A/O X3, no focal deficits, strength 4/5 throughout, no tremors. Pertinent Results: . CXR [**8-20**]: IMPRESSION: Diffuse airspace process, new since [**7-25**], and most likely representing pulmonary edema; extensive aspiration pneumonitis is a more remote consideration. . CT HEAD noncontrast [**8-21**]: IMPRESSION: Stable head CT examination demonstrating chronic microvascular ischemic changes as above. . CT ABDOMEN, CHEST, PELVIS W/O CONTRAST [**2125-8-24**] 1:31 PM 1. No evidence of intraperitoneal or retroperitoneal bleeding. 2. Grossly unchanged appearance of large left groin hematoma, which contains layering fluid-fluid levels suggestive of hematocrit effect, likely reflective of recent bleeding. 3. New smaller right groin hematoma. 4. Moderate hiatal hernia. 5. Multiple sub 5-mm noncalcified pulmonary nodules. Followup chest CT recommended in [**6-19**] months' time. . CHEST U.S. RIGHT Study Date of [**2125-8-28**] 3:54 PM Right chest wall collection with apparently artificial tram tracking tubular structure that likely represents foreign body. . SHOULDER [**2-10**] VIEWS NON Study Date of [**2125-8-29**] 5:49 PM There are areas of sclerosis and lucency in the femoral head, probably related to the previously seen osteoarthritic changes. If there is strong clinical suspicion of septic arthritis, joint aspiration may be of use. Brief Hospital Course: #. Mental Status changes: per OMR notes, pt with h/o delirium in setting of infectious process, however, was oriented during MICU stay and upon transfer to the floor. Was intermittently somnolent without clear etiology - all electrolytes, glucose levels, O2 saturations WNL, which was likely related to poor sleep during stay. Continued to be oriented upon return to floor. On day of discharge was alert and oriented, without concern for mental status changes. . # HTN - Blood pressure was initially low in the MICU secondary to acute blood loss. Upon transfer to the floor he was restarted on his home dosing of metoprolol initially poorly controlled upon admit to the floor. Started on metoprolol 25mg po TID in MICU. Now on Metoprolol 100mg po TID, lisinopril 40mg and Norvasc 10mg with much improvement. Was monitored throughout stay and discharged on this regimen. - Discharged on ACE, BB and CCB dosing, monitor. . # Gram + bacteremia- Was called to return to the hospital once return of positive blood culture growing coag (-) staph on [**2125-8-22**]. Being treated with vancomycin on HD protocol since with good effect. Original source of infection remains unclear - HD catheter, thigh hematoma, or right chest wall wound with known foreign body. Additionally there were concerning changes on prior spinal imaging, however pt refused MRI to assess for osteomyelitis. He continually denied tenderness in low back on exam. Infectious disease, renal and transplant surgery were consulted and helped facilitate therapy. TTE to evaluate for endocarditis was inconclusive, however TEE was not persued given it would not change the duration of recommended therapy. Ultimately the chest wall foreign body was removed by transplant surgery. Wound consult was obtained and followed his chest wound throughout his stay. Following this, a new HD catheter was placed by Interventional Radiology as requested by Renal given that he has a history of access problems. Infectious disease recommended 6 weeks of Vancomycin therapy and he was discharged on this medication. - Vanc per HD protocol for 6 weeks per HD protocol, check vanco level at HD . # Right chest wall wound - Discovered on admission with open, nonpurulent drainage. Ultrasound evaluation of the area revealed a foreign body consistent with prior wick or catheter remnant. Transplant surgery was consulted and and attempted to remove the foreign body while inpatient without complication. He was followed by Transplant surgery throughout his stay. He should have dressing changed daily and packed with [**Last Name (un) **] packing strip and covered with dry sterile bandage. . # Right shoulder - Deformed on admit. Unable to raise arm past 7cm off of bed. Likely diagnosis include torn rotator cuff vs. frozen shoulder. Not erythematous, warm or painful with movement. Was considered to be possible site of bursitis/infection. Xray with degenerative OA changes. Given our low suspicion for septic arthritis and exam inconsistent with diagnosis - shoulder tap was not pursued. Instructed to follow-up with PCP for further management. . # Large left thigh hematoma: Prior to admit had L femoral HD cath placed. Upon admit had falling Hct in setting of elevated INR, and was transfused PRBC, FFP and Vitamin K. Surgery was consulted but did not recommend intervention. Repeat CT imaging revealed stable left groin hematoma. Hct was monitored at least once daily and remained stable for the remaining of his inpatient stay. He should have hematocrit checked the day after line changed over wire which would be [**9-4**] (tuesday). . # CHF- echo [**10/2123**] w/ EF 60%, pt does not appear overloaded on exam, no respiratory symptoms. Throughout stay he did not have signs/symptoms consistent with CHF exacerbation. Was restarted on metoprolol with the addition of lisinopril for improved BP control as well as cardioprotection. - Dishcarged on BB, statin, ACE. - ASA held on discharge do to acute bleed, should restart next week. . # HIV- last VL [**11/2124**] <50, CD4 290. Currently on HAART, followed by Dr. [**Last Name (STitle) 1057**]. Confirmed his regimen with Dr. [**Last Name (STitle) 1057**] upon admit and his medication was only adjusted per HD dosing. - Continued current HAART regimen of indinavir, ritonavir, lamivudine . # ESRD- Secondary to DM. On normal tues/thurs/sat HD schedule. Was continued on his HD schedule inpatient and was continued on nephrocaps and sevelamer. - Continue nephrocaps and sevelamer. - Continue current HD schedule Tues/Thurs/Sat - Follow-up with Renal for continued line monitoring . # Diabetes- insulin dependent, last hgb A1c 6.3% in 11/[**2124**]. Was started on an ISS and his home dose of NPH on admit, but did not require NPH. Throughout his stay his fingersticks were well controlled with only rare ISS. Gabapentin was continued for his peripheral neuropathy with a minor decrease in dose given his HD dependent status. - Continue gabapentin, renal dose adjusted - Continue insulin, should follow-up with PCP concerning good control without need for daily NPH while inpatient. . # Anemia- Secondary to acute blood loss. Mr. [**Known lastname 7493**] was dialyzed [**8-23**] and given 2UPRBC. Simultaneously, while his L fem HD line was being accessed, it began oozing. Pt noted to have a large thigh hematoma and initial INR 9.0. He was then transfused an additional 2 UPRBC and 1UFFP with inappropriate response from HCT 18.3-->22.7-->19.5. Thus, he was transferred to the MICU with an additional 1UPRBC transfused. On [**8-24**] his Hct continued to drop to 19 despite 2UPRBC, he was given a dose of Vit K and FFP. Surgery was consulted, recommended serial exams but no surgical intervention. Once he coagulopathy was reversed, he was followed with [**Hospital1 **] Hct for 3 days. He did not require further transfusion. Upon discharge his Hct was stable, and there was no evidence of acute bleed for several days. - Transfused 5u PRBC - INR elevation reversed with Vit K and FFP - Thigh hematoma & Hct stable at discharge . #. Coagulopathy. History of multiple clots in grafts and IVC in past, so is now on chronic coumadin. Upon admit he had a supratherapuetic INR 9.0 that was reversed with VitK and 1unit FFP to 1.5. He was then held at this level awaiting new HD catheter placement. After having a stable Hct of three days duration, a new HD catheter was placed in IR. Prior to discharge he was restarted on anticoagulation with goal INR [**2-10**]. - Continue anticoagulation, goal INR [**2-10**]. . # Access problems - [**Name (NI) **] renal team, pt with extensive h/o access problems, [**Name (NI) 94992**] occluded, [**Name (NI) 94993**] thrombosed, IVC occlusion, R-AVgraft failed. Thus, was consulted to replace his HD line in a presumedly patent RIJ. Upon transport to Interventional, however, it was found to be non-patent. Was discharged with schedule to change the line on [**Last Name (LF) 766**], [**9-3**] in IR. Medications on Admission: 1. Albuterol Sulfate 2. Methadone 80 mg daily 3. Indinavir 800 mg Capsule [**Hospital1 **] 4. B Complex-Vitamin C-Folic Acid 1 mg 5. Gabapentin 300 mg [**Hospital1 **] 6. Quinine Sulfate 325 mg PO HS 7. Ritonavir 100 mg [**Hospital1 **] 8. Oxycodone-Acetaminophen 5-325 mg 9. Senna 8.6 mg [**Hospital1 **] 10. Docusate Sodium 100 mg [**Hospital1 **] 11. Stavudine 20 mg daily 12. Metoprolol Tartrate 25 mg [**Hospital1 **] 13. Sevelamer 800 mg TID 14. Ammonium Lactate 12 % [**Hospital1 **] 16. Lamivudine 150 mg Tablet QHD 17. Insulin 18. cymbalta Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Indinavir 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). 3. B-Complex with Vitamin C Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Ritonavir 80 mg/mL Solution [**Hospital1 **]: 1.25 mL PO BID (2 times a day). 6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. Psyllium 1.7 g Wafer [**Hospital1 **]: One (1) Wafer PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: ISS per scale Subcutaneous ASDIR (AS DIRECTED). 15. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every 24 hours). 16. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 17. Stavudine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every 24 hours). 18. Lamivudine 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 19. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 20. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 21. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 22. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 23. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) g Intravenous HD PROTOCOL (HD Protochol) for 5 weeks: Levels to be checked in HD and dosed appropriately. 24. [**Last Name (un) **] packing strip please change right chest wall wound daily w/ [**Last Name (un) **] packing strip. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary: GPC bacteremia, altered mental status Secondary: HIV, Diabetes Mellitus, type 2, ESRD on Hemodialysis, Hepatitis C, Congestive heart failure, Hypertension, Hypercholesterolemia, LE Diabetic ulcers, Obesity, acute blood loss anemia, Peripheral neuropathy, Diastolic CHF, Hyperdynamic LV systolic fxn, Thrombosis of dialysis line, Emphysema Discharge Condition: Good, hemodynamically stable and afebrile. Discharge Instructions: You have been hospitalized for fever and altered mental status and were found to have Gram Positive bacteria in your blood. You have been treated with antibiotics, specifically vancomycin at hemodialysis. Your hospital course was complicated by acute blood loss with an elevated INR (coagulopathy) that required both transfusion of red blood cells and plasma. Once your blood levels were stable, you were transferred to the floor. Since that time, we attempted to place a new HD catheter but were unable to because you have a clot in your neck vein. Thus, you are being discharged back to your facility and instructed to return to [**Hospital1 18**] for exchange of your catheter. . Return to the Emergency Department if you develop new fevers, chills, altered mental status or any other symptoms for which you are concerned. . Your medications were continued while inpatient with the following changes. - We held your aspirin and coumadin because you had acute blood loss anemia - Your blood pressure medications have been changed to the following: Metoprolol 100mg po TID, lisinopril 40mg daily and norvasc 10mg daily. . Please keep all scheduled appointments. . Please keep your HD schedule Tuesday, Thursday, and Saturday. You will be given antibiotics at these sessions. . Please return to [**Hospital1 18**] [**Hospital Ward Name 121**] Building, [**Location (un) **], Day care unit on [**Last Name (LF) 766**], [**9-3**] at 8:30am for placement of a new HD catheter. Followup Instructions: Provider: [**Name10 (NameIs) 454**],SIX [**Name10 (NameIs) 454**] Date/Time:[**2125-9-3**] 8:30 . Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2125-9-3**] 10:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15624, 15795

5591, 12596

308, 322

16188, 16233

4287, 5568

17759, 18119

3614, 3633

13196, 15601

15816, 16167

12622, 13173

16257, 17736

3648, 4268

253, 270

350, 1005

1027, 3070

3086, 3598

13,169

125,457

28251

Discharge summary

report

Admission Date: [**2126-8-16**] Discharge Date: [**2126-8-21**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: sigmoid mass Major Surgical or Invasive Procedure: LAPAROSCOPICALLY ASSISTED SIGMOID COLECTOMY ([**8-16**]) History of Present Illness: The patient is an 86-year-old woman who underwent a screening colonoscopy on [**2126-7-8**] in [**Location 8398**]where a large, broad-based friable mass was seen at 20 cm. Biopsy of this mass revealed a tubular adenoma negative for high-grade dysplasia. In the rectum, there was also a 4 mm polyp which was a tubular adenoma with no high-grade dysplasia. In the transverse colon was a 3 mm polyp which was a tubular adenoma with no high-grade dysplasia. The two small polyps were snared excised. The patient reports that she has always taken some herbal laxatives but has recently had to use them much more frequently and feels that her bowels are not the same as they had been a month or two earlier. She has had a 10 pound weight loss over the last 6-7 months. She states that this has changed to eating meals on wheels rather than cooking for herself. Past Medical History: HTN OA, especially of R hip Social History: Denies cig/recreational drug, one EtOH/wk Retired, was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] teacher for autistic children x20yrs Widowed 2yrs ago Has son and daughter Family History: Sister died of ?colon CA [**2089**] Daughter with [**Name2 (NI) 14165**] cell trait Physical Exam: 152/92 82 20 General: Elderly B female walking slowly with cane, very alert, oriented, accompanied by son. Neck: Kyphosis, no thyroid mass, no LA, carotid 4+, no bruit Chest: CTAB, ant & post COR: Reg rhythm, but drops beats every 3-10besast with subsequent pause pending drop Back: no spine or CVA tenderness Abd: Slightly obese, +abd wall laxity, soft, nondistended, nontender, no masses, no organomegaly, small 1x1cm umbilical hernia Ext: [**11-26**]+edema to mid-shin, no cyanosis, no clubbing, no PT pulses, 4+DP bilaterlly Pertinent Results: [**2126-8-17**] 03:43AM BLOOD WBC-13.4*# RBC-4.25 Hgb-11.9* Hct-32.6* MCV-77* MCH-27.9 MCHC-36.4* RDW-17.0* Plt Ct-118* [**2126-8-18**] 12:34AM BLOOD WBC-9.6 RBC-3.75* Hgb-10.7* Hct-28.6* MCV-76* MCH-28.6 MCHC-37.5* RDW-17.2* Plt Ct-125* [**2126-8-19**] 02:58AM BLOOD WBC-8.0 RBC-3.68* Hgb-10.4* Hct-28.4* MCV-77* MCH-28.4 MCHC-36.7* RDW-16.7* Plt Ct-110* [**2126-8-20**] 06:07AM BLOOD WBC-7.6 RBC-3.87* Hgb-10.7* Hct-29.3* MCV-76* MCH-27.7 MCHC-36.6* RDW-16.7* Plt Ct-135* [**2126-8-20**] 08:00PM BLOOD Hct-30.9* [**2126-8-18**] 12:34AM BLOOD PT-14.2* PTT-32.7 INR(PT)-1.3* [**2126-8-17**] 03:43AM BLOOD Glucose-150* UreaN-7 Creat-0.6 Na-142 K-3.3 Cl-106 HCO3-25 AnGap-14 [**2126-8-18**] 12:34AM BLOOD Glucose-115* UreaN-8 Creat-0.5 Na-144 K-4.3 Cl-112* HCO3-26 AnGap-10 [**2126-8-19**] 02:58AM BLOOD Glucose-90 UreaN-7 Creat-0.4 Na-143 K-4.7 Cl-109* HCO3-27 AnGap-12 [**2126-8-20**] 06:07AM BLOOD Glucose-92 UreaN-8 Creat-0.4 Na-141 K-3.7 Cl-105 HCO3-30 AnGap-10 [**2126-8-18**] 09:51AM BLOOD CK(CPK)-88 [**2126-8-17**] 03:43AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.5* [**2126-8-18**] 12:34AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2 [**2126-8-19**] 02:58AM BLOOD Calcium-9.1 Phos-2.4* Mg-1.9 [**2126-8-20**] 06:07AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9 Brief Hospital Course: Pt was admitted after having undergone a laparoscope assisted sigmoid colectomy. The details of the procedure are available in the operative report elsewhere. She tolerated the procedure very well, without any complications. Given her age and not well controlled hypertension, she was admitted to the SICU overnight for observation. Overnight between POD#0 and POD#1, pt's SBP was elevated to 180s-210s and was managed with labetalol down to 118. However, given her usual state of high BP, her urine output fell. Henceforth, her BP was not treated with antihypertensive unless her SBP>210. Pt was mildly disoriented the morning of POD#1, requiring restraints overnight. Pt did not require any medication for confusion, and restraints were removed later that day. Due to bed shortage, pt remained in the SICU over the course of POD#1 through POD#3; pt was started on sips on POD#3. Her diet was advanced as tolerated, and she was transferred to the floor on POD#4, on which day she had a return of her bowel functions. She was consulted by PT that suggested further treatment, but she was able to get out of bed and ambulate with assistance and walker by POD#5. Pt remained afebrile with stable vital signs, tolerated a regular diet, was ambulant with assistance, and her pain was well controlled on POD#5. Pt was discharged to a rehabilitation facility on POD#5 in good condition. Medications on Admission: Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily) Tolterodine 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QHS Advil 2 tabs [**Hospital1 **] Discharge Medications: 1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Tolterodine 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO QHS (once a day (at bedtime)). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 4. Dilaudid 2 mg Tablet Sig: 0.25-1 Tablet PO q3-4hrs as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: sigmoid mass Discharge Condition: Afebrile, stable vital signs, tolerating po, ambulant with assistance, pain controlled. Discharge Instructions: Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. Please resume taking all medications as taken prior to this surgery and pain medications and stool softener as prescribed. Please follow-up as directed. No heavy lifting for 4-6 weeks or until directed otherwise. [**Month (only) 116**] leave wound open to air, please leave steri-strips intact until they fall off. Followup Instructions: Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to schedule a follow up appointment: ([**Telephone/Fax (1) 15665**]. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] will be following up on your medical care at the rehab facility to which you will be discharged. Please call his office this week to discuss her care: [**Telephone/Fax (1) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2126-8-21**]

[ "211.3", "293.0" ]

icd9cm

[ [ [] ] ]

[ "54.21", "45.76" ]

icd9pcs

[ [ [] ] ]

5598, 5664

3427, 4821

282, 341

5721, 5811

2163, 3404

6430, 7013

1510, 1596

5079, 5575

5685, 5700

4847, 5056

5835, 6407

1611, 2144

230, 244

369, 1229

1251, 1280

1296, 1494

27,242

127,979

17635

Discharge summary

report

Admission Date: [**2151-4-28**] Discharge Date: [**2151-5-3**] Date of Birth: [**2128-3-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Nausea and vomiting. Major Surgical or Invasive Procedure: IR-guided tunneled HD catheter Hemodialysis History of Present Illness: 23 y.o. M with h/o HTN, CKD, and morbid obesity, presented to ED on [**4-28**] with nausea and vomiting x 2-3 weeks, after being found by PCP to have [**Name9 (PRE) 49114**] 250. Pt had not refilled BP meds. ROS at the time notable for malaise but no CP, SOB, dizziness, headaches, visual changes, weakness or any other neurological deficits. ED course: # VS: T 99.3, HR 107, BP 246/154, RR 16, O2sat 100% RA. # Meds/IVF: 2L NS, labetalol 20 mg IV x 3, labetalol 100 mg PO x 3, 1" nitropaste x 3, acetaminophen 1 gram. # Labs/studies: --EKG: Sinus rhythem 90s, LVH, nl axis, intervals, [**Apartment Address(1) **] mm V1-3 likely early repolarization, TWI I, L, ?LAE. --Cr 17 Initial floor course: BP improved to 190/110 upon transfer to the floor, but patient reported a new frontal headache. BP elevated despite nitro paste Q6H, labetalol 200mg TID, labetalol 400mg PO x1, hydralazine 20mg IV x3, furosemide 80mg IV x1. MICU course: Initial ROS positive for persistent headache; negative for nausea, vision changes, CP, SOB, abdominal pain or edema. Pt received labetalol gtt and PO. IR-placed tunneled catheter received, and pt started HD. Past Medical History: Hypertension CRI (baseline CR 5) c/b nephrotic range proteinuria [**Apartment Address(1) **] Hyperlipidemia Social History: Professional: [**Hospital1 2177**] systems analyst Substance use: No current tobacco, alcohol; occasional marijuana use. Family History: Mother: HTN Father, died 31: Renal failure, expired on HD Physical Exam: Initial PE =========== VS: T 97.9, BP 198/126, HR 84, RR 22, O2sat 100% RA, 341 lbs Gen: obese, lying in bed with eyes closed, cooperative, NAD Heent: OP clear, moist, anicteric, PERRL, EOMI, fundoscopic exam with venous pulsations Neck: supple, no LAD CV: nl S1 S2, rrr, II/VI SEM Lungs: CTAB Abd: obese, soft, NT Ext: no c/c/e Neuro: A&O x3, appropriate, CN II-XII intact to testing, sensations intact, full strength, gait not observed Subsequent PE upon transfer out of MICU ======================================== VS: T afebrile, BP 194/92, HR 105, RR 18, O2sat 100 on RA Gen: NAD Heent: NCAT, MMM, OP clear, PERRL, EOMI, neck supple, no LAD CV: RRR, S1 S2, no m/r/g noted by this examiner Chest: CTAB Abd: Soft, NT, ND, BS+, obese, no HSM Ext: No c/c/e Neuro: A&Ox3, CN II-XII intact Pertinent Results: ADMISSION LABS: =============== 9.1 13.5 >------< 121 26.2 MCV 82 Neuts 76 Lymphs 17 Monos 3.6 Eos 1.9 Basos 0.2 139 104 90 -----|-----|------< 107 3.6 17 17.6 Ca 8.5 Phos 5.4 Mg 1.8 ALT 17 AST 17 Alk Phos 96 Bili 0.4 Lipase 56 Serum Tox: negative UA: large blood, negative nitrite, protein 500, negative leukocytes, RBC [**4-14**], WBC [**7-20**], Granular 0-2, Epi [**4-14**] Urine Cr 155 Urine Na 24 Urine osmolality 314 MICROBIOLOGY: ============= [**2151-4-29**] 8:38 am URINE Source: CVS. URINE CULTURE (Final [**2151-5-1**]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. STUDIES: ======== RENAL U.S. [**2151-4-28**] IMPRESSION: Limited study with inability to visualize either kidney. If necessary, noncontrast CT may be performed. EKG [**2151-4-28**] Sinus rhythm. Left ventricular hypertrophy with ST-T wave changes. The ST-T wave changes are more prominent in leads I and aVL as compared with prior tracing of [**2150-11-19**] with the finding of biphasic T waves in leads I, aVL and V6. Followup and clinical correlation are suggested. CHEST (PORTABLE AP) [**2151-4-30**] FRONTAL CHEST RADIOGRAPH: The heart is top normal in size. The pulmonary vasculature is normal. The lungs are clear without focal consolidation, pneumothorax, or pleural effusion. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: 23 y.o. M with HTN, CKD admitted with hypertensive emergency and acute on chronic renal failure. # Hypertension: SBP was in the 220s on admission. With patient's blood pressure not being well controlled on the floor, he was transferred to the MICU for better BP control with labetalol gtt and hydralazine IV prn. He was transferred back to the floor with SBP from 130s to 170s on labetalol 400 mg PO tid. His labetalol was increased to 600 mg TID on the medicine floor, and his SBPs ranged from 130-150. He was discharged with this increased dosage. # Acute on chronic renal failure: Renal followed the patient while he was hospitalized. Ultrafiltration was initiated in the MICU, and a tunnelled HD line was placed. Patient was still making urine. There was no hyperkalemia, encephalopathy, bleeding, or pericarditis. He received hemodialysis 3 times a week while in the hospital. Prior to discharge, he was set up with outpatient hemodialysis. He was unable to get venous mapping prior to discharge, and he will need this as an outpatient. # [**Month/Day/Year **] and thrombocytopenia: Hct was in the low 20s during the hospital stay. Hematology was consulted in the setting of concern for hemolysis with elevated LDH and decreased haptoglobin. No concern for TTP. It was proposed that the [**Month/Day/Year **] might be due to multiple factors including chronic kidney disease and possible hemolysis from shear force from malignant hypertension. His Hct remained stable during hospitalization. An ADAMST13 will need to be followed up as an outpatient. # UTI: With 10-100K gram positive alpha hemolytic colonies on UCx. Pt was started on ciprofloxacin to complete a 7 day course with instructions to hold ciprofloxacin on HD days until HD is completed. # Hyperlipidemia: Continued Statin. # FEN: Cardiac diet. Repleted lytes prn. # PPx: heparin SC # Dispo: Home with outpatient hemodialysis. Medications on Admission: Labetalol 200 mg TID (not taking for 1.5 months) PhosLo 1 tab PO TID with meals (mostly noncompliant) Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:*6 Tablet(s)* Refills:*0* 4. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Malignant Hypertension 2. End Stage Renal Disease . Secondary Diagnosis: 1. [**Month/Day/Year **] 2. Thrombocytopenia 3. Urinary tract infection 4. Hyperlipidemia Discharge Condition: Stable. Better controlled blood pressures. Afebrile. Discharge Instructions: You were admitted for very high blood pressures. You were briefly in the MICU for IV blood pressure medications and then transferred to the medicine floor. Your blood pressure was closely monitored, and your medications were changed for better control. The kidney doctors saw [**Name5 (PTitle) **], and you had hemodialysis while in the hospital. You will need hemodialysis 3 times a week. This is being set up for you. You were also seen by the Hematology doctors for your [**Name5 (PTitle) **] (low blood counts) which was felt to be due to your chronic kidney disease. Please take your medications as prescribed: 1. Please take atorvastatin 20 mg daily 2. Please take Calcium Acetate 1334 mg three times daily with meals 3. Please take Ciprofloxacin 750 mg daily for 6 more days (on your hemodialysis days, please take this medication after hemodialysis) 4. Please take labetalol 600 mg three times daily. This is a very important medication to help control your blood pressure. Please keep all your follow up appointments. Please make an appointment with [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**], RN for possible fistula at ([**Telephone/Fax (1) 23063**]. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on [**5-10**] at 2:15 PM. Call [**Telephone/Fax (1) 7477**] if you need to cancel. You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (kidney doctor) on Thursday, [**5-13**] at 8 AM. Please go to [**Location (un) 8661**] [**Location (un) **], Medical Specialties. If you need to cancel/reschedule, please call ([**Telephone/Fax (1) 773**]. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, worst headache in your life, sudden double vision or worsening of vision, constant nausea/vomiting, abdominal pain, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 49115**], on [**5-11**] at 10:00AM. Call [**Telephone/Fax (1) 7477**] if you need to cancel. Please make an appointment with [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**], RN for a possible fistula for hemodialysis at ([**Telephone/Fax (1) 20193**]. You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (kidney doctor) on Thursday, [**5-13**] at 8 AM. Please go to [**Location (un) 8661**] [**Location (un) **], Medical Specialties. If you need to cancel/reschedule, please call ([**Telephone/Fax (1) 773**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2151-5-4**]

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Discharge summary

report

Admission Date: [**2156-3-29**] Discharge Date: [**2156-4-1**] Date of Birth: [**2120-12-9**] Sex: M Service: MEDICINE Allergies: Bactrim DS Attending:[**First Name3 (LF) 1377**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Endoscopy with re-banding History of Present Illness: 35 y/o man with PSC c/b recurrent cholangitis ([**8-/2155**], [**10/2155**]) s/p CBD stenting and cholecystectomy ([**2155-10-29**]) as well as cirrhosis (MELD 7) c/b grade II/III esophageal varicies presenting to the ED with syncope. Pt states he noted lightheadedness and palpitations the morning of admission while lying in bed. He stood up to go to the bathroom and awoke on the floor some time later, does not know how long he was unconscious for. He also reports 3 days of fatigue and dark stools, but denies BRBPR or hematemesis. Of note, he underwent EGD ([**2156-3-2**]) that showed grade II/III esophageal varicies and portal gastropathy; 3 bands were placed without complication. He has had multiple admissions for chonangitis, but no admissions to [**Hospital1 18**] for GI bleeding and has never had hematemesis in the past. . In the ED, initial VS were: T 98 HR 75 BP 93/51 RR 16 O2 Sat 98% RA He received 2L NS with improvement in his BP to the 110s. He subsequently became hypotensive again to the 80s. NG lavage was performed and returned BRB that did not clear. 16G and 18G PIVs were placed. Labs were notable for HCT 20 (baseline 30-35), INR 1.1, platelets 351. He was transfused 2 units pRBCs. Liver was called and recommended Octreotide/Pantoprazole gtt and Ceftraixone 1g. . On arrival to the MICU, initial VS were: T 98 HR 83 BP 93/53 RR 14 O2 Sat 100% RA He denied CP/SOB, lightheadedness, palpitations. Stated he felt tired but otherwise had no complaints. Past Medical History: - Ulcerative colitis c/b dysplasia now s/p colectomy - Primary sclerosing cholangitis c/b recurrent cholangitis, now s/p cholecystectomy - Esophageal varices s/p banding --> GIB --> sclerosed band, s/p rebanding - ITP status post IVIG - Osteoporosis - h/o Cdiff Social History: Pt is a school teacher in [**Location (un) 14753**] and lives with a roomate. He denies any ETOH, smoking or illicit drug use. Family History: No colon cancer, IBD, autoimmune disease in family Physical Exam: Admission Exam: T 98 HR 83 BP 93/53 RR 14 O2 Sat 100% RA General: Pale, NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP at the clavicle 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, well healed midline scar GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A/Ox3, no asterexis, CNII-XII intact, non focal Discharge PEx: General: sitting up, well appearing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL 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, well healed midline scar Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A/Ox3, no asterexis, CNII-XII intact, non focal Pertinent Results: [**2156-3-29**] 12:50AM BLOOD WBC-6.2 RBC-1.85*# Hgb-6.1*# Hct-20.4*# MCV-110* MCH-32.8* MCHC-29.7* RDW-19.4* Plt Ct-351# [**2156-3-29**] 04:26AM BLOOD WBC-6.3 RBC-2.96*# Hgb-9.2*# Hct-29.4*# MCV-99*# MCH-30.9 MCHC-31.2 RDW-20.3* Plt Ct-295 [**2156-3-29**] 08:05AM BLOOD Hct-28.8* [**2156-3-29**] 11:39AM BLOOD Hct-28.2* [**2156-3-29**] 05:48PM BLOOD Hct-28.9* [**2156-3-30**] 12:31AM BLOOD Hct-28.8* [**2156-3-30**] 03:54AM BLOOD WBC-6.1 RBC-2.93* Hgb-9.1* Hct-29.7* MCV-101* MCH-31.0 MCHC-30.6* RDW-21.8* Plt Ct-277 [**2156-3-30**] 11:03AM BLOOD Hct-28.7* [**2156-3-29**] 12:50AM BLOOD Neuts-63.8 Lymphs-21.9 Monos-5.2 Eos-8.4* Baso-0.7 [**2156-3-29**] 04:26AM BLOOD Neuts-77.3* Lymphs-12.7* Monos-4.6 Eos-4.9* Baso-0.5 [**2156-3-30**] 03:54AM BLOOD Plt Ct-277 [**2156-3-29**] 04:26AM BLOOD Plt Ct-295 [**2156-3-29**] 04:26AM BLOOD PT-11.8 PTT-31.7 INR(PT)-1.1 [**2156-3-29**] 12:50AM BLOOD Plt Ct-351# [**2156-3-29**] 12:50AM BLOOD PT-11.7 PTT-30.3 INR(PT)-1.1 [**2156-3-29**] 04:26AM BLOOD Ret Aut-2.8 [**2156-3-30**] 03:54AM BLOOD Glucose-95 UreaN-13 Creat-0.6 Na-141 K-3.7 Cl-108 HCO3-27 AnGap-10 [**2156-3-29**] 04:26AM BLOOD Glucose-121* UreaN-16 Creat-0.5 Na-137 K-4.2 Cl-107 HCO3-23 AnGap-11 [**2156-3-29**] 12:50AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-141 K-3.9 Cl-108 HCO3-27 AnGap-10 [**2156-3-29**] 12:50AM BLOOD ALT-110* AST-136* AlkPhos-351* TotBili-1.0 [**2156-3-29**] 12:50AM BLOOD Albumin-2.7* [**2156-3-29**] 04:26AM BLOOD Calcium-7.4* Phos-3.7 Mg-1.7 [**2156-3-30**] 03:54AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8 [**2156-3-30**] 03:54AM BLOOD Lipase-68* [**2156-3-29**] 05:28AM BLOOD Type-[**Last Name (un) **] pH-7.38 Comment-GREEN TOP [**2156-3-29**] 05:28AM BLOOD freeCa-1.02* [**2156-3-29**] 12:55AM BLOOD Lactate-1.2 [**2156-4-1**] 12:45PM BLOOD Hct-31.4* [**2156-4-1**] 06:15AM BLOOD WBC-5.9 RBC-2.72* Hgb-8.6* Hct-27.9* MCV-103* MCH-31.6 MCHC-30.8* RDW-20.6* Plt Ct-251 [**2156-3-31**] 07:25PM BLOOD Hct-31.4* [**2156-3-31**] 05:30AM BLOOD WBC-6.8 RBC-3.15* Hgb-10.1* Hct-31.7* MCV-101* MCH-32.1* MCHC-31.9 RDW-22.1* Plt Ct-241 Micro: [**2156-3-31**] 2:29 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2156-4-2**]** FECAL CULTURE (Final [**2156-4-2**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2156-4-2**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [**2156-4-2**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2156-4-2**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2156-4-2**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-4-1**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Blood cultures: NGTD Urine CX: neg MRSA screen: negative Imaging: CHEST (PORTABLE AP) Study Date of [**2156-3-29**] 3:35 AM FINDINGS: There are increased pulmonary vascular markings and redistribution. Prominent azygos vein is also noted. There is mild cardiomegaly, unchanged. No focal consolidation, pleural effusion, or pneumothorax is seen. The NG tube courses through the esophagus and terminates outside the field of view. IMPRESSION: Mild volume overload. US ABD LIMIT, SINGLE ORGAN Study Date of [**2156-3-29**] 3:16 PM IMPRESSION: 1. Small volume ascites. 2. Heterogeneous, coarsened liver, consistent with known primary sclerosing cholangitis and cirrhosis. [**2156-3-29**] EGD A large clot was found in the body and stomach. Due to it size, it could not be suctioned out. The remainder of the stomach appeared normal. Varices at the upper and middle third of the esophagus Varices at the lower third of the esophagus (ligation) Normal EGD to third part of the duodenum CXR [**3-31**]: As compared to the previous radiograph, there is no relevant change. No evidence of focal parenchymal opacities indicative of pneumonia. The orogastric tube has been removed. Unchanged borderline size of the cardiac silhouette without pulmonary edema. The lateral radiograph reveals a minimal pleural effusion bilaterally, restricted to the dorsal parts of the costophrenic sinus. Brief Hospital Course: 35 y/o man with PSC c/b cirrhosis and grade II/III esophageal varicies presenting with syncope in the setting of HCT 20 and recent melena and fatigue, found to have sclerosis near prior banding site, likely source of GIB, s/p re-banding. . # Syncope: Likely related to orthostasis [**2-5**] GIB given HCT drop and known portal gastropathy, which is the most likely source of his bleeding. Also consider gastric ulcer given epigastric pain the morning or admission. Given BRB did not clear with NG lavage, concern for ongoing bleeding. Given his age, cardiogenic syncope is unlikely. EKG without block or abnormal intervals. No h/o seizure, not post-ictal after the event. patient was given PRBCs and GI was consulted. They performed an endoscopy where they found a bleeding ulceration near a previous banding site. They placed another band and stopped the bleeding. Given the patient's GI bleed he was given ceftriaxone x 24 hrs. He was also given carafate 1gm [**Hospital1 **] for 7 days, pantoprazole 40mg daily for 7 days, cipro 500mg daily for 7 days, Octreotide for 3 days per GI recommendations. His Hematocrits were trended every four hours and remained stable. He was then transferred to the floor and continued to have stable Hct prior to discharge. . # Hypotension: SBP 80s in the ED was responsive to volume recussitation. Based on clinic notes, pts BP runs 90-120s at baseline. Likely hypovolemia in the setting of GIB. Please see above for more discussion. Upon discharge, patient's SBPs were 100-110s. # Fever: Patient had 1 episode of fever to 102.5 with associated feelings of warmth, no chills, sweats, localizing symptoms. Patient was worked up with blood, urine, stool cultures, as well as CXR, all of which were negative for infection. Patient was on ciprofloxacin given GI bleed and was empirically broadened to levo to cover for possible pna (increased incidence of aspiration during GIB event, even though patient did not recall ever vomiting). Patient was discharged on a 5 day totaly course of levofloxacin to end on [**2156-4-5**] since patient remained afebrile for 24 hours with negative cultures. C. diff was negative as well (patient had been on abx and had a very remote h/o of C. diff). During episode of fever, patient had very brief episode of 5-20sec of tachycardia to 140. His UOP was low during this period of time despite good PO intake of fluids. It is likely that he was behind with fluids from day prior and patient was initiated on IVF bolus and maint fluids with improvement in both VS and UOP. Patient's IVFs were stopped upon d/c given that patient maintained good PO intake and UOP and stable VS. No additional episodes of tachycardia or hypotension. Patient did not have any symptoms during this time. . Chronic Problems: . # Ulcerative Colitis: Pt is s/p colectomy. Patient was continued on home mesalamine and azathioprine. . # Cholestatic Hepatitis: Currently at baseline, likely [**2-5**] PSC. The patient's LFTs were trended during his hospitalization. His ALT/AST were mildly elevated int he low 100s though his baseline appears to be around 70s to 100s. His alk phos was at baseline (350-400s) . # Macrocytic Anemia: Likely [**2-5**] reticulocytosis given elevated RDW and MVC. His reticulocyte count was checked and he was felt to have a normal bone marrow response. He would benefit from folate/B12 level testing as an outpatient. . # Cirrhosis: MELD 7, on this admission. he was continued on home ursodiol. . Transitional Issues: -Patient to follow up with PCP and GI as outpatient. -Patient's B12 last checked in [**10/2155**] found to be high at 1583, higher than prior. Will need to be followed up on by PCP. Medications on Admission: AZATHIOPRINE [IMURAN] - 50 mg Tablet - 1 Tablet(s) by mouth once a day MESALAMINE [ASACOL] - 400 mg Tablet, Delayed Release (E.C.) - 4 (Four) Tablet(s) by mouth three times a day NADOLOL - 40 mg Tablet - one Tablet(s) by mouth daily SUCRALFATE - (Not Taking as Prescribed: only after endosc) - 1 gram/10 mL Suspension - 10 cc(s) by mouth three times a day URSODIOL - 300 mg Capsule - 1 Capsule(s) by mouth twice a day . Medications - OTC ASCORBIC ACID - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE [CALCIUM 500] - (Prescribed by Other Provider) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other Provider) - 400 unit Capsule - 2 (Two) Capsule(s) by mouth once a day FOLIC ACID - (Prescribed by Other Provider) - 0.4 mg Tablet - 1 (One) Tablet(s) by mouth once a day LACTOBACILLUS RHAMNOSUS GG [PROBIOTIC] - (Prescribed by Other Provider) - 10 billion cell Capsule - Capsule(s) by mouth MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2) Capsule PO once a day. 6. lactobacillus rhamnosus GG 10 billion cell Capsule Oral 7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Carafate 1 gram Tablet Sig: One (1) Tablet PO twice a day for 9 doses: to end on [**2156-4-5**]. Disp:*9 Tablet(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 4 days: to end on [**2156-4-5**]. Disp:*4 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. ascorbic acid Oral 11. calcium carbonate Oral 12. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 13. lactobacillus rhamnosus GG 10 billion cell Capsule Sig: One (1) Capsule PO once a day. 14. multivitamin Oral Discharge Disposition: Home Discharge Diagnosis: UGI bleed s/p banding . Secondary: UC s/p colectomy PSC with cirrhosis & varices portal hypertension gastropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 1349**], It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to [**Hospital1 827**] for a gastrointenstinal bleed. As you had a low blood count and low blood pressures, you were initially admitted to the Intensive Care Unit for treatment. We transfused you with blood and our gastrointenstinal doctors saw [**Name5 (PTitle) **]. They performed an endoscopy where they found some ulcerations near of the bands of a previous varix. They placed another band and stopped the bleeding. Your blood counts stabilized as did your blood pressures, and you were transferred to the liver service. During this time you had an isolated fever of unclear origin. We empirically covered you with antibiotics and performed a workup, which did not reveal an infection. Since you have been afebrile and continue to look well clinically, we believe it is safe for you to return home. Please don't hesitate to call us should you have fever, chills, or any concerning symptoms. You will also have close followup, detailed below. The following changes have been made to your medications: START Carafate, to end on [**4-5**] START Pantoprozole, to end on [**4-5**] START Levofloxacin, to end on [**4-5**] Please continue to take all of your other medications as previously prescribed. Followup Instructions: You have the following appointments: You have requested to make a PCP appointment on your own; please make an appointment with your PCP ([**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 798**]) for 7-10 days from now. Department: ENDO SUITES When: TUESDAY [**2156-4-6**] at 2:00 PM Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2156-4-6**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: RADIOLOGY When: SATURDAY [**2156-4-10**] at 11:15 AM With: RADIOLOGY MRI [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "556.9", "276.52", "571.5", "572.3", "486", "780.2", "733.00", "456.20", "281.9", "573.8", "537.89", "285.1" ]

icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

[ [ [] ] ]

13471, 13477

7571, 11039

278, 306

13634, 13634

3384, 7548

15126, 16178

2265, 2317

12309, 13448

13498, 13613

11269, 12286

13785, 15103

2332, 3365

11060, 11243

231, 240

334, 1819

13649, 13761

1841, 2104

2120, 2249

29,552

154,158

31203

Discharge summary

report

Admission Date: [**2111-12-5**] Discharge Date: [**2111-12-12**] Date of Birth: [**2064-2-2**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 2724**] Chief Complaint: Purulent drainage from previous surgical site Major Surgical or Invasive Procedure: T9-L2 incision and drainage of wound infection History of Present Illness: This is a 47 year old man with metastatic Renal Cell Carcinoma status post T9-L2 fusion with Dr. [**Last Name (STitle) 548**] on [**2111-10-8**]. He finished chemotherapy several weeks ago. He has not had radiation since his surgery. He was doing well when he saw Dr. [**Last Name (STitle) 548**] on [**2111-11-10**]. He reports that he developed more back pain and lethargy during the past 2 weeks. He was at home and was in bed most of the day. He can ambulate short distances independently. On the day of admission, he developed new purulent drainage from his thoracic wound. He denied lower extremity pain, paresthesias or numbness. He had no incontinence. He denied fever, chills, diaphoresis. Past Medical History: - Renal Cell Carcinoma (please see below) - h/o RLE DVT [**8-/2107**] - Colonic perforation - Hyponatremia - Anemia - Cervical surgery with rod-placement due to C2 met -[**2110-11-14**] Right colectomy, Segment VI partial liver resection, resection of retroperitoneal tumor mass; ileal transverse colostomy anastomosis (side to side). - T9-L2 posterior fusion with T11 vertebrectomy Social History: Married and lives with wife. Family History: Mother died of a brain tumor. Father diagnosed with prostate cancer in his 70s and is still living. He has 3 siblings and 2 children without medical concerns. Maternal aunt with lymphoma. Father and sister have had h/o "blood clots." Physical Exam: PHYSICAL EXAM: O: T: 97.6 F BP: 104/71 HR: 51 R 20 O2Sats 95 % RA Gen: NAD at rest, cachectic T/L spine wound: mild dehiscence, purulent drainage saturating dressing. No active drainage. Erythema at wound and areas of tape. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Motor:Moves LE with good strength. Testing causes significant back pain. Sensation: Intact to light touch Reflexes: Pa Ac Right 1 0 Left 2 0 No clonus Upon discharge; cachetic, awake and alert, full motors, draining thoracic wound with JP and pouch Pertinent Results: [**2111-12-4**] 11:45PM PLT COUNT-523* [**2111-12-4**] 11:45PM NEUTS-89.4* LYMPHS-5.7* MONOS-3.5 EOS-0.7 BASOS-0.8 [**2111-12-4**] 11:45PM WBC-10.8 RBC-4.06* HGB-11.2* HCT-33.8* MCV-83 MCH-27.6 MCHC-33.1 RDW-14.3 [**2111-12-4**] 11:45PM CRP-291.3* [**2111-12-4**] 11:45PM GLUCOSE-150* UREA N-19 CREAT-0.9 SODIUM-129* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-28 ANION GAP-17 [**2111-12-5**] 04:15AM PT-15.0* PTT-25.4 INR(PT)-1.3* CT Thoracic spine [**2111-12-4**] 1. S/P T9-L2 posterior spinal fusion. R paraspinal fluid collections with rim enhancement and increasing amount of air within , concerning for paraspinal abscess. Two components of the collection- the collection apposed to the spine and the thecal sac measures approx 5.9 x 2.5 x 3.5 cm , extends from T11-T12 level. The second collection more lateral in the paraspinal soft tissues measures 8.0 x 5.2 x 1.7 cm. There is enhancement of the thecal sac.No definite cord compression is seen, but this study is limited given the streak artifacts. 2. Significant distention of the gall bladder, correlate clinically for signs of acute cholecystitis. 3. Known metastatic disease CT Torso [**2111-12-6**] 1. Expected postoperative changes at the lower thoracic spine as described above, with a small amount of residual post-surgical gas and fluid. 2. No findings to suggest abdominal or pelvic abscess. 3. Stable appearance of known pulmonary metastatic disease. Abdominal CT with contrast [**2111-12-9**] 1. Appearances are consistent with an enterocutaneous fistula passing from the right upper quadrant via the surgical drain tract to the skin at the level of the surgical incision. The precise site of communication cannot be identified; however, the mid jejunal loops are considered the most likely given the proximity to the extraluminal contrast. Air and oral contrast seen in close relationship to the thecal sac at T12. 2. Enhancement of the paraspinal muscles suggestive of inflammation, no collection seen. 3. Multiple stable pulmonary metastases. 4. Duodenal diverticulum. Brief Hospital Course: Pt was admitted to the neurosurgery service and was kept NPO after midnight in preparation of wound washout the following morning. On laboratory studies his serum sodium was found to be 129 and he was started on NaCl tabs and his sodium levels were checked daily. The ID team was consulted for appropriate antibiotic regimen and he was initially started on vancomycin 1g IV q12 with plan to add more broad spectrum coverage after cultures were obtained from the OR. On [**12-5**], he underwent incision and drainage of his infected surgical wound with placement of a drain and tolerated this procedure very well with no complications. Post-operatively he was seen and he had no change in his previous physical exam. Ciprofloxacin, flagyl and cefepime were added per ID recommendations. The patient serum sodium was 129. This was reevaluated on [**12-6**] and was 134 without treatment. Wound and blood cultures were sent. On [**12-6**], the patient's exam was unchanged. He was experiencing pain at his surgical site a level of 5 on a [**12-14**] pain scale. His pain medications were reviewed and the patient was not maximizing the currently ordered doses of pain medication.This was discussed with the patient and nursing. Physical therapy and occupational therapy consults were ordered. The patient was unable to get out of bed due to his discomfort. A picc line was placed for long term antibiotic therapy. A CT of the lumbar spine was ordered to evaluate the post operative surgical site. This was stable with only minimal residual fluid collection at surgical site. Per infectious disease recommendations antibiotics were optimized for coverage. 1/3-4 The patient was seen by physical therapy and was able to get OOB and ambulate. The JP drain remained in place due to high output and he was continued on his antibiotic regimen per the ID team. On [**12-8**] the cefepime was discontinued per the ID team. His vanco trough on the evening of [**12-8**] was 21.7 and his a.m dose on [**12-9**] was held. His pain was better controlled with PO dilaudid every three hours and he required less IV pain medication for breakthrough. His wound continued to drain copious amounts of fluid, he was maintained on IV antibiotics with ID consultation as cultures grew enterococcus. He underwent CT of abdomen which showed and enteric fistula. He was seen in consultation by Dr [**Last Name (STitle) **] who had cared for the patient for fistula 3 years ago. He had been scheduled to return to OR for thoracic washout [**12-10**] but in light of fistula this was cancelled as would not provide any relief to drainage of wound. Mr [**Known lastname 73648**] case was discussed at length with Neurosurgery, General Surgery, Oncology, Infectious Disease, Palliative Care and the patient and his wife. Surgery would be extensive and high risk with likely more risk than benefit. The lower end of the incision was opened and he was fit with colostomy drainage system. Care was arranged for transfer of patient to home with palliative care bridging to hospice. He will maintain on antibiotics and pain medication and will take PO only for comfort. Medications on Admission: -fentanyl 400 mcg/hour Patch 72 hr -hydromorphone 2 mg Tablet [**12-6**] Tablet(s) by mouth as needed, for breakthrough pain -lorazepam 1 mg Tablet 1 Tablet(s) by mouth every eight (8) hours as needed for anxiety -methadone 5 mg Tablet 0.5 (One half) Tablet(s) by mouth twice a day -ondansetron HCl 8 mg Tablet 1 Tablet(s) by mouth every eight (8) hours as needed for nausea/vomiting -prochlorperazine maleate 10 mg Tablet 1 Tablet(s) by mouth every six (6) hours as needed for nausea/vomiting -Scopolamine patch Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 12H (Every 12 Hours). Disp:*[**Numeric Identifier **] mg* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp/HA. 3. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr Transdermal Q72H (every 72 hours). 6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for nausea. 7. ceftriaxone 2 gram Recon Soln Sig: Two (2) gm Intravenous Q24H (every 24 hours). Disp:*60 gm* Refills:*2* 8. hydromorphone 2 mg Tablet Sig: 8-10 Tablets PO q3h as needed for pain. Disp:*180 Tablet(s)* Refills:*0* 9. hydromorphone 1 mg/mL Liquid Sig: 8-12 mg 10 mg/ml PO q3h as needed for pain: Hydromorphone concentrated liquid 10mg/ml. Disp:*250 ml* Refills:*0* 10. fluconazole in NaCl (iso-osm) 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q24H (every 24 hours). Disp:*[**Numeric Identifier 890**] mg* Refills:*2* 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for spasm. Disp:*40 Tablet(s)* Refills:*0* 12. Drainage Bag Please dispense [**Location (un) **] [**Numeric Identifier 63605**] High Output drainage pouch. 110mm (4 [**12-7**] inch) Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: metastatic Renal cell carcinoma T9-L2 surgical wound infection enteric fistula hyponatremia urinary retention anemia of chronic disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair.as tolerated for pain management Discharge Instructions: Take your pain medication as instructed Followup Instructions: Follow up with Dr [**Last Name (STitle) 43131**] for medication refills as needed. Follow up with Dr [**Last Name (STitle) 548**] as needed. Completed by:[**2111-12-12**]

[ "V45.4", "V10.52", "V45.72", "198.3", "788.20", "569.81", "996.67", "285.29", "197.7", "E878.1", "V12.51", "V15.3", "V44.3", "V87.41", "324.1", "V85.0", "041.04", "338.18", "041.3", "198.5", "285.9", "197.0", "276.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.04" ]

icd9pcs

[ [ [] ] ]

9671, 9745

4513, 7662

353, 401

9925, 9925

2433, 4490

10199, 10372

1599, 1834

8228, 9648

9766, 9904

7688, 8205

10135, 10176

1864, 2081

268, 315

429, 1129

9940, 10111

1151, 1536

1552, 1583

9,269

179,608

14944

Discharge summary

report

Admission Date: [**2155-8-10**] Discharge Date: [**2155-8-27**] Service: HISTORY OF THE PRESENT ILLNESS: This is a 80-year-old white female with a past medical history significant for non-Q-wave MI on 6/[**2155**]. The patient was transferred to [**Hospital1 346**] from [**Hospital6 33**] with a question of small-bowel obstruction. The patient was in her a bowel movement. Prior to admission she felt bloated, although she did not have any nausea or vomiting, but had stopped passing gas approximately two days prior to admission. The patient was brought to [**Hospital6 33**] on [**8-9**] secondary to increased abdominal pain, which was diffuse across the lower abdomen, mostly crampy. She was admitted and fluid resuscitated at [**Hospital6 33**]. NG [**Hospital **] Hospital showed dilated loops of small bowel with an air-fluid level. PAST MEDICAL HISTORY: 1, The patient was found to have small-bowel obstruction and she was transferred to the [**Hospital1 188**] for exploratory laparotomy and lysis of adhesions. Past medical history is significant for non-Q-wave MI in [**2155-6-21**], at which time approximately four cardiac stents were placed. 2. Chronic obstructive pulmonary disease. 3. Hypertension. PAST SURGICAL HISTORY: The patient had a colectomy approximately 30 years ago and vaginal hysterectomy. ALLERGIES: The patient has no known allergies to medications. HOME MEDICATIONS: 1. Serevent two puffs q.h.s. 2. Combivent 2 puffs q.i.d.p.r.n. 3. Albuterol and Atrovent 25/500 q.i.d. 4. Zantac 50. 5. Ativan 2 mg q.4h. to 6h. for anxiety. 6. Morphine for pain. 7. Hydralazine 2 mg IV q.8h. for blood pressure control. SOCIAL HISTORY: The patient is a long-term smoker. PHYSICAL EXAMINATION: Physical examination on admission revealed the following: VITAL SIGNS: Temperature 97.4, blood pressure 150/20, pulse 82, respiratory rate 16, saturation 93% on room air. HEAD AND NECK: Head and neck examination: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes moist. RESPIRATORY: The patient is clear to auscultation bilaterally. She is moving air well. CARDIAC: Examination showed regular rate and rhythm, normal S1 and S2 without murmurs, rubs, or gallops. ABDOMEN: Abdomen was noted to be soft, distended, with mild tenderness diffusely. There is no guarding or rebound. EXTREMITIES: Without edema, stools were guaiac negative at that time. LABORATORY DATA: Prior to admission, labs drawn at [**Hospital6 3622**] revealed the white count of 11.0, hematocrit 37.1, platelet count 346,000, sodium 136, potassium 3.5, BUN 25, creatinine 1.3, glucose 132, calcium 10.5, magnesium 1.9, LFTs and ALT 1125, AST 21, amylase 20, lipase 22. On [**2155-8-11**], the patient received a CT scan of the abdomen, which demonstrated multiple loops of small bowel with a region of narrowing in the right lower quadrant and iliac fossa consistent with mechanical small-bowel obstruction, single low attenuation cyst in the liver, tiny gallstone without evidence of cholecystitis, scattered sigmoid diverticula without diverticulitis, extensive vascular calcification in the region of the mesenteric artery. HOSPITAL COURSE: Given the patient's CT findings, it was decided that the patient would be taken to the operating room for emergent exploratory laparotomy and lysis of adhesions. On [**2155-8-11**], the patient had the exploratory laparotomy and she tolerated the operation well. Approximate blood loss was 200 cc. She was transfused intraoperatively with six units of platelets, 800 cc crystalloid. Intraoperative central line was placed, and a chest film was obtained to confirm placement The patient was transferred from the operating room to the Post Anesthesia Care Unit. From there, she was transferred to the Surgical Intensive Care Unit for observation and monitoring after laparotomy given her history of non-Q-wave MI and chronic obstructive pulmonary disease. In the Post Anesthesia Care Unit, the patient was evaluated by the Cardiology Service, where she was noted to have transient right bundle branch block and the Post Anesthesia Care Unit decided to resume her Aspirin. Overnight, from postoperative day #0 to postoperative day #1, the patient did not have any major events. She was continued to be monitored in the Surgical Intensive Care Unit. In the Intensive Care Unit it was decided to diurese the patient. She was transfused with one unit of packed red blood cells. The hematocrit was noted to increase to 29.7. Overnight, from postoperative day #1 to postoperative day #2, the patient was noted to have low urine output. While in the ICU, the patient was kept NPO. She was noted to have an increasing hematocrit after infusion of one unit of packed red blood cells. On [**2155-8-12**] the patient received a transthoracic echocardiogram, which demonstrated preserved left ventricular ejection fraction. It was decided to start Lopressor on the patient for rate and pressure control. From postoperative day #2 to postoperative day #3, the patient continued to do well without major events. The NG tube was noted to be draining 350 cc from postoperative day #2 to postoperative day #3. Again, the patient was noted to have a low hematocrit of 27.7 on [**2155-8-13**]. The patient continued to do well, although she did have one episode of anxiety. It was decided on [**2155-8-13**] to change the patient from a pCO2, regular morphine prn. She was found to be stable on Lopressor and IV Vasotec. She was transfused again with one unit of packed red blood cells. During the evening of [**2155-8-13**], the patient was transferred from the Intensive Care Unit to the floor, where she was noted to be doing well with no overnight events from [**8-13**] to [**8-14**]. Overnight, from [**8-13**] to [**8-14**], the patient's NG tube put out approximately 150 cc. She was still not passing flatus. On postoperative day #4 to postoperative day #5, [**2155-8-14**] to [**2155-8-5**] the patient continued to do well. She had decreased abdominal pain, and she was able to ambulate. The patient remained without flatus. The patient was diuresed 3.5, which was repleted. At this point, total parenteral nutrition was started for the patient. The patient tolerated TPN well and she was advanced to goal total parenteral nutrition on [**2155-8-15**]. On [**2155-8-16**], the patient was evaluated by rehabilitation services and physical therapy. The patient was noted to be making progress with ambulatory ability. Overnight, from [**2155-8-16**] to [**2155-8-17**] the patient noticed increased amounts of flatus. She was able to pass flatus at this point. She remained on TPN on [**2155-8-17**]. The NG tube was noted to put approximately 250 cc out on [**2155-8-16**]. On [**2155-8-17**] to [**2155-8-18**] the patient continued to do well. On [**2155-8-17**], the patient had the NG tube pulled. She is to be taking small sips. TPN was continued, IV fluids were not. On [**2155-8-18**], the Dermatology Service was consulted for a facial rash. Their impression was that she was an 80-year-old female with onset of malar rash after treatment for small-bowel obstruction. They prescribed hydrocortisone 1% cream for the patient, which seemed to help with the contact dermatitis. Overnight, [**2155-8-18**] to [**2155-8-19**], the patient complained of some shortness of breath to approximately 4 in the morning, which was relieved with nebulizers. LABORATORY DATA: The patient was found to have a hematocrit of 26. TPN was continued through [**2155-8-19**]. On [**2155-8-19**], the Pulmonary Service was consulted because of the patient's complaint of dyspnea. Their impression was that she was an 80-year-old female with known chronic obstructive pulmonary disease status post myocardial infarction and recent abdominal surgery with the differential diagnosis for episodes of dyspnea were mostly multifactorial with chronic obstructive pulmonary disease exacerbation. They recommended increasing Atrovent to four puffs b.i.d.; restarting Flovent and checking for PFTs. Also, the differential diagnosis of bronchitis with increased amounts of sputum and increased shortness of breath. However, the patient was without any clear chest x-ray or infiltrate. The patient was treated with Azithromycin for possible tracheobronchitis for a total course of five days. The differential diagnosis was pulmonary edema and deconditioning given prolonged hospital course. It was decided to treat the patient with approximately five days of Azithromycin and to adjust her MDIs and nebulizers according to the recommendations. On [**2155-8-20**], the patient was transfused with one unit of packed red blood cells. The hematocrit improved from 26 to 33. The patient continued to do well. She was ambulating. However, overnight from [**2155-8-19**] to [**2155-8-20**], the patient started to vomit twice. The nasogastric tube was replaced, it drained approximately 100 cc from the stomach. The Dermatology Department followed the patient. The patient was given an increase in the Hydrocortisone ointment from 1% to 2.5% b.i.d. for the worsening facial rash. Overnight, from [**2155-8-20**] to [**2155-8-21**], the patient had no complaints. She felt that her respiratory status was better in the morning. She was without nausea or vomiting after the NG tube was replaced. Overnight, the NG was noted to put out approximately 350 cc. The hematocrit was stable at 33.8 from 33.9 the day before. Overnight, from [**2155-8-21**] to [**2155-8-22**], the patient did well. The nasogastric tube was noted to have put out only 650 cc of fluid the previous day. The hematocrit was stable at 33.2. The blood pressure medications at this time were IV Lopressor Enalapril, and Hydralazine. The patient tolerated these well with good pressures and rate. She was maintained on telemetry. The patient was diuresed with 2 mg of Lasix on [**2155-8-21**]. On [**2155-8-22**], it was decided that the patient was passing flatus and was able to have a bowel movement. At this point, the nasogastric tube was taken out. The patient was noted to tolerate about 630 PO ice chips on [**2155-8-22**]. Overnight, from [**2155-8-22**] to [**2155-8-23**], the patient continued to do well with the nasogastric tube discontinued and she had no complaints of nausea, vomiting, or abdominal pain. The TPN was continued. At this point, the patient decided that the best course of action would be to go to acute rehabilitation prior to leaving for home in [**State 760**]. Overnight, from [**2155-8-23**] to [**2155-8-24**], the patient continued to do well. She began tolerating a clear liquid diet. She continued to pass flatus. The labs were noted to be stable. She was diuresed again with 10 mg of Lasix on [**2155-8-24**]. Overnight, from [**2155-8-24**] to [**2155-8-25**], the patient continued to do well. She was able to tolerated her clear liquid diet throughout the day without nausea or vomiting. The hematocrit was noted to be stable at 32.8. Overnight, from [**2155-8-25**] to [**2155-8-26**] the patient continued to do well. She felt a slight amount of nausea with soft diet. She was diuresed with approximately 20 mg of Lasix from [**2155-8-25**] to [**2155-8-26**] given the positive fluid balance over the course of the past two days, weight was noted to be 75.8, which was fairly close to her known dry weight. The patient, however, did not have emesis with her soft diet. It was decided to continue the soft diet. At this point, it was decided to stop the patient's TPN; discontinued the central line; switch her from the IV cardiac medications to PO cardiac medications; and take her off telemetry. Overnight, from [**2155-8-26**] to [**2155-8-27**], the patient continued to do well. It was decided at this point that she be transferred to an acute rehabilitation facility here in [**State 350**], prior to her going her to [**State 760**]. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Small-bowel obstruction, status post exploratory laparotomy. 2. Non-Q-wave myocardial infarction. 3. Chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Protonix 40 mg PO q.d. 2. Enalapril 5 mg PO b.i.d. 3. Metoprolol 12.5 mg PO b.i.d. 4. Enteric aspirin 325 mg PO q.d. 5. Ativan 0.5 mg 6. Colace 10 mg PO b.i.d. 7. Ipratropium bromide 4 puffs q.i.d. 8. Flovent 110 mcg two puffs b.i.d. 9. Albuterol nebulizers one nebulizer q.6h.p.r.n. bronchospasm. 10. Albuterol one to two puffs q.4h. to 6h.p.r.n. bronchospasm. 11. Salmeterol two puffs b.i.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Name8 (MD) 16207**] MEDQUIST36 D: [**2155-8-27**] 04:56 T: [**2155-8-27**] 10:02 JOB#: [**Job Number 43770**]

[ "410.92", "560.81", "V45.82", "401.9", "491.21", "E878.8", "998.11", "530.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.91", "89.64", "54.59", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

12077, 12224

12247, 12928

3223, 12024

1263, 1409

1427, 1672

1748, 3205

882, 1239

1689, 1725

12049, 12056

18,648

140,132

4301

Discharge summary

report

Admission Date: [**2182-8-15**] Discharge Date: [**2182-8-22**] Service: CHIEF COMPLAINT: [**Hospital **] transfer from DWH for cardiac intervention HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female with no significant past medical history with no cardiac risk factors other than age. She was in her usual state of health until 11:30 p.m. on [**2182-8-13**] when she "was not feeling well". She called her son at the time who found her slumped over in the bathroom and called 911, unclear if there was loss of consciousness or trauma. The patient was brought to the DWH Emergency Room at which time she was awake and alert. She was complaining of substernal chest pain, shortness of breath and nausea. Vital signs at the time were blood pressure 120/66, heart rate 60. Electrocardiogram disclosed ST elevations in 2, 3, AVF, reciprocal depressions in V1, V2 and T-wave inversions in 1, [**Year (4 digits) **]. No right sided leads were done at the time. She was given sublingual nitro with a drop in her systolic blood pressure to the 80s. She was subsequently started on intravenous fluids and the decision was made to thrombolyse her. She received 325 mg of aspirin and 30 mg of TNK intravenous and was intubated electively. By report, the intubation was traumatic and there was blood removed from the OG tube. She was transferred to the Intensive Care Unit. While in the Intensive Care Unit, her cardiac enzymes continued to climb with CKs of 127, 639 and 1207. She had an episode of complete heart block to the 30s and hypertension which was treated with dopamine which in turn caused her to go into atrial fibrillation with a rapid ventricular rate. At that time, her dopamine dose was decreased and she was started on Levophed with aversion to normal sinus rhythm. She also had asymptomatic five to seven beat runs of nonsustained ventricular tachycardia while at the outside hospital. She received two units of packed red blood cells for a hematocrit of 27. She was transferred to [**Hospital6 256**] at 9 p.m. on [**8-15**]. Upon arrival to [**Hospital6 256**], after consultation with Dr. [**Last Name (STitle) **], it was felt that the patient would benefit from cardiac catheterization. She was subsequently taken to the catheter lab where a right heart catheter showed: RA 15/10/8, RV 23/8/13, PA 24/15/18, PCW 14/13/12, PA saturation 61%; there is significant difficulty advancing the right heart catheter. Anatomy LMCA separate ostia, LAD with mild disease, occlusion of OM1 which appeared old and collateralized by LAD, RCA subdural occlusion proximally. The RCA received a 3 x 18 mm stent which was complicated by ............. reflow phenomenon which required treatment with IC diltiazem and adenosine. She had a period of approximately a four second asystole at which time atropine, dopamine, Levophed, neo and amiodarone GGT were given with recovery of cardiac .............. It was felt that this was due to lack of capture of the pacer wire. IABPs were placed and the patient was transferred to the CCU for further monitoring. While in the CCU overnight, she was switched from 1 to 3 on IABPs from 1 to 1. She also required 1 unit packed red blood cells and [**Pager number **] cc normal saline bolus to maintain her systolic blood pressure. She was continued on Levophed and dopamine GGT for blood support as well. PAST MEDICAL HISTORY: 1. Arthritis 2. Recent cosmetic surgery 3. Easy bruising with normal CBC 4. Depression 5. Anxiety 5. Vertigo 6. Actinic keratosis on the right wrist 7. Bilateral cataract removal 8. Hard of hearing ALLERGIES: No known drug allergies. HOME MEDICATIONS: 1. Zoloft 50 q day 2. Multivitamin 3. Bufferin prn TRANSFER MEDICATIONS FROM OUTSIDE HOSPITAL: 1. Dopamine 5 2. Levophed 5 mcg 3. Aspirin 325 4. Heparin 500 units an hour 5. Zantac 50 intravenous q8h FAMILY HISTORY: Father died of a myocardial infarction in his 80s, mother died in her 70s. She had four siblings, three brothers and one sister. Two of her brothers died from myocardial infarction at ages 58 and 73, one from subarachnoid hemorrhage at 60. One sister died from pancreatic cancer. SOCIAL HISTORY: No tobacco, no alcohol. She is one of 12 children. Both her parents immigrated from [**Country 532**]. She is widowed. She has two sons and a daughter. Lives in [**Hospital3 12272**] with help of her son, actively walks daily. PHYSICAL EXAM: VITAL SIGNS: Temperature 99??????, pulse of 89, blood pressure of 99/41, respiratory rate of 13. O2 saturation was 98%. She was on AC 40%, TB 500, RR 12/20, PEEP of 5. GENERAL: She was an elderly female intubated, sedated and appears younger than stated age. HEAD, EARS, EYES, NOSE AND THROAT: Poor dentition. Mucous membranes dry. Pupils equal, round and reactive to light. Mild blood in oropharynx. NECK: Supple with no bruits. Normal upstroke. CHEST: Bibasilar crackles, no wheezes. HEART: Regular, 2/6 systolic murmur at left lower sternal border, normal S1, S2, no S3, S4. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: No cyanosis, clubbing or edema. Peripheral pulses bilaterally. NEUROLOGIC: Withdraws to pain, pupils reactive. TRANSFER LABS: White count of 16.8, hematocrit of 33.2, platelets 199. PT 13.6, PTT 47, INR 1.3. Chem-7 revealed a sodium of 138, potassium 4.1, chloride 107, bicarbonate 19, BUN of 48, creatinine of 0.9 with a glucose of 126. CK was 1443, MB 280, troponin greater than 50. AST 257, ALT 150, LDH 438, amylase 77, total bilirubin 0.3, lipase 18. IMAGING: Electrocardiogram from the outside hospital showed sinus rhythm at 53 beats per minute, normal axis, ST elevation in 3, greater than 2. Primary AV block, T-wave inversions in 1, [**Last Name (LF) **], [**First Name3 (LF) **] depressions in V1, V2. ST elevation in V5-V6. Chest x-ray showed no effusion. ETT in place. IABP in place. HOSPITAL COURSE: 1. Cardiac: As mentioned in the history of present illness, the patient was taken to cardiac catheterization lab on transfer to [**Hospital6 256**] after catheterization. She also underwent an echocardiogram which disclosed an ejection fraction of 45%, 1+ AR, 1+ MR and the inferior left ventricle was akinetic. The patient was transferred to the CCU and she was amiodarone, dopamine, Levophed, heparin, aspirin, Plavix and Lipitor. Eventually, the IABP was weaned and she was weaned off pressors on [**8-17**]. She was transferred to C-Med on [**8-20**] for further management. She was administered a beta blocker and ACE inhibitor and underwent further diuresis on the floor. 2. Pulmonary: While in the CCU, the patient was intubated. It was difficult to extubate the patient due to the traumatic intubation that she had experienced at the outside hospital. Anesthesia was consulted for assistance with her extubation. She was administered Decadron 10 gm q8h x48 hours to help prevent laryngeal edema following extubation. On the 22nd, the patient was extubated. 3. Gastrointestinal: It was noted that the patient had maroon aspirate from her OG tube. Her hematocrit was followed while in the CCU and she was transfused to maintain a hematocrit greater than 30. GI consult was obtained to help evaluate the source of her upper GI bleed. It was determined that the bleed was likely due to the administration of thrombolytics or NSAIDS. She was administered Protonix 40 mg intravenous [**Hospital1 **]. On [**8-19**], it was noted that the patient had melenic stools but this was attributed to her upper GI bleed. Since transfer to C-Med, her hematocrit has remained stable. 4. Heme: As mentioned above, the patient required transfusions to maintain her hematocrit greater than 30. Her hematocrit has been stable while on the floor. She was given Venodyne boots for deep venous thrombosis prophylaxis. 5. Fluids, electrolytes and nutrition: The patient was administered intravenous fluids and TPN while in the CCU since she has been on the floor and the C-Med service. She has been eating a cardiac diet. 6. Infectious disease: The patient remained afebrile, however it was noted that she had an elevated white count which was initially attributed to stress dose steroids that were administered in the CCU, but urinalysis from [**8-21**] indicates possible urinary tract infection. Urine culture is still pending. The patient is started on a seven day course of levofloxacin. DISPOSITION: The patient will be discharged to a rehabilitation facility. She will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5507**], who she says also takes care of her cardiac issues. CONDITION: Stable DISCHARGE DIAGNOSES: 1. Acute myocardial infarction 2. Hypercholesterolemia 3. Upper GI bleed 4. Urinary tract infection DISCHARGE MEDICATIONS: 1. Lisinopril 10 po qd 2. Lasix 20 mg po qd 3. Levofloxacin 500 mg po qd for five days 4. Protonix 40 mg po qd 5. Senna 1 tablet po qd 6. Colace 100 mg po bid 7. Atrovent inhaler 1 to 2 puffs q6h prn 8. Orabase dental paste one application as needed 9. Plavix 75 mg qd for 30 days 10. Tylenol 325 to 650 mg q 4 to 6 hours prn 11. Atorvastatin 10 mg po qd 12. Aspirin 325 mg po qd 13. Insulin sliding scale DISCHARGE INSTRUCTIONS: The patient is instructed to go to rehabilitation and she will follow up with Dr. [**Last Name (STitle) 5507**] when she is discharged. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 18632**] MEDQUIST36 D: [**2182-8-22**] 10:54 T: [**2182-8-22**] 10:55 JOB#: [**Job Number 18633**]

[ "424.0", "785.51", "414.01", "458.9", "410.51", "599.0", "E935.9", "997.1", "578.9" ]

icd9cm

[ [ [] ] ]

[ "36.06", "99.15", "96.04", "88.53", "88.56", "96.71", "37.65", "36.01", "38.93", "37.23" ]

icd9pcs

[ [ [] ] ]

3914, 4198

8756, 8861

8884, 9300

5959, 8735

9325, 9769

4463, 5942

3687, 3897

101, 161

190, 3401

3423, 3669

4215, 4448

6,184

128,235

12942

Discharge summary

report

Admission Date: [**2102-11-24**] Discharge Date: [**2102-11-29**] Date of Birth: [**2070-8-8**] Sex: F Service: ANTEPARDUM CHIEF COMPLAINT: 32-year-old G1 at 24 weeks and six days gestation presented to clinic for a one hour GLT complaining of left flank pain. HISTORY OF PRESENT ILLNESS: Patient presented to the clinic for a routine prenatal care appointment and developed urinary frequency and rigors. Patient had nausea and vomiting. Patient denied any diarrhea, constipation, loss of fluid, vaginal bleeding or contractions at the time. Patient did note fetal movement. Patient stated that there were positive sick contacts at work. PRENATAL COURSE: Estimated due date of [**2103-3-8**] by LMP of [**2102-5-28**]. Triple screen normal. ULTRASOUND: First trimester ultrasound about six week size equal to dates. Level II ultrasound at 17 weeks noted a normal survey with size equal to dates. PAST MEDICAL HISTORY: 1. Lymphoma in [**2090**] status post diagnostic staging laparotomy. 2. Hypothyroidism. PAST SURGICAL HISTORY: 1. Staging laparotomy. 2. Lymph node biopsy times two. ALLERGIES: ? NyQuil. MEDICATIONS: 1. Prenatal vitamins. 2. Levoxyl 100 mcg p.o. q.d. SOCIAL HISTORY: No tobacco, alcohol or drugs. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 101.9 F, pulse 128, blood pressure 120/65. General: In no apparent distress. Cardiovascular: Tachycardia, no murmurs, rubs, or gallops. Chest clear to auscultation bilaterally. Abdomen: Soft, nontender, gravid, minimal left CVA tenderness, no rebound. Extremities: No edema. Sterile vaginal exam: Closed, long, posterior. LABORATORY DATA: External fetal monitoring 140s. Tocometer irritability noted. White count 10.1, hematocrit 30.1, platelets 299. TSH 0.92. Free T4 0.8. ASSESSMENT: 32 year-old G1 at 24 weeks and six days with fever, nausea, vomiting, urinary frequency and left flank pain. HOSPITAL COURSE: 1. PYELONEPHRITIS: Patient was essentially ruled out for gastroenteritis secondary to her symptoms being more consistent with pyelonephritis. Her urine sample is noted to be positive for gram negative rods and gram positive rods. At the time of admission, culture was pending and patient was started empirically on Kefzol IV. Additionally, the patient was noted to have 26 white blood cells and many bacteria on urinalysis. Patient's course was monitored with serial laboratory values and her white blood cell count increased to 22.1 on the same day. Patient was given Morphine Sulfate for her pain which helped modify it somewhat initially. During the course of hospital day #2, the patient developed a temperature with spike to 103.6 F and her pain was substantially greater. Patient had a renal ultrasound which showed moderate left hydronephrosis and mild right hydronephrosis. Obstructing stone could not be ruled out at the time. (Please see formal radiology report for details). Cultures are still pending and Ampicillin was added to the antibiotic regimen. On hospital day #3, the patient's white count was elevated to 40.4 with bandemia of 30. Sensitives did come back and patient was switched to Ceftriaxone and Ampicillin IV. On the night of hospital day #2, patient noted shortness of breath and was requiring oxygen. This was the point at which patient's white count had been increasing and bandemia was worsening. Secondary to her tachypnea and patient's blood pressure ranging in the 90s over 30 to 60s, the patient was transferred to the Intensive Care Unit for closer monitoring. Sensitivities were obtained and the culture grew out E.coli which was pan sensitive. The patient's antibiotic regimen was changed to Ceftriaxone and Vancomycin to cover sepsis in an asplenic patient. Patient also seemed to be somewhat volume depleted and upon improvement of her volume status, the patient's tachycardia decreased and urine output increased. Additionally, patient's pressure seemed to be dependent on position and this might of been an element of decreased venous return when the fetus rested on the IVC. The patient was switched to Ceftriaxone and broadened coverage with Ampicillin secondary to her asplenism. Patient was transferred back to the floor on hospital day #4 and continued to improve her IV antibiotics. Serial urinalysis were done in addition to her complete blood count. 2. RESPIRATORY: Left lower lobe pneumonia was noted after patient had complaints of shortness of breath. The patient was tachypneic in the Intensive Care Unit and the chest x-ray showed low volume, but no edema or infiltrates. Patient was noted to have respiratory alkalosis with metabolic acidosis with a gap of 16 and lactate. Patient's acid base status improved on hospital day #3 and was repleted accordingly. 3. FETAL WELL-BEING: A MSM consult was obtained on hospital day #3 and biophysical testing was noted to be [**6-29**]. The amniotic fluid volume was 15 and the estimated fetal weight was 1028 grams which placed it in the 67th percentile at 25 weeks four days gestation. DISCHARGE DIAGNOSES: 1. 25 weeks and five days gestation single intrauterine pregnancy. 2. Urosepsis with E.coli status post Ceftriaxone and Ampicillin. 3. Left lower lobe pneumonia. 4. Hodgkin's lymphoma status post staging laparotomy. 5. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Ampicillin 500 p.o. q.i.d. times five days. 2. Macrobid 100 mg p.o. q.d. 3. Maalox / TUMs p.r.n. DISCHARGE PLAN: Patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two weeks in clinic. CONDITION ON DISCHARGE: Stable. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11383**], M.D. [**MD Number(1) 39745**] Dictated By:[**Last Name (NamePattern4) 8102**] MEDQUIST36 D: [**2102-11-29**] 15:47 T: [**2102-11-29**] 15:52 JOB#: [**Job Number **]

[ "646.63", "518.0", "280.9", "648.13", "244.9", "276.4", "V10.72", "648.23", "590.10" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1275, 1293

5095, 5336

5359, 5463

1957, 5074

1062, 1210

1316, 1939

158, 280

309, 926

5480, 5604

948, 1039

1227, 1258

5629, 5913

9,984

194,393

10059+56099

Discharge summary

report+addendum

Admission Date: [**2136-10-11**] Discharge Date: [**2136-10-29**] Service: TRAUMA HISTORY OF PRESENT ILLNESS: This is a 79 year old female who was a pedestrian struck by a car with loss of consciousness. She recovered consciousness once the medics arrived. She complained of lower extremity and head pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. High cholesterol. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission, temperature is 96.7, blood pressure 164/palpable, heart rate 72, respiratory rate 20, oxygen saturation 98% in room air. She was alert and oriented times three. Head, eyes, ears, nose and throat examination showed a stellate laceration over the right frontal parietal area. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Neck - cervical collar was in place. Cardiovascular - regular rate and rhythm, no murmurs, rubs or gallops. The lungs are clear to auscultation bilaterally. Back - There was no step-off but there was scoliosis and there was tenderness over the thoracic spine. Rectal was guaiac negative with normal tone. Extremities - bilateral lower extremity swelling and deformities at the level of the proximal tibial region, 1+ radial, femoral, popliteal pulses, dorsalis pedis and posterior tibial pulses. Neurologically, she was alert and oriented times three and following commands. LABORATORY DATA: White blood cell count 9.0, hematocrit 23.0, platelet count 205,000. INR 1.1, prothrombin time 12.5, partial thromboplastin time 23.8. Sodium 134, potassium 4.0, chloride 103, blood urea nitrogen 29, creatinine 0.9, glucose 116. Toxicology screen was negative. Urinalysis was negative. Arterial blood gases was 7.42/37/66/25/0. Chest x-ray showed no pneumothorax or widened mediastinum. Pelvis showed no gross deformity. Head CT was negative for bleed. CT cervical spine showed a C2 fracture involving the vertebral artery foramen. Abdominal and pelvic CT showed a right sacral fracture, symphysis pubic fracture and inferior pubic rami fracture. Lower extremity x-rays showed right lateral tibial plateau split fracture with metaphyseal segmental fracture. On the left lower extremity, there was a tibial plateau fracture. HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit for further management. The patient developed bilateral compartment syndrome and was taken to the operating room on [**2136-10-11**], for bilateral fasciotomies and external fixation of her bilateral tibial plateau fractures. The patient remained in the Intensive Care Unit until [**2136-10-15**]. She was appropriately weaned off pressors and drips. On [**2136-10-16**], the patient was transferred to the floor. For her C2 fracture involving the vertebral artery foramen, orthopedic spine was consulted and recommended a hard collar to stay in place for two to three months. On [**2136-10-22**], the patient returned to the operating room for open reduction and internal fixation of her bilateral tibial fibular fractures. Postoperatively, the patient remained in the Post Anesthesia Care Unit for two days and was appropriately weaned off pressors. Her wound culture grew pseudomonas which was sensitive to Ciprofloxacin. The patient was initially started on Zosyn and then changed to Ciprofloxacin. While in the hospital, the patient was started on TPN and tolerated tube feeds and p.o. calorie counts were done and were adequate. Towards the end of her hospital course, the patient developed some edema and required diuresis with Lasix. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged to rehabilitation. DISCHARGE DIAGNOSES: 1. Status post pedestrian struck by motor vehicle with a right sacral fracture with pubic rami fracture, C2 fracture of the vertebral artery foramen, bilateral tibial fibular fractures, status post open reduction and internal fixation. 2. Hypertension. MEDICATIONS ON DISCHARGE: 1. Lovenox 30 mg subcutaneous twice a day. 2. Metoprolol 25 mg p.o. twice a day. 3. Ciprofloxacin 500 mg p.o. twice a day to be administered for two weeks starting from [**2136-10-27**]. 4. Benadryl 25 mg p.o. q.h.s. p.r.n. 5. Morphine Sulfate 2 to 4 mg intravenously q2hours p.r.n. pain. 6. Percocet Elixir 5/325, 5 to 10 ccs q4-6hours p.r.n. pain. 7. Dulcolax 10 mg PR p.r.n. 8. Bacitracin Ointment to the right forehead three times a day. 9. Lipitor 10 mg p.o. once daily. The patient is to remain in her cervical collar for approximately six to eight weeks. She is to have a follow-up appointment with orthopedic spine, Dr. [**First Name (STitle) 1022**], in three weeks. The patient is nonweight-bearing bilateral lower extremities for six to eight weeks and is to follow-up with orthopedics in one to two weeks. The patient is to have CPM of the right lower extremity and her dressing changed once daily. The patient is to follow-up with orthopedic spine in three weeks and with orthopedics in one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**] Dictated By:[**Last Name (NamePattern1) 13577**] MEDQUIST36 D: [**2136-10-28**] 10:43 T: [**2136-10-28**] 11:19 JOB#: [**Job Number 21797**] Name: [**Known lastname 5405**], [**Known firstname **] Unit No: [**Numeric Identifier 5878**] Admission Date: [**2136-10-11**] Discharge Date: [**2136-10-30**] Date of Birth: [**2056-10-11**] Sex: F Service: Trauma ADDENDUM: The patient was discharged from the hospital to rehabilitation on [**10-30**]. MEDICATIONS: (Add to Discharge Medications) The patient is discharged on Lipitor 10 mg p.o. once a day, Lasix 20 mg p.o. once a day for approximately five to seven days and K-dur 20 mEq p.o. q. day while she is on the Lasix. [**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**] Dictated By:[**Last Name (NamePattern1) 5879**] MEDQUIST36 D: [**2136-10-30**] 14:22 T: [**2136-10-30**] 14:44 JOB#: [**Job Number 5880**]

[ "808.2", "E814.7", "958.8", "823.00", "287.5", "805.6", "806.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "86.22", "79.36", "78.67", "99.15", "83.14", "78.17" ]

icd9pcs

[ [ [] ] ]

3757, 4013

4039, 6210

2324, 3636

408, 453

476, 2306

123, 321

343, 384

3661, 3736

24,229

121,295

45495

Discharge summary

report

Admission Date: [**2171-4-25**] Discharge Date: [**2171-5-14**] Date of Birth: [**2114-7-7**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1973**] Chief Complaint: Fever and shortness of breath. Major Surgical or Invasive Procedure: 1) intubation and ventilation 2) right wrist arthrocentesis 3) bronchoscopy 4) echocardiogram History of Present Illness: Patient is a 56 year old man with a past medical history significant for hepatitis C, on interferon, COPD, yearly pneumonias, with one in [**2163**] that required medical induced coma and ventilator for one month who developed fever and shortness of breath over the past three days. Per the patient's wife, the couple had babysat their sick one year old nephew this past weekend. Subsequently, he developed three days of progressive fever, nonproductive cough, and shortness of breath. Of note, he recently completed a z-pack for a pneumonia three weeks ago, that was prescribed by his outpatient physician. [**Name10 (NameIs) **] the past twenty four hours, the patient became more weak and had increased shortness of breath. Concerned, he was brought to the ED by his wife on the day of admission. In the ED, patient was noted to have a temperature of 99.1 on admission (spiked to 104.1), HR 133, BP 90/56, RR 20, and oxygen saturation was 74% on room air. He had a white count of 7.2, with 72% PMNs and 22 bands. Lactate was 6.3. First set of troponins were negative. Chest xray revealed interstitial and alveolar edema, so he received IV lasix. In addition, he was started on vancomycin, ceftriaxone, and azithromycin. A trial on BiPap was started for hypoxia to the 70's. The oxygen saturations did not improve, so he was intubated. Blood pressure was noted to decrease to the 70-80s, so he was given three liters of IV fluids, started on levophed, and transferred to the ICU on a sepsis protocol. Had traumatic foley insertion on admission which resulted in transfusion of 7 units of PRBCs during his ICU stay as well as CBI for large bladder clot. By the time he was tx'ed to 11 [**Hospital Ward Name **], his urine was clear and the foley was removed, although he continued to pass intermittant small clots (per GU this was expected) Shortly after admission, he grew out strep pneumomonia in his blood cx's from admission and his sputum had MRSA. Was seen by ID in ICU because of persistent fevers. Bronch on [**5-3**] with dynamic lower trachea collapse. He finished 14 days of abx by the time he was tx'ed out of the ICU. Pt was initially on levofloxacin then CTX, then Zosyn/vanco MRSA (VAP). Zosyn was stopped for rash followed by ARF. Past Medical History: -Hepatitis C virus, genotype 1a (most recent liver biopsy was performed in [**2170-9-19**] revealing stage IV fibrosis and grade 2 inflammation); being treated with pegylated interferon and ribavirin; most recent viral load not detected in [**2171-3-19**]. -History of GI bleed in [**2164**]: Grade [**11-20**] esophagitis with no bleeding in the lower third of the esophagus. No definite varices were seen ([**2170-10-19**]). -Paget's disease. -History of severe pneumonia (required intubation in [**2163**]); yearly pneumonias that usually resolve with outpatient antibiotics. -Barrett's esophagus. -H/O chronic osteomyelitis of the spine as well as multifocal osteomyelitis. -Asthma. -prior MRSA. -Hypertension. -COPD. -GERD. -Endocarditis in the early [**2153**]'s. -Seasonal allergies. -Osteoarthritis. -History of mumps and measles as a child. -Depression. . Past Surgical History: -b/l hip replacements -irrigation/debridement L hip -Ankle flap -CEA -s/p 3 lumbar spine surgeries, including ? multilevel fusion -Bilateral hip arthroplasty. -Irrigation debridement of left hip. -Ankle flap. -Strangulated hernia surgery repair. -Ruptured appendectomy repair. -Right ulnar joint surgery. -Bilateral carpal tunnel surgery. Social History: Patient lives with wife. On disability following crush injury in railroad yard. Former heavy smoker (60 pack year smoking history) and alcohol user, but has not used either substance in the past eighteen months. TOB-occas cigar ETOH-occasional IVDA-denies Family History: Noncontributory Physical Exam: T:102.7 BP:107/61 HR:116 RR:29 O2saturation:98% on 70% FiO2, PEEP 10. Gen: Intubated man laying in bed. Withdraws to pain. Warm to touch. HEENT: No icterus. Pupils 3mm. NECK: Right IJ in place. Left JVP appeared at 8cm, but difficult to assess with intubation. CV: Tachycardic. Regular. Normal S1 and S2, with 3/6 systolic murmur at left lower sternal border. No rubs or [**Last Name (un) 549**] appreciated. LUNGS: On anterior examination, rhonchorous breath sounds. No wheezing appreciated. ABD: Well healed surgical scar in right upper quadrant. No bowel sounds appreciated. Distended, but soft abdomen. In left upper quadrant, indurated 10x5cm erythematous patch with mild scale on border edge. Liver edge not palpated, but auscultated at approxiamtely 10cm. No splenomegaly appreciated. EXT: Warm and well perfused. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally. Well healed skin graft over left medial ankle. Pertinent Results: [**2171-4-25**] 12:45PM PT-17.4* PTT-40.3* INR(PT)-1.6* [**2171-4-25**] 12:45PM PLT SMR-LOW PLT COUNT-83* [**2171-4-25**] 12:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2171-4-25**] 12:45PM NEUTS-72* BANDS-22* LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2171-4-25**] 12:45PM WBC-7.2 RBC-4.01* HGB-12.7* HCT-38.7* MCV-97 MCH-31.6 MCHC-32.8 RDW-15.3 [**2171-4-25**] 12:45PM CRP-GREATER TH [**2171-4-25**] 12:45PM CORTISOL-45.8* [**2171-4-25**] 12:45PM CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-1.6 [**2171-4-25**] 12:45PM cTropnT-<0.01 [**2171-4-25**] 12:49PM LACTATE-6.3* K+-7.0* [**2171-4-25**] 02:49PM O2 SAT-96 [**2171-4-25**] 02:49PM LACTATE-4.5* K+-3.2* [**2171-4-25**] 02:49PM TYPE-[**Last Name (un) **] TEMP-37.3 RATES-14/14 TIDAL VOL-500 O2-100 INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-GREEN TOP [**2171-4-25**] 02:50PM ALBUMIN-2.7* CALCIUM-6.8* PHOSPHATE-2.4* MAGNESIUM-1.3* [**2171-4-25**] 02:50PM CK-MB-3 proBNP-1339* [**2171-4-25**] 02:50PM LIPASE-7 [**2171-4-25**] 02:50PM ALT(SGPT)-46* AST(SGOT)-112* LD(LDH)-229 CK(CPK)-273* ALK PHOS-33* AMYLASE-17 TOT BILI-2.3* [**2171-4-25**] 02:50PM GLUCOSE-136* UREA N-37* CREAT-1.1 SODIUM-132* POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-19* ANION GAP-15 [**2171-4-25**] 04:11PM LACTATE-3.9* [**2171-4-25**] 08:01PM FIBRINOGE-612*# [**2171-4-25**] 08:01PM FDP-10-40 [**2171-4-25**] 08:01PM PT-17.6* PTT-45.5* INR(PT)-1.6* [**2171-4-25**] 08:01PM PLT COUNT-68* [**2171-4-25**] 08:01PM WBC-6.4 RBC-3.18* HGB-10.4* HCT-30.4* MCV-95 MCH-32.7* MCHC-34.3 RDW-14.9 [**2171-4-25**] 08:01PM CALCIUM-6.7* PHOSPHATE-2.2* MAGNESIUM-1.4* [**2171-4-25**] 08:01PM CK-MB-4 cTropnT-<0.01 [**2171-4-25**] 08:01PM LD(LDH)-268* CK(CPK)-307* [**2171-4-25**] 08:01PM GLUCOSE-108* UREA N-39* CREAT-1.3* SODIUM-137 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-20* ANION GAP-16 . [**4-26**] CXR Lung volumes have improved since [**4-25**] along with a component of pulmonary edema, but there is still extensive opacification in the lower lungs and a suggestion of cavitation bilaterally which would be due to pneumonia. Heart size is normal and there is no appreciable mediastinal vascular engorgement. ET tube and right jugular line are in standard placements. There is no pneumothorax. Small bilateral pleural effusions are presumed. If the clinical picture is not clear, CT scanning would be helpful. . [**4-30**] CT HEAD FINDINGS: There is no intracranial hemorrhage. There is no midline shift, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is atherosclerotic disease within the vertebral and internal carotid arteries. The paranasal sinuses are well aerated. IMPRESSION: No intracranial hemorrhage or mass effect. . [**4-30**] CT TORSO IMPRESSION: 1. Consolidation in the lower lobes and nodular opacities in the upper lobes bilaterally consistent with multifocal pneumonia. 2. Small bilateral pleural effusions, partially loculated at the apex; however, no evidence for empyema. 3. 4-mm non-obstructing stone in the lower pole of the left kidney. 4. Cardiomegaly. 5. Mild periportal lymphadenopathy, likely due to the patient's known hepatitis. 6. No free intra-abdominal air. TEE: Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. There are no aortic atheroma to 35 cm past the incisors. TTE: Conclusions: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal(LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch 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. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No valve vegetations seen. If clinically indictaed, a TEE may better exclude endocarditis. Compared to the prior study dated [**2171-4-26**], tricupsid regurgitation is more prominent (may not have been as well characterized on the prior study). Otherwise, no change. Brief Hospital Course: 1. Acute Renal Failure due to Acute Interstitial Nephritis - Presumed due to Zosyn - Renal was consulted, no eos's in urine, but timing with rash classic for AIN, and steady resolution was consistent with time course - Medications were renally dosed - Given the ARF, we did not start NSAIDS for pseudogout 2. Pseudogout - Rheum consulted [**2171-5-7**] for wrist swelling - Arthrocentesis of right wrist with calcium pyrophosphate crystals - oral prednisone with symptomatic improvement, as NSAIDs were contraindicated due to his ARF - Pain control with topical lidocaine, oxycodone 3. Pneumococcal Pneumonia - Extubated [**5-8**] after failing multiple trials in ICU - O2 Sats were normal on arrival to floor - Treated with Vanco/Zosyn, now off both - Incentive Spirometry - Nebulizers 4. Acute Blood Loss Anemia due to Massive Hematuria due to traumatic foley catheter insertion - Transfused 7units PRBC - CBI was used - GU consultation - HCT stable - No further gross hematuria - GU notes may be several days of passing additional clots 5. Hepatitis C, Chronic - [**Month (only) 116**] resume peg-intron as an outpatient - [**Month (only) 116**] resume ribavirin Medications on Admission: -Spiriva. -Advair. -Albuterol. -Peg-Inteferon 150 micrograms injecting 0.5 ml weekly. -Ribavirin 1200 mg daily. -Percocet 10-325 1.5 tablets every 4-6 hours as needed for pain. Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical once a day as needed for pain for 7 days: Apply for 12 hours only in a 24 hour period. Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0* 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 15 days. Disp:*30 Tablet(s)* Refills:*0* 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*0* 7. Peg-Intron 150 mcg/0.5 mL Kit Sig: One (1) injection Subcutaneous once a week. 8. Ribavirin 600 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1) Pneumococcal sepsis with hypotension requiring pressor support 2) multifocal pneumonia with respiratory failure 3) acute renal failure 4) hematuria with bladder hematoma 5) acute blood loss anemia 6) Pseudogout flare of right wrist 7) MRSA in sputum Discharge Condition: stable Discharge Instructions: Return to the hospital if you have chest pain, fevers/chills, shortness of breath, Followup Instructions: 1) PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 11139**] 2) Dr. [**First Name (STitle) **] [**Name (STitle) **] in rheumatology clinic [**Telephone/Fax (1) 1668**] within 4 wks of dc 3) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] in urology clinic

[ "112.2", "428.0", "580.9", "530.85", "V09.0", "E879.6", "584.9", "867.0", "287.5", "481", "041.11", "730.18", "274.0", "038.2", "070.70", "285.1", "799.02", "995.92", "599.7", "401.9", "711.03", "E849.7", "311", "996.62", "518.81", "493.20" ]

icd9cm

[ [ [] ] ]

[ "38.91", "33.23", "93.90", "81.91", "88.72", "99.04", "96.04", "03.31", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

13077, 13083

10538, 11709

302, 398

13379, 13387

5255, 10515

13518, 13881

4220, 4237

11937, 13054

13104, 13358

11735, 11914

13411, 13495

3589, 3930

4252, 5236

232, 264

426, 2678

2700, 3566

3946, 4204

15,595

153,762

7862

Discharge summary

report

Admission Date: [**2133-3-16**] Discharge Date: [**2133-3-20**] Date of Birth: [**2056-6-18**] Sex: M Service: DISCHARGE DIAGNOSIS: Intracranial hemorrhage. MEDICATIONS: 1. Somantadine 20 mg po b.i.d. 2. Glycerine 25 mg po q.i.d. 3. Insulin sliding scale. 4. Metoprolol 25 mg po b.i.d. 5. Percocet 5 ml NG q 6 hours. 6. Dilantin 300 mg q.h.s. 7. Pravastatin 40 mg po q day. HISTORY OF PRESENT ILLNESS: This is a 76 year-old right handed man who presents with a past medical history significant for severe vascular disease, who presented with a left facial droop and was transferred to [**Hospital1 346**] from an outside hospital after a head CT at the outside hospital showed a right frontal intraparenchymal hemorrhage. His wife states that about nine years ago he was arrested and as he was put in the police car hit his head on the door. Since then he states he has been having headaches. His family states that for the past several days he has also been vomiting and increasingly somnolent. On Saturday his wife also noted left facial droop, which he did not himself noticed and she brought him to an outside hospital. It was there that a head CT was done, which showed not only a right frontal intraparenchymal hemorrhage, but also a subacute infarct in his right parietal occipital area with a question of whether or not he had bled into the area of the stroke. There was also some mass effect around the area of the hemorrhage. In evaluation by Neurosurgery in the Emergency Department it was deemed that no acute invasive intervention was required. The patient states that he feels well and is having no problems currently. [**Name2 (NI) **] does complain of some back pain, but states that he has been having this for 20 years. PAST MEDICAL HISTORY: 1. Bilateral carotid endarterectomies. 2. Hypertension. 3. Hypercholesterolemia. 4. Status post abdominal aortic aneurysm repair. 5. Status post bilateral femoral popliteal bypass. 6. Rheumatoid arthritis. 7. Macular degeneration with very poor eyesight. 8. Status post femoral bypass and aortobifemoral bypass. 9. Chronic back pain on Percocet for years. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Plavix. 2. Pravachol. 3. Aspirin. 4. Atenolol. 5. Percocet. SOCIAL HISTORY: He quit smoking four years ago. He is married and lives with his wife. [**Name (NI) **] was recently arrested for tax evasion as well as possible other issues. At the time of admission the head CT from the outside hospital showed a right frontal intraparenchymal hemorrhage as well as some evidence for a subacute infarct. The patient was admitted to the Intensive Care Unit for blood pressure control initially. HOSPITAL COURSE: The patient had multiple imaging studies during this hospitalization. An MRI with MRA was done on admission. It showed that he had a large area in the right frontal lobe consistent with the area of hemorrhage with a mild displacement of the anterior septum callosum of approximately 3 mm from right to left. There is no evidence of restrictive diffusion on the MRI to indicate acute infarction. There were multiple T2 abnormal signal fossae on the right parietal temporal occipital region perhaps related to an infarct of an unknown nature. On examination of the MRA the patient had total occlusion of his left internal carotid artery. There is also intermittent occlusion of his left vertebral artery in the neck with reconstitution of the occipital branches. He had a carotid series obtained on [**3-16**] that showed he had no significant stenosis of his right or left internal carotid arteries. The patient did have follow up head CTs on [**3-16**] and [**3-17**] and [**3-18**] all of these showed that the patient had stable size in his intraparenchymal hemorrhage with no extension of the hemorrhage and with no further displacement of brain. The patient also had a chest x-ray to rule out pneumonia with no evidence of any focal consolidations and minimal atelectasis at the bases. After admission the patient's medications were changed. His aspirin and Plavix were stopped. The AVM was excluded after neurosurgery did an angiogram showing that there is no evidence for intracranial AVM either elsewhere in the brain or at the site of the bleed. The patient did initially require some sedation, because he became quite agitated at night and Seroquel was used, but this tended to make him sleepy as well during the day. After several days we did stop the Seroquel on both prn orders as well as a night time order, because the family's concern that this was making him increasingly agitated. There was some confusion with family members as well as discretion and some disagreements between family members about the course of action for the patient as well as which medications the patient should receive. We did keep him on scheduled doses of Percocet, because of his chronic history of Percocet use and to prevent withdraw seizures or problems from the Percocet. The patient did not have any problems with this. The family did request extra Percocet, but the patient himself was not requesting extra Percocet, so we did not increase his Percocet dose. To help prophylactic against the possibility of seizures the patient was started on Dilantin at the time of admission with 300 mg po q day. His levels remained stable at around 11 and he did not exhibit any seizures. We evaluated the patient's cardiac status at the time of admission. He had no evidence for myocardial infarction. We did two sets of enzymes both of which were negative. He remained in normal sinus rhythm during his hospitalization here. The patient was evaluated by Vascular Surgery who did not feel that intervention at this time was indicated. In terms of the patient's disposition he was evaluated by physical therapy and occupational therapy who felt that the patient would benefit from acute rehabilitation services. This will be arranged for the patient for his discharge. A nodule was noted on his chest x-ray after his admission here. A chest CT was performed to evaluate this and revealed that it was an old asbestos scar and that no further intervention was indicated to evaluate this. The Vascular Surgery Service did evaluate the patient and suggested that they would consider surgery on his left carotid occlusion once his hemorrhage clears entirely, which may be several months and he should follow up with them as an outpatient. Follow up appointments for this patient will be arranged with Vascular Surgery and with the Stroke Service as well as with his primary care physician. [**Name10 (NameIs) **] the time of this dictation the patient's mental status had improved. He is able to tell us his name, location. His speech is fluent and follows simple one or tow step commands. His face is grossly symmetric. His tongue is midline. He moves all extremities. He is able to sit up on the side of his bed as well as stand up on his own. He walks on his own with no assistance currently. The patient had been complaining of headaches since he has been alert enough to talk to us. We initially tried starting the patient on Neurontin, but the family refused to have the patient receive this medication. We also tried to start Glycerine, but the family was initially refusing this medication as well. His blood pressure will need to be monitored as an outpatient with a goal systolic blood pressure less then 160. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 28327**] Dictated By:[**Last Name (NamePattern1) 10209**] MEDQUIST36 D: [**2133-3-20**] 07:20 T: [**2133-3-20**] 07:49 JOB#: [**Job Number 28328**]

[ "851.80", "414.01", "433.10", "276.5", "714.0", "272.0", "V45.82", "401.9", "E917.4" ]

icd9cm

[ [ [] ] ]

[ "88.41" ]

icd9pcs

[ [ [] ] ]

152, 403

2737, 7756

432, 1776

1798, 2284

2301, 2719

22,714

172,150

53401

Discharge summary

report

Admission Date: [**2122-3-31**] Discharge Date: [**2122-4-3**] Service: CHIEF COMPLAINT: Jaundice and hematemesis. HISTORY OF PRESENT ILLNESS: This is an 89-year-old woman resident of [**Location 109829**] with a history of chronic obstructive pulmonary disease, congestive heart failure, and hypertension, admitted from [**Hospital3 **] due to several episodes of hematemesis at nursing facility. Per [**Hospital3 **] records she has had nausea and vomiting over the past two weeks with jaundice noticed the day of admission. By Ms. [**Known lastname 109830**] report she denies fevers, chills, diarrhea, melena, or hematemesis prior to this recent episode. She cannot quantify how many times she has vomited, but denies abdominal pain, or history of ulcer disease. Per chart she is alert and oriented x 3, independent, with 100% activities of daily living. Her last admission to [**Hospital1 1444**] was in [**2119**]. In the Emergency Department Ms. [**Known lastname **] was noted to be very jaundiced. Bilirubin was 8 (6.9 direct), white blood cell count 25, alkaline phosphatase over 1,000. Right upper quadrant ultrasound showed common bile duct 13 mm, distended gallbladder, no choledocholithiasis, no obstructing mass. In the Emergency Department the patient had hematemesis of about 1-2 liters of coffee ground emesis, cleared with 750 cc of nasogastric lavage. The patient was hemodynamically stable. Blood pressure was about 170 systolic, heart rate in the 80s, with an hematocrit of 34.2, which dropped to 31. She was treated with normal saline boluses, and Protonix intravenously. Endoscopic retrograde cholangiopancreatography fellow was called and scoped in the AM. The patient is DNR/DNI. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Congestive heart failure. Echocardiogram showed normal biventricular function, moderate MR, moderate to severe TR, and pulmonary hypertension. 3. Hypertension. 4. Deep venous thrombosis of left popliteal, right popliteal, and STV in [**2119-4-3**]. 5. VRE in [**2114-4-3**]. 6. Clostridium difficile in [**2119-6-3**]. 7. Left hemispheric stroke with residual right hemiplegia, upper extremities greater than lower extremities. 8. Peripheral vascular disease status post femoral-popliteal bypass on the left side. MEDICATIONS ON ADMISSION: Tylenol 650 once daily; Norvasc 2.5 once daily; aspirin 325 once daily; Os-Cal 500 once daily; Colace 100 b.i.d.; Estraderm patch q. three days; beclomethasone; AeroBid 4 twice a day; Axid; [**Doctor First Name **] 60 mg once daily; Zestril 5 mg once daily; Citrucel; M.V.I.; and Detrol. ALLERGIES: Penicillin, Keflex, Captopril, erythromycin, and shellfish. PHYSICAL EXAMINATION: On admission her temperature was 100.3, pulse 89, blood pressure 188/45, respiratory rate 20, 97% on room air. In general she was a thin, elderly lady lying in bed in no acute distress. Head, eyes, ears, nose and throat - normocephalic, atraumatic, extraocular movements intact, sclerae icteric, pupils small, 2 mm, surgical, oropharynx dry. Chest had rales at the right base. Heart was regular rate and rhythm with a 2/6 systolic ejection murmur at the right upper sternal border. The abdomen was soft with bowel sounds, healed mid lower abdominal scar, nontender, no hepatosplenomegaly noted. Extremities had 1+ bilateral edema. The right lower extremity was in an Aircast. Rectal examination showed guaiac-positive stools, brown. Neurologic examination showed her to be alert and oriented x 3, moving all four extremities. Ultrasound showed dilatation of intrahepatic and common bile duct 13 mm, distended gallbladder, no pericholecystic fluid, positive dilated bile duct, no choledocholithiasis, no obstructing mass, normal kidneys. There was a 2-cm simple cyst in the right kidney. LABORATORY STUDIES: On admission her white count was 25.7, hematocrit 34.2, platelets 506, sodium 130, potassium 4, chloride 91, bicarbonate 27, BUN 18, creatinine 0.8, glucose 115, ALT 316, AST 369, alkaline phosphatase 1097, bilirubin 8.7 with direct of 6, amylase 79, lipase 98, INR 1.3, and partial thromboplastin time 28. HOSPITAL COURSE: This is a [**Age over 90 **]-year-old female resident of [**Hospital3 **] admitted with at least four days of intermittent nausea, vomiting, and jaundice x 1 day with coffee ground emesis. 1. Gastrointestinal: The patient underwent endoscopic retrograde cholangiopancreatography which had demonstrated stenosed and ulcerated distal esophagus and a duodenal mass suggestive of cancer, which was biopsied. There was moderate common bile duct dilatation and successful plastic stent placement in the common bile duct. The patient subsequently underwent CT of the abdomen for further staging, which demonstrated three hypodense lesions in the liver (the biggest at 13 mm) and an atrophic pancreas. A hypodense mass of 20 mm was noted in the head of the pancreas which abuts the superior mesenteric vein but does not compress it. The patient was also noted to have pleural effusion bilaterally and a hiatal hernia. No other nodes or significant lymphadenopathy was noted on CT of the chest and pelvis. Ulcerations in the esophagus were treated with Protonix b.i.d. The patient was able to tolerate food very well after her procedure and no further hematemesis was noted. The patient's hematocrit remained stable and on the day of discharge was noted to be 34.3 down from 38 on the day of admission. The patient's white count also decreased and the patient will continue a course of levofloxacin for seven days after endoscopic retrograde cholangiopancreatography as prophylaxis. Liver chemistries were noted to taper down and on discharge, ALT was 201, AST 179, alkaline phosphatase peaked at 1,402, but dropped down to 1,084, and total bilirubin was down to 3.1. 2. Oncology: Biopsies from the periduodenal mass are still pending but likely a metastatic adenocarcinoma to the liver. We contact[**Name (NI) **] and spoke with the oncology fellow who will attempt to arrange follow up for the patient in clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Until biopsy results have returned, the patient should not and will not start chemotherapy at this point and will not be followed in the hospital for this. 3. Infectious disease: The patient was noted to have low-grade fevers status post procedure and will continue antibiotics for six to seven more days. White blood cell count was noted to be decreasing from 19 on admission to 16.2 on the day of discharge. 4. Cardiovascular: The patient has a history of hypertension and congestive heart failure. Zestril had been held on admission but was restarted and the patient responded well, however was noted to have blood pressures ranging 140s to 170s systolic, and probably should be followed up in the next week or two for a possible increase of Zestril. Code status: DNR/DNI. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was noted to have hypomagnesemia and was repleted with two to three days of magnesium oxide; also noted to be hypocalcemic, and will receive Tums x 3 days with meals. She was also noted to be hypophosphatemic and received Neutra-Phos with meals and responded quite well to this treatment. DISPOSITION: The patient will be discharged back to [**Hospital3 1761**] Center. The patient will follow up with oncology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at a to be determined date. The patient should have electrolytes followed and repleted in the next 1-2 weeks. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. once daily x [**6-8**] more days. 2. Flovent 2 puffs b.i.d. 3. Albuterol metered dose inhaler two puffs q. 4-6 hours p.r.n. 4. Protonix 40 mg p.o. b.i.d. 5. Tums 500 mg p.o. t.i.d. x two more days. 6. Neutra-Phos two packets p.o. x 1 at nursing home. 7. Magnesium oxide 400 mg p.o. t.i.d. x 2 more days. 8. Zestril 5 mg p.o. once daily. 9. Colace 100 mg p.o. b.i.d. 10. Milk of Magnesia 30 cc p.o. q. 4 hours p.r.n.. 11. Dulcolax 10 mg p.o./p.r. b.i.d. p.r.n. 12. Trazodone 50 mg p.o. q.h.s. p.r.n. 13. Norvasc 2.5 mg p.o. once daily. 14. Os-Cal 500 once daily. 15. Estraderm patch q. 3 days. 16. Citrucel, M.V.I., [**Doctor First Name **] 60 mg b.i.d., AeroBid, and beclomethasone. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSES: 1. Possible adenocarcinoma of pancreas. 2. Esophageal ulcerations. 3. Liver lesions. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-806 Dictated By:[**Last Name (NamePattern1) 19212**] MEDQUIST36 D: [**2122-4-3**] 11:44 T: [**2122-4-3**] 12:13 JOB#: [**Job Number 11285**]

[ "428.0", "416.0", "197.7", "424.0", "530.2", "496", "438.20", "397.0", "157.0" ]

icd9cm

[ [ [] ] ]

[ "51.85", "45.14" ]

icd9pcs

[ [ [] ] ]

8370, 8377

8398, 8716

7636, 8348

2353, 2715

4184, 7613

2738, 4166

101, 128

157, 1735

1758, 2326

49,080

163,099

41158

Discharge summary

report

Admission Date: [**2128-3-6**] Discharge Date: [**2128-3-8**] Date of Birth: [**2109-6-12**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: Skateboard vs. car Major Surgical or Invasive Procedure: none History of Present Illness: This is an 18 year-old Male who, per report, was skateboarding in the road and was involved in pedestrian vs. car strike and he was thrown approximately 100 feet. GCS on the scene was [**4-3**] and patient was vomiting, combative with intermittent LOC. Patient transfered to [**Hospital1 18**] from [**State 77532**] Ctr where he was intubated for inability to protect his airway. Per report, single episode of hypotension to the 40s systolic, with resolution. 3L IVFs prior to arrival. Past Medical History: PMH ADHD PSH R thumb surgery, bilateral tympanostomy tubes Social History: HS student, + ETOH, no tobacco Family History: non contributory Physical Exam: VITALS: T 98.5 BP 128/54 P 68 RR 15 O2sats 100% CMV/AS CMV/AC 550 / 16 / 5 / 0.4 GEN: Intubated, sedated not following commands (with sedation infusing), non-verbal, no eye opening, minimal withdrawal to pain with noxious stimuli HEENT: Left supraorbital region with 3-4-mm laceration with surrounding abrasion. Palpation reveals minimal step-off and deformity overlying supero-lateral aspect of the orbital roof, minimal visible deformity. Right superior eyelid with ecchymosis and swelling. Pupils pinpoint, minimally reactive 3-2 mm bilaterally. Nasal bones stable. Zygomatic complex without deformity or malalignment. CVS: Regular rate and rhythm, no murmurs, rubs or gallops. RESP: Clear to auscultation, no wheezes, rales or rhonchi. EXTR: 2+ pulses, no cyanosis, clubbing or edema Pertinent Results: [**2128-3-6**] 03:05AM WBC-12.2* RBC-4.84 HGB-15.3 HCT-43.2 MCV-89 MCH-31.5 MCHC-35.3* RDW-12.5 [**2128-3-6**] 03:05AM PLT COUNT-214 [**2128-3-6**] 03:05AM PT-13.9* PTT-21.0* INR(PT)-1.2* [**2128-3-6**] 03:05AM ASA-NEG ETHANOL-172* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2128-3-6**] 03:05AM UREA N-9 CREAT-0.8 [**2128-3-6**] 03:21AM GLUCOSE-97 LACTATE-2.8* NA+-143 K+-3.7 CL--105 TCO2-20* [**2128-3-6**] Head CT : 1. Hyperdense foci in the left parasagittal frontal lobe are concerning for small areas of intraparenchymal hemorrhage (contusions/[**Doctor First Name **]-diffuse axonal inury). Follow-up CT or MRI (with diffusion) is recommended. 2. Fractures through the left frontal bone, orbital roof and frontal process of the left maxilla extending into the left nasal bone with associated left frontal subgaleal hematoma. [**2128-3-6**] CT Chest/Abd/pelvis : 1. Small tiny foci of free air in the anterior pericardial fat of unlikely of clinical significance. 2. No evidence of post-traumatic solid visceral, vascular, or osseous injury to the chest, abdomen, or pelvis. [**2128-3-6**] MRI C spine : No significant abnormalities on MRI of the cervical spine. No evidence of ligamentous disruption or bony injury identified. [**2128-3-6**] MRI Head : Multiple foci of susceptibility low signal in both cerebral hemispheres consistent with diffuse axonal injury. These foci are seen at the [**Doctor Last Name 352**]-white matter junction. No significant corresponding diffusion abnormalities or FLAIR abnormalities are seen at this point. No focal abnormalities noted within the brainstem. Other findings as above. [**2128-3-6**] CT Mandible/Maxilla : Left hemifacial fractures as described above Brief Hospital Course: On [**2128-3-6**], the patient was admitted intubated to the TICU on acute care surgery. Later that day, he was extubated. MR brain showed diffuse axonal injury, but he awoke and had GCS 15. On [**2128-3-7**], he was transferred to the floor. Following transfer to the Trauma floor he remained hemodynamically stable without any neurologic deficits. He was re evaluated by the Plastic surgery service who plan non operative treatment at this point but will re examine in 1 week after his swelling had diminished. In the mean time he will maintain sinus precautions. He is tolerating a regular diet and walking independently. Due to his head injury he was evaluated by the Occupational Therapy service and it seems that he has some decreased working memory and inattention at times. His history of ADHD could be part of the problem but a follow up appointment with Cognitive Neurology is recommended to clarify the issue. After an uneventful recovery he was discharged to home on [**2128-3-8**]. Medications on Admission: Adderall 30 mg daily Discharge Medications: 1. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day): Apply to abrasions on back and abdomen. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: use while taking Oxycodone. 5. Adderall 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: S/P Fall 1. [**Doctor First Name **] 2. Left frontal subgaleal hematome 3. Left frontal bone fracture, orbital roof and frontal process of left maxilla into left nasal bone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital after your skateboarding accident with some facial bone fractures, some lacerations on your fingers and scattered bruising on your abdomen and bask. You also have a head injury which may cause you some problems with memory and recall. This should get better with time. * Continue sinus precautions including keeping the head of your bed > 30 degrees, cough with your mouth opened, do NOT use a [**Last Name (LF) **], [**First Name3 (LF) **] Not blow your nose. * No contact sports or skateboarding for 2 months. * Continue to eat a regular diet and stay well hydrated. * You will follow up with the Plastic Surgery service in 1 week to assess your facial fractures after the swelling has diminished. * If you develop any visual changes, blurred vision, double vision, severe headache or any symptom that concern you, please call the Acute Care Clinic at [**Telephone/Fax (1) 600**]. Followup Instructions: Call the Plastic Surgery Clinic at [**Telephone/Fax (1) 6742**] for a follow up appointment in 1 week. Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Cognitive Neurology at [**Telephone/Fax (1) 1690**] for a follow up appointment in 4 weeks. Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 253**] for a follow up appointment in [**11-30**] weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2128-3-8**]

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icd9cm

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icd9pcs

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45409

Discharge summary

report

Admission Date: [**2185-5-11**] Discharge Date: [**2185-5-22**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy, lysis of adhesions, small bowel resection. History of Present Illness: 84 year old woman, who presented to [**Hospital1 69**] with 3 days of nausea and increasing abdominal pain. She was diffusely mildly tender on abdominal exam and had an elevated band forms on her white blood cell differential. CAT scan showed pneumatosis of a pelvic loop of small intestine as well as a complete small bowel obstruction. Past Medical History: aortic stenosis Social History: no EtOH, no smoking, no drugs Family History: n/c Physical Exam: on admission: A&Ox3, NAD CTAB RRR abd: mildly distended, diffusely tender, no guarding, hypoactive bowel sounds extremities: warm, well perfused, no edema Pertinent Results: [**2185-5-11**] 10:59PM GLUCOSE-166* UREA N-31* CREAT-1.2* SODIUM-132* POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-10 [**2185-5-11**] 06:33PM LACTATE-1.7 [**2185-5-11**] 02:10PM ALT(SGPT)-18 AST(SGOT)-50* ALK PHOS-77 AMYLASE-21 TOT BILI-0.8 [**2185-5-11**] 02:10PM WBC-8.1 RBC-4.36 HGB-14.0 HCT-40.8 MCV-94 MCH-32.1* MCHC-34.4 RDW-14.4 [**2185-5-11**] 02:10PM PT-13.3* PTT-24.7 INR(PT)-1.2* Brief Hospital Course: The patient presented to the [**Hospital1 18**] ED on [**5-11**] with abdominal pain and constipation. She had CT findings and physical exam consistent with complete small bowel obstruction along with pneumatosis. The decision was made to proceed to the OR for small bowel ischemia and she underwent an ex-lap, LOA, reduction of small bowel volvulus, small bowel resection with primary anastomosis. She had a noncomplicated operative course and was taken to the PACU and then to the floor in stable condition. She started having flatus on POD 4 and her diet was advanced. On POD 5 she started having bowel movements. On POD 6 she had multiple loose bowel movements and two samples were sent for c. diff toxin. She continued to have increasing volume loose bowel movements and was given increased IV hydration and started on empiric antibiotic therapy for c. diff. On POD 8 her c. diff studies came back negative and she was taken off the antibiotics. On POD 9 and 10 her stool patterns began to normalize and she was taken off IV fluids. She was discharged on POD 11, having had normal bowel movements, good activity levels, regular diet. She was given adequate discharge and follow up instructions. Medications on Admission: mvi, calcium Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO ONCE (Once) for 3 days. Disp:*6 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Small bowel necrosis Discharge Condition: good Discharge Instructions: Please call your doctor or come to the emergency room if you experience wound swelling, redness, purulent discharge, have a fever greater than 101.5, have severe pain not controlled by medications, have nausea or vomiting and are unable to tolerate food or liquids, or have any other questions or concerns. Please call if you continue to have diarrhea. Please eat a diet high in fiber and drink plenty of fluids. Please continue taking your medications as prior to admission. Your wound is covered by steri strips. These will fall off on their own. You may get them wet but blot dry afterward. Followup Instructions: Please call Dr.[**Name (NI) 15146**] clinic to schedule an appointment in 2 weeks. The phone number is ([**Telephone/Fax (1) 2537**]. Completed by:[**2185-5-23**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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3018, 3024

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276, 345

3113, 3120

1010, 1418

3765, 3931

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3144, 3742

835, 835

222, 238

373, 713

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17,125

100,933

4501

Discharge summary

report

Admission Date: [**2103-3-28**] Discharge Date: [**2103-3-30**] Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old female with a history of severe chronic obstructive pulmonary disease and chronic syndrome of inappropriate diuretic hormone who was recently admitted for a chronic obstructive pulmonary disease exacerbation to [**Hospital6 649**]. She was discharged to [**Hospital3 537**] on [**2103-3-24**]. She was noted to have a variable level of responsiveness with intermittent hypoxia with oxygen saturations in the 60s. She is known to become somnolent and retain carbon dioxide if her oxygen saturations are too high. She was brought to the Emergency Department for an evaluation. She denied any chest pain, shortness of breath, cough, fevers, or chills. An arterial blood gas revealed an elevated carbon dioxide level of 78, higher than her baseline in the 60s. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Chronic syndrome of inappropriate diuretic hormone. 3. Seizures. 4. Mild dementia. 5. Hypertension. 6. Colon cancer, status post resection. 7. Osteoarthritis. 8. Lacunar infarcts. 9. Iron deficiency anemia. 10. Hard of hearing. ALLERGIES: Doxycycline. MEDICATIONS: 1. Sodium chloride 1 gram po t.i.d. 2. Solu-Medrol inhaler 20 mcg 2 puffs po b.i.d. 3. Calcium carbonate 1.25 grams po t.i.d. 4. Vitamin D 400 units po q.d. 5. Protonix 40 mg po q.d. 6. Fosamax 70 mg po q. Friday. 7. Aspirin 81 mg po q.d. 8. Colace 100 mg po b.i.d. 9. Iron sulfate 225 mg po q.d. 10. Atrovent nebulizers, 1 nebulizer po q. 6 hours prn. 11. Combivent inhaler 2 puffs po q. 4 hours. 12. Ritalin 5 mg po b.i.d. 13. Prednisone taper, currently 40 mg po q.d. 14. Dilantin taper, currently 100 mg po b.i.d. SOCIAL HISTORY: The patient lives at home with her family, but was recently a resident of the [**Hospital3 537**]. PHYSICAL EXAMINATION: The patient was afebrile with a temperature of 97. Heart rate 86. Blood pressure 150/80. Respiratory rate 20. Oxygen saturation 89% on room air, improving to 95% on two liters by nasal cannula. In general, the patient was somnolent, but arousable. Head and neck exam are significant for moist mucous membranes, supple neck, and no lymphadenopathy. Lungs had crackles at the left base with very poor air movement bilaterally. Cardiac exam revealed a regular rate and rhythm with no murmurs. Abdomen was benign. Extremities had no edema. LABORATORIES STUDIES: Significant for a hematocrit of 36.7 and a platelet count of 516,000. Panel 7 is significant for a sodium of 122, chloride 80, and bicarbonate of 32. The patient's baseline sodium is known to be 125-132. Arterial blood gas revealed a pH of 7.35, pCO2 of 75, pO2 of 78, and bicarbonate of 43. Chest x-ray revealed hyperinflated lung fields with no infiltrates or effusions. Electrocardiogram showed normal sinus rhythm at 85 beats per minute with normal axis and intervals and no ST-T wave changes compared to old electrocardiograms. HOSPITAL COURSE: 1. Chronic obstructive pulmonary disease: It is not believed that the patient had an exacerbation of her chronic obstructive pulmonary disease, but instead was somnolent from elevated oxygen saturations. She was continued on her current admission dose of steroids, continue with inhalers, and started on antibiotics. She received BiPAP at night with settings of 12 and 5, had an improvement in her arterial blood gas showing a pH of 7.42, pCO2 of 59 and pO2 of 134. She was quickly weaned down to 2 liters of oxygen by nasal cannula, which the patient receives at home. At the time of discharge, the patient had no shortness of breath or productive cough, and maintained good oxygen saturations on one liter of oxygen by nasal cannula. She will continue on her steroid taper, as well as on her inhalers, but does not require further antibiotic treatment. Of greatest benefit to her, would be the continued use of her BiPAP machine at night. 2. Syndrome of inappropriate diuretic hormone: The patient was fluid restricted to one liter of free water per day, and her sodium chloride tablets were continued. At the time of discharge, her sodium had returned to her normal baseline level of 127. 3. Neurology: The patient is continued on her Dilantin taper. She did not have any seizures during her hospitalization. It was felt that her prior seizures were secondary to toxic metabolic events, which do not require antiepileptic medications. DISCHARGE CONDITION: The patient was discharged in stable condition to the [**Hospital3 537**]. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Chronic syndrome of inappropriate diuretic hormone. 3. Seizures. 4. Mild dementia. 5. Hypertension. 6. Colon cancer, status post resection. 7. Osteoarthritis. 8. Lacunar infarcts. 9. Iron deficiency anemia. 10. Hard of hearing. DISCHARGE MEDICATIONS: 1. Sodium chloride 1 gram po t.i.d. 2. Solu-Medrol inhaler 20 mcg 2 puffs po b.i.d. 3. Calcium carbonate 1.25 grams po t.i.d. 4. Vitamin D 400 units po q.d. 5. Protonix 40 mg po q.d. 6. Fosamax 70 mg po q. Friday. 7. Aspirin 81 mg po q.d. 8. Colace 100 mg po b.i.d. 9. Iron sulfate 225 mg po q.d. 10. Atrovent nebulizers, 1 nebulizer po q. 6 hours prn. 11. Combivent inhaler 2 puffs po q. 4 hours. 12. Ritalin 5 mg po b.i.d. 13. Prednisone taper, 40 mg po q.d. times two days, 30 mg po times three days, 20 mg po q.d. times three days, 10 mg po q.d. times three days, then off. 14. Dilantin 100 mg po b.i.d. times two days, then 100 mg po q.d. times seven days, then off. DISCHARGE FOLLOW-UP PLANS: 1. The patient should follow-up with her primary care physician in one to two weeks. 2. The patient should follow-up with a pulmonologist as needed for the treatment of her chronic obstructive pulmonary disease. 3. The patient was encouraged and should continue to use her BiPAP at night with settings of 8 and 5. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2103-3-30**] 10:41 T: [**2103-3-30**] 11:03 JOB#: [**Job Number 19224**]

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icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

4531, 4607

4628, 4911

4934, 5626

3055, 4509

1930, 3037

5643, 6209

129, 918

940, 1790

1807, 1907

50,010

111,699

10236+56126

Discharge summary

report+addendum

Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-21**] Date of Birth: [**2120-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2185-3-16**] - Urgent coronary artery bypass graft times 3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal 1 and 2. [**2185-3-15**] - Cardiac Catheterization History of Present Illness: 65M with h/o htn and hyperlipidemia who has developed dyspnea on exertion over the preceeding months. Stress test was abnormal and cardiac cath reveals left main disease. He is referred for cardiac surgery. Past Medical History: hypertension hypercholesterolemia chronic renal insufficiency gout melanoma obstructive sleep apnea (does not use CPAP) Social History: Last Dental Exam: 2 weeks ago, in the process of periodontal work Lives with: daughter Occupation: retired, volunteers at soup kitchen, babysits grandchildren 1-2 days/week Tobacco: none ETOH: 1/week Family History: dad died at 78 CHF mom died 83 lung cancer Physical Exam: Pulse: 62 Resp: 18 O2 sat: 96%RA B/P Right: 181/77 Left: Height: 5'[**84**]" Weight: 90kg General: NAD, pleasant Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities Neuro: Grossly intact x Pulses: Femoral Right: cath Left: DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no carotid bruits appreciated Pertinent Results: [**2185-3-16**] ECHO PRE-BYPASS - The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. - Left ventricular wall thicknesses and cavity size are normal. - Overall left ventricular systolic function is normal (LVEF>55%). - Right ventricular chamber size and free wall motion are normal. - There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. - The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. - Mild (1+) mitral regurgitation is seen. - There is no pericardial effusion. - Dr. [**Last Name (STitle) **] was notified of the TEE findings in person on [**2185-3-16**] at 11 am. POST-BYPASS - Post-bypass on Phenylephrine infusion. A-V pacing. - LV function hyperdynamic with perserved EF. No regional wall motion abnormalities. - Mild mitral regurgitation - Trace aortic insufficiency. - Aorta intact. [**2185-3-15**] Carotid Ultrasound There is less than 40% stenosis within the internal carotid arteries bilaterally. [**2185-3-15**] Cardiac Catheterization 1. Coronary angiography in this right dominant system revealed significant 3-vessel coronary artery disease involving the LMCA. The LMCA was mildly calcified, with an 80% stenosis in the mid portion, as well as an 80% distal stenosis extending into an ostial LCX stenosis. The LAD was moderately calcified, with an ostial 50% stenosis with post-stenotic dilatation, a proximal 40% stenosis, and a mid-portion that was likley deeply intramyocardial after a large branching D2 branch. The LAD had TIMI 2 fast flow consistent with microvascular dysfunction. The LCX was mildly calcified, with an ostial 80% stenosis, and supplied OM1, OM2, OM3, OM4 (which was actually a vertical L-PL), and AV-groove LCX, and had TIMI 2 flow as well. The OM1 had a mild stenosis at the origin. The RCA had mild diffuse plaquing to 30% proximally and distally, with a diffuse disease up to 30% stenotic in the proximal R-PDA, a large long R-PL2 with plaquing to 30% in the distal AV-groove RCA and mid R-PL2, and TIMI 2 flow consistent with microvascular dysfunction. 2. Left ventriculography revealed normal estimated stroke volume of 60 mL/beat, with a normal ejection fraction of 65% and mild mitral regurgitation. There was very mild inferior wall hypokinesis. 3. Resting hemodynamics revealed mild systemic hypertension with SBP of 147 mmHg, and mildly increased left-ventricular filling pressures with LVEDP of 17 mmHg. There was no evidence of aortic stenosis as measured by LV pull-back technique. [**2185-3-21**] 04:39AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.3* Hct-29.4* MCV-85 MCH-29.7 MCHC-34.9 RDW-14.8 Plt Ct-211 [**2185-3-18**] 04:35AM BLOOD PT-12.4 PTT-30.1 INR(PT)-1.0 [**2185-3-21**] 04:39AM BLOOD Glucose-95 UreaN-29* Creat-1.6* Na-141 K-3.7 Cl-103 HCO3-29 AnGap-13 [**2185-3-20**] 03:58AM BLOOD UreaN-33* Creat-1.5* K-4.1 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2185-3-15**] for a cardiac catheterization. This revealed severe left main and two vessel disease. The cardiac surgical service was consulted and he was worked-up in the usual preoperative manner. A carotid duplex ultrasound was obtained which showed less then 40% stenosis of the bilateral internal carotid arteries. On [**2185-3-16**] he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative noted for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next 24 hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. There was some suggestion of pericarditis and a nonsteroidal anti-inflammatory was used with good results. Later on postoperative day one, he was transferred to the step down unit for further recovery. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. The patient developed rapid atrial fibrillation. He was loaded with amiodarone and beta blocker was titrated accordingly. He did convert to sinus rhythm. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: atenolol 25', plavix 300mg x1, 75mg', lisinopril 15', sl NTG prn, ambien 10 prn, asa 325', MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then 200mg daily until further instructed. Disp:*120 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: coronary artery disease s/p CABGx3 hypertension hypercholesterolemia chronic renal insufficiency gout melanoma obstructive sleep apnea (does not use CPAP) Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics 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 from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**2185-4-18**] 2:00PM Please follow-up with Dr. [**Last Name (STitle) 1968**] in [**1-26**] weeks. [**Telephone/Fax (1) 250**] Please follow-up with Dr.[**Name (NI) 3733**] in [**1-26**] weeks. [**Telephone/Fax (1) 62**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2185-3-21**] Name: [**Known lastname 6000**],[**Known firstname **] P Unit No: [**Numeric Identifier 6001**] Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-21**] Date of Birth: [**2120-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Right upper extremity numbness of the ulnar distribution: Dr.[**First Name (STitle) **] evaluated Mr.[**Known lastname 6002**] right upper extremity strength and grip. Ulnar distribution weakness noted. Pt reports this since time of surgery. A/P: Dr [**First Name (STitle) **] explained to Mr.[**Known lastname **] that positioning during the operation can sometimes transiently affect the ulnar nerve. He requested that Mr.[**Known lastname **] call to make an appointment to see him in clinic, in 1 week, to reevaluate the right upper extremity. Dr.[**First Name (STitle) **] discussed with Mr.[**Known lastname **] allowing Neurology to assess him prior to his discharge today. Mr.[**Known lastname **] [**Last Name (Titles) 6003**] to see Neurology and stated he would follow up in 1 week's time with Dr.[**First Name (STitle) **]. Discharge Disposition: Home With Service Facility: [**Company 720**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2185-3-21**]

[ "403.10", "272.4", "423.9", "411.1", "274.9", "997.1", "414.01", "424.0", "354.2", "427.31", "V10.82", "327.23", "E878.2", "585.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.55", "39.61", "88.52", "36.12", "37.22" ]

icd9pcs

[ [ [] ] ]

10838, 11006

5039, 6678

340, 566

8286, 8385

1950, 5016

9183, 10815

1183, 1227

6824, 8015

8108, 8265

6704, 6801

8409, 9160

1242, 1931

281, 302

594, 805

827, 949

965, 1167