ChanBeDu/relevant_section_length · Datasets at Hugging Face

10,751

180,245

8789

Discharge summary

report

Admission Date: [**2114-10-28**] Discharge Date: [**2114-11-7**] Date of Birth: [**2082-8-18**] Sex: F Service: SURGERY Allergies: E-Mycin / Neurontin Attending:[**First Name3 (LF) 1234**] Chief Complaint: right foot infection Major Surgical or Invasive Procedure: Incision and Drainage right foot History of Present Illness: 32 y/o female with DM, presenting with a 2-weeks history of progressive infection in her right foot. Her foot was run over 2 wks ago by a car while she was getting inside the car, did not notice any injury immediately and did not recall any skin breaks, however developed the progressive infection between her 4th and 5th digits of her right foot shortly thereafter. Has noted subjective fevers and chills at home. Lives in [**Location 6185**] but traveled to see her parents (from RI) here yesterday and now presents to the ED for worsening of her infection and swelling of her leg. Past Medical History: Type I and II diabetes mellitus, c/b previous episodes of DKA chronic sinusitis Irritable bowel syndrome Gerd asthma Social History: works as preschool teacher, lives with her husband, no children at this time, occasional EtOH, denies tob, illicits Family History: type II DM in maternal grandmother, paternal grandmother, and one uncle, also CAD Physical Exam: Physical Exam: 97.2 96 145/73 14 A&O, NAD RRR CTA b/l Abd obese, soft, nondistended, nontender RLE swollen in calf and foot, erythema from mid calf distally, ulceration with fibrinous exudate and necrotic area beginning 4th/5th interspace and extending along the plantar surface of foot. Exquisitely tender to palpation. Pertinent Results: Laboratory: 136 94 16 ------------< 243 3.9 27 0.9 15.5 >32.2 < 474 ∆ N:85 Band:0 L:6 M:5 E:2 Bas:1 Atyps: 1 Lactate 2.7 Imaging: RLE venous ultrasound: No DVT. Edema with vascular right inguinal nodes. Xray: significant soft tissue swelling with soft tissue defect plantar/lateral. No definite fracture evident. No subcutaneous gas. Brief Hospital Course: Patient was admitted yesterday with worsening right foot infection after a traumatic injury 2 weeks ago. On exam her lateral aspect of the right 4th and 5th toes had a large area of ulceration with fibrinous exudate and some necrotic area extending to the plantar surface. Based on the extension of the lesion and the risks of progressive infection of the foot a procedure in the operating room was decided to be the most adequate management. As the patient did not agree to undergo an amputation of the 5th toe in case this was felt to be necessary in the OR, an incision and drainage of the wound was performed. Patient tolerated the procedure well and specimen was sent for cultures and pathology. Her preoperative blood sugars were in the 350s, therefore insulin by sliding scale was infused with improved blood sugar control post-surgery. Patient strongly felt that she would like to be transferred to Rode Island, and be managed by her podiatrist [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30696**] DPM at the [**Hospital 30697**], so arrangements were done and patient will be transferred stable post incision and drainage to that institution for further management. A vac wound care system was placed on her right foot and changed after three days. Vac was replaced and patient was discharged home with home vac wound care supplies. Patient continued on abx as an outpatient. Medications on Admission: Levimir 40units [**Hospital1 **], Novolog ISS, Protonix 40 daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for mild pain / fever. 2. insulin Insulin SC Fixed Dose Orders Breakfast Bedtime Glargine 40 Units Glargine 40 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Glucose Insulin Dose 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-199 mg/dL 5 Units 5 Units 5 Units 5 Units 200-239 mg/dL 8 Units 8 Units 8 Units 8 Units 240-279 mg/dL 11 Units 11 Units 11 Units 11 Units 280-319 mg/dL 14 Units 14 Units 14 Units 14 Units > 320 mg/dL Notify M.D. 3. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. 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. 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN severe pain 10. Wheelchair Miscellaneous 11. Wheelchair Device Sig: One (1) 730.07 Miscellaneous once a day: MANUAL WHEEL CHAIR WITH ELEVATING LEG RESTS IN THE SETTING OF OSTEOMYELITIS. Disp:*1 1* Refills:*0* 12. Nafcillin 2 gram Recon Soln Sig: Two (2) gm Intravenous every four (4) hours for 38 days. Disp:*456 gm* Refills:*0* 13. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 38 days: please give equivalent on oral suspension. Disp:*76 tablet (s)* Refills:*0* 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 38 days: please give equivalent in oral suspension. Disp:*114 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Bayada Nurses Inc. Discharge Diagnosis: Traumatic/diabetic right foot wound infection Status post incision and drainage Discharge Condition: stable Discharge Instructions: Patient will be transferred to [**Hospital6 30698**], under the care of [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30696**], DPM for further management as requested by patient. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. Followup Instructions: Follow-up with your podiatrist, Dr. [**Last Name (STitle) **] after discharge Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-11-16**] 9:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2114-11-19**] 2:50 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2114-12-17**] 11:00 Please call the [**Hospital **] clinic and schedule an appointment for 1 week. The can be reached at ([**Telephone/Fax (1) 21608**]. Dr [**Last Name (STitle) **] is the podiatrist.

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icd9cm

[ [ [] ] ]

[ "86.22", "86.28", "84.11", "38.93" ]

icd9pcs

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46197

Discharge summary

report

Admission Date: [**2203-10-23**] Discharge Date: [**2203-10-27**] Date of Birth: [**2129-3-14**] Sex: F Service: MEDICINE Allergies: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 74 yo woman with past medical history of CHF, coronary artery disease s/p CABG in [**2190**] who presents to the hospital with 4 days of worsening shortness of breath at home. The dyspnea was worst last night, when she was gasping for air and also had some associated chest tightness and wheeze. She took a sublingual nitroglycerin with some improvement in her symptoms. However, at 3 in the morning, she woke up with severe dyspnea, and when her daughter took her vital signs, her blood pressure was elevated (unclear to what degree), HR was 111 and her O2 saturation was 64%. The patient has O2 at home which she uses at night normally at flow of 2L, however the daughter turned up the flow to 10L with improvement of saturations only to 84%. At this point the patient's daughter called EMS and she was brought to the emergency room. Of note, the patient reports that she is quite limited by exertional dyspnea and shortness of breath at baseline. She has 23 steps at home, and is able to get up those stairs but only very slowly. Her exertional dyspnea is predictable and rapidly resolves with cessation of activites. She also had a recent admission to [**Hospital3 **] for a CHF exacerbation in [**Month (only) 956**], at which time she also had a cardiac catherization which per the patient showed patency in 3 of her 4 bypass grafts. After that admission, she was weaned off of her lasix by [**Month (only) 547**] due to drops in blood pressure. She had a stress test in [**Month (only) 216**] which showed possible perfusion abnormalities in the back of her heart In the ED, she received 40mg of IV lasix and put out 300cc of urine. Initially tachypneac to high 30s on intake, diaphoretic. She was weaned off of the bipap and also given 1g vancomycin and 750mg of levofloxacin. Her most recent vitals where afebrile, 101 111/44 22-25, 100% on 100% non-rebreather. She reports feeling much better since her admission and is currently chest pain free. . On review of systems, she reports that she has had some recent URI symptoms. She also has a history of DVTs x2 and had previously been on coumadin, but has been off of coumadin for at least 2 years. She has 3 pillow orthopnea. She denies fevers, chills or rigors. No change in bowel habits. No symptoms of claudication. No recent weight gain or change in eating habits. Past Medical History: Coronary artery disease s/p coronary artery bypass graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr. [**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution consistent with old finding.) 2. Carcinoid tumor of right middle lobe s/p resection. 3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**]) 4. Obesity. 5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC filter, [**2197**] 6. Oxygen dependent since lung surgery and for obstructive sleep apnea, uses 2L nasal cannula 02 at night at home. NO Bpap 7. obstructive sleep apnea. 8. restrictive lung disease 9. carpel tunnel syndrome b/l, [**2179**] 10. congestive heart failure (left atrium is mildly dilated. LVEF 67%/[**2199**]) 11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10. 12.HTN 13.hypercholesterolemia Social History: -Tobacco history: None -ETOH: None -Illicit drugs: None Is married, lives with husband, daughter and 1 of her sons. [**Name (NI) **] 2 other children. She lives with her husband, adult daughter and son (38 yo) in a [**Location (un) 1773**] apartment in [**Location (un) 538**], Mass. The indicates that she has 31 steps to climb. Her family is very supportive. Daughter, [**Name (NI) 98232**], is the contact @ Cell [**Telephone/Fax (1) 98233**]/Home [**Telephone/Fax (1) 98234**]. Retired office asst. Pt is a native of [**Country 5881**], where she used to work as a nurse. [**First Name (Titles) **] [**Last Name (Titles) **] currently or in past. No Etoh intake. Family History: Mother - diabetes Physical Exam: PHYSICAL EXAM on Admission: GENERAL: Well appearing woman in NAD. Oriented x3. Mood, affect appropriate. Speaking in full sentences. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. Negative hepatojuglar reflex. CARDIAC: Slightly muffled S1. 3/6 systolic murmur radiating to apex, possible [**2-2**] diastolic murmur. Normal S2. No S3/S4 LUNGS: Bibasilar crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Mild bilateral edema. Vein harvest scar on left leg. Warm and well perfused. PULSES: 1+ radial pulses bilaterally. DP and PT Pulses not palpable. . Pertinent Results: Labs on admission: [**2203-10-23**] 02:02PM SODIUM-137 POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14 [**2203-10-23**] 02:02PM CK(CPK)-63 [**2203-10-23**] 02:02PM CK-MB-7 cTropnT-0.07* [**2203-10-23**] 02:02PM CALCIUM-8.7 PHOSPHATE-5.3* MAGNESIUM-1.8 [**2203-10-23**] 05:44AM TYPE-ART PEEP-5 O2- PO2-263* PCO2-67* PH-7.22* TOTAL CO2-29 BASE XS--1 [**2203-10-23**] 05:44AM GLUCOSE-238* LACTATE-1.4 NA+-138 K+-4.2 CL--101 TCO2-27 [**2203-10-23**] 05:44AM freeCa-1.21 [**2203-10-23**] 05:30AM GLUCOSE-247* UREA N-15 CREAT-0.7 SODIUM-141 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18 [**2203-10-23**] 05:30AM cTropnT-<0.01 [**2203-10-23**] 05:30AM proBNP-1443* [**2203-10-23**] 05:30AM WBC-17.4*# RBC-4.46 HGB-12.1 HCT-37.2 MCV-84 MCH-27.2 MCHC-32.6 RDW-16.5* [**2203-10-23**] 05:30AM NEUTS-84.1* LYMPHS-11.4* MONOS-3.0 EOS-1.0 BASOS-0.6 [**2203-10-23**] 05:30AM PLT COUNT-245 [**2203-10-23**] 05:30AM PT-12.7 PTT-23.0 INR(PT)-1.1 . Imaging: CXR [**10-23**]: Bilateral pleural effusions and findings consistent with fluid overload. The presence of an underlying infection remains a possibility. LENI [**10-23**]: IMPRESSION: No DVT in the left lower extremity Discharge Labs: [**2203-10-26**] 07:35AM BLOOD WBC-9.4 RBC-4.30 Hgb-11.4* Hct-34.9* MCV-81* MCH-26.4* MCHC-32.5 RDW-16.2* Plt Ct-218 [**2203-10-26**] 07:35AM BLOOD Plt Ct-218 [**2203-10-26**] 07:35AM BLOOD Glucose-199* UreaN-31* Creat-0.9 Na-139 K-4.3 Cl-92* HCO3-35* AnGap-16 [**2203-10-26**] 07:35AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.8 Brief Hospital Course: 74 y.o woman with history of CABG and CHF, also DVT who presents with acute onset of dyspnea and evidence of pulmonary edema, consistent with a severe exacerbation of congestive heart failure. . # Congestive heart failure: She presented with worsening dyspnea, diaphoresis, and tachycardia consistent with a CHF decompensation. She she had not been on lasix due to labile blood pressures. She was admitted to the CCU for diruesis with lasix and a nitroglycerin drip. Her lower extremity dopplers were negative for DVT. She was transitited to PO lasix on the floor, with the goal to take 40 mg PO lasix in the am while at home; this was subsequently changed to 20mg PO the day prior to discharge due orthostatic hypotension. . # CORONARIES: She had a history of CABG with a recent abnormal stress test. Based upon her laboratory data and findings on EKG, there is no acute evidence of ACS. Her history is consistent with chronic stable angina with likely anginal pain with increased demand from congestive heart failure exacerbation. She was placed on a nitroglycerin drip as above, and continued on ASA 325 mg, and Atorvastatin 80 mg. Her home dose of isosorbide was restarted when she was stable on the floor. . # Hypertension: She was continued on her quinipril throughout her hospital course. . # Diabetes Mellitus: Initially her home insulin of 70/30 was converted to NPH, and she was maintained on NPH with 20U in morning and 8U at night. She was given an ISS for meal time coverage and started on Metformin. Prior to discharge her glucose was labile into the 500s, prompting her to be restarted on her home insulin regimen of insulin 70/30 50 units in the AM and 20 with dinner with sliding scale coverage. Medications on Admission: Amlodipine 2.5mg qdaily - recently started [**8-28**] Quinapril 20 mg Po daily Metformin 1000mg [**Hospital1 **] isosorbide mononitrate 30mg daily Ferrous sulfate 325 tid omeprazole 40mg [**Hospital1 **] Klor-con 8meq [**Hospital1 **] Magnesium oxide 400mg tid Insulin 70/30 50U qam, 20U qhs Multivitamin 1 tab daily Calcium + vitamin D 750/400mg [**Hospital1 **] vitamin C 500mg [**Hospital1 **] Vitamin b12 1 tab daily Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: 1.5 Tablet, Chewables PO twice a day. 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take as directed. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 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:*2* 7. XIBROM 0.09 % Drops Sig: One (1) drop Ophthalmic daily (). 8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Klor-Con 8 8 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO three times a day. 11. Vitamin B-12 Oral 12. Ferrous Sulfate 324 mg (65 mg Iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 13. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Fifty (50) units Subcutaneous once a day. 14. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Twenty (20) units Subcutaneous at bedtime. 15. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): do not take if BP top number is less than 90. . 17. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 19. Quinapril 10 mg Tablet Sig: 0.5 Tablet PO once a day: do not take if systolic blood pressure is less than 100. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Acute on chronic Diastolic congestive Heart Failure Hypertension Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had an acute exacerbation of your congestive heart failure. We gave you medicine to take the extra fluid off and your weight this morning is 183 pounds. We adjusted your medicine to help your heart work better. You will need to take your medicine every day and weigh yourself every day to prevent another hospitalization. Call Dr. [**First Name (STitle) 2031**] if your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. Also call Dr. [**First Name (STitle) 2031**] for any trouble breathing, especially at night or for any swelling in your legs or abdomen. Medications changes: 1. STOP taking Amlodipine 2. Start taking aspirin to prevent a heart attack 3. Decrease the Quinapril to 5 mg daily (one half a pill) 4. Start taking furosemide (lasix) 20 mg daily to prevent fluid buildup and shortness of breath. . If your systolic blood pressure is less than 100, please do not take the Quinipril. You should continue to take the furosemide and isosorbide mononitrate unless your systolic blood pressure is less than 90. Followup Instructions: Cardiology: Name: [**Last Name (LF) **],[**First Name3 (LF) **] P. Location: [**Hospital **] HOSPITAL Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 38978**] Phone: [**Telephone/Fax (1) 77385**] Appt: [**11-1**] at 2pm

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10853, 10859

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331, 338

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46067

Discharge summary

report

Admission Date: [**2131-9-10**] Discharge Date: [**2131-9-20**] Date of Birth: [**2053-2-19**] Sex: M Service: [**Doctor First Name 147**] Allergies: Procainamide Attending:[**First Name3 (LF) 301**] Chief Complaint: epigastric abd pain / nausea / vomiting Major Surgical or Invasive Procedure: Exploratory laparatomy with lysis of adhesions History of Present Illness: Mr. M.W. is a 78 yo man with a h/o of atrial fibrillation on coumadin and amiodarone, CHF, s/p cholecystectomy in [**2117**] who presents with 1 d of severe epigastric abdominal pain, nausea, and vomiting. Last night, five hours after eating ??????questionable?????? Chinese food, he began experiencing progressive epigastric pain, coming in waves. Eventually, the pain was severe, [**10-14**], which felt like ??????wringing of his intestines, spasms.?????? He noted that he had similar pain (though not as severe) before his cholecystectomy, and that this pain was much more severe than prior episodes of heartburn. The pain did not radiate, and was not relieved with TUMS, gas pills, or anything else he tried. The pain was so severe that he ??????would??????ve taken a black [poison] pill.?????? It was associated with nausea, dry heaves, and cold sweats. He had no fever, no CP / SOB, though he noted that he had been having sparse BMs over the past [**2-6**] d. No melena / hematochezia / diarrhea / constipation. When he presented to the [**Hospital 7188**] Hospital ED, his vital signs were noted to be 116/69, 68, 20, 95% on RA. He received hydromorphone 2 mg IV x2, which relieved his pain to [**4-14**] severity. Past Medical History: 1. Atrial Fibrillation ?????? on coumadin and amiodarone s/p pacemaker placement ?????? Dr. [**Last Name (STitle) **] - [**2126**] 2. Aortic valve disease s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] replacement - [**2118**] 3. CHF hospitalization [**2131-6-5**] 4. Hypothyroidism ?????? secondary to amiodarone 5. pancytopenia 6. BPH ?????? Dr. [**Last Name (STitle) 986**] 7. Hiatal hernia w/o GERD 8. s/p cholecystectomy [**2117**] 9. HTN 10. hypercholesterolemia ?????? last panel [**2130-3-4**] LDH=123, HDL=58, Triglyc=81 Social History: Family: lives with wife in [**Name (NI) **]. Travel/Exp/Pets: no recent travel or exposures. No pets. Alc/Tob: No EtOH in past 14 years, before that, social EtOH. no tobacco. Family History: FH: Father had mouth CA thought secondary to smoking not significant for DM, HTN, or other CA history Physical Exam: Vital Signs: Temp: 96.5 Pulse: 70 BP: 160/110 RR: 18 O2 sat: 98% on RA General: On physical exam, the patient was comfortable, in NAD HEENT: Head NC/AT. Sclerae anicteric, conjunctiva pink. PERRLA, EOMs intact, VFs full. No sinus tenderness. Oropharynx clear and nonerythematous. Mucous membranes slightly dry. Neck: Trachea midline. Neck supple. Thyroid not appreciated. No palpable lymph nodes. JVP = 6 cm. Cardiac: Carotid pulses 2+ bilaterally. PMI non-displaced, in mid-clavicular line. RRR. Normal S1, with mechanical S2. Systolic murmur (St. Jude valve?) best heard at LUSB. No rubs. No heaves. Vascular: radial pulses 2+, DP, PT pulses 2+. Feet warm. Pulmonary: Rales at R base. No wheezing or rhonchi. Abdomen: distended, tender to deep palpation in epigastric area and LUQ. No rebound or guarding. Minimal BS. Liver and spleen tips not felt. No CVA tenderness. Extremities: No clubbing, cyanosis, or edema. Neurologic: MMSE: alert, oriented x 3. Rest of MMSE not performed. CNs: CN II-XII examined and intact. Sensory: Light touch, JP sense, and vibration intact in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. Motor: Tone normal. No pronator drift. Strength 5/5 throughout. [**Last Name (Prefixes) 8259**]: [**Name2 (NI) 8259**] not tested. Gait and Romberg examinations not performed. On Discharge the patient's abdomen was soft and nontender, with a well healing midline abdominal incision Pertinent Results: Abdominal Xray [**2131-9-10**]: There are a few mildly gas distended loops of small bowel with scattered small air fluid levels with gas and fecal residue present throughout the colon. There is a large air fluid level in the upper abdomen in the upright film likely within a distended stomach but the upper abdomen is not included on the supine view. No free gas under right diaphragm. Calcification in aorta. Lumbar scoliosis. IMPRESSION: Few scattered air fluid levels in small bowel but no evidence for definite intestinal obstruction. Probable marked gastric distention. Correlate clinically and with repeat films to include upper abdomen and/or CT if indicated. CT abdomen [**2131-9-11**]: IMPRESSION: 1. Early vs. partial small bowel obstruction with transition point in the ileum. Free fluid within the abdomen was present and likely secondary to the small bowel obstruction. No evidence of perforation. 2. Normal appearing pancreas. CT abdomen [**2131-9-11**]: IMPRESSION: No passage of contrast since the previous study six hours earlier. A well defined transition point remains in the right lower mid quadrant. There is a similar amount of air seen within the large bowel however, and there is no change to the amount of intraabdominal free fluid. Findings are consistent with mechanical obstruction. Brief Hospital Course: When he presented to the [**Hospital1 18**] ED on [**2131-9-10**], his vital signs were noted to be 96.5, 160/110, 70, 18, 98% on RA. He began receiving IV fluids (1000 ml NS) and some addtl hydromorphone. He was admitted to the medicine service, and a surgery consult was obtained. He was NPO and was receiving IV fluids. Abdominal xray and CT suggested a diagnosis of a small bowel obstruction. The patient was distended and, his exam remained unchanged, however a NG tube decompression helped relieve the symptoms partially. A repeat CT 6 hours after the initial scan failed to demonstrate passage of contrast beyond the transition point, and a decision was made to bring the patient to the operating room for an exploratory laparotomy with lysis of adhesions. His coags were reversed and the patient was brought to the operating room. The patient tolerated the procedure well, and postoperatively the patient was admitted to the surgical service. He was admitted to the surgical intensive care unit for hemodynamic monitoring and continued ventilator support. He was continued on antibiotics (ampicillin/Levo/Flagyl) which continued for a 1 week course. He was started on TPN. He was actively resuscitated in the intensive care unit, and his vent was weaned on postoperative day 1, and the patient was transferred to the floor in stable condition on post operative day 2. The patient had some increased work of breathing on post operative day 2, that was responsive to lasix and nebulizer treatments. The patient had some confusion and required a sitter for 2 days, but this resolved spontaneously. The patient had an uneventful hospital course while we awaited the return of bowel function. Physical therapy evaluated the patient and felt the patient was an excellent candidate for rehab. On post operative day 6 the patient had 2 large bowel movements, the NG tube was discontinued and the patient was started on sips of clear liquids. On post operative day 7 the patient was tolerating a regular diet, was restarted on all of his home meds, he remained hemodynamically stable, and had a therapeutic INR of 2.4. The patient was prepared for discharge to a rehab facility. Prior to discharge the patient had an ultrasound of his right upper extremity for some slight upper extremity swelling, which revealed no clot in the arm veins, but did demonstrate a small clot in his internal jugular, although flow through was patent. Given that the patient was therapeutic on his coumadin, the patient should have a repeat ultrasound in 2 weeks, continue his coumadin, and the primary care physician was informed Medications on Admission: 1. Aspirin 81 mg PO M/W/F 2. Coumadin 1 mg / 1.5 mg PO alternate days 3. Amiodarone 200 mg PO QD 4. HCTZ 12.5 mg PO QD 5. Isosorbide Dinitrate 30 mg PO QD 6. Finasteride (Proscar) 5 mg PO QD 7. Tamsulosin (Flomax) 0.4 mg PO QD 8. Allopurinol 100 mg PO qAM 9. Folate 1 mg PO QD 10. Levothyroxine 75 mcg PO QD 11. Iron 325 mg PO QD Discharge Medications: 1. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO QD (once a day). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO MWF (Monday-Wednesday-Friday). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 7. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 10. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 14. Isosorbide Mononitrate 30 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* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Small bowel obstruction status post exploratory laparatomy and lysis of adhesions Malnutrition Atrial fibrillation with pacer aortic valve replacement hypothyroidism pancytopenia benign prostatic hypertrophy hypertension Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet [**Name8 (MD) **] MD if there for worsening pain, intractable nausea, inability to tolerate food. You should also call if there is any increased drainage from your wound, redness, or new swelling around your wound. You may resume your diet that you were taking prior to discharge You should resume any medications you were taking prior to this admission. You should not do any heavy lifting (greater than 5 pounds) for 5 weeks. You should keep a dry sterile dressing over your wound. Followup Instructions: You should follow up with Dr. [**Last Name (STitle) **] in [**1-5**] weeks. You should call your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] after you are discharged from rehab. You should follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-5**] weeks (Dr. [**Last Name (STitle) **]

[ "E878.8", "284.8", "428.0", "427.31", "453.8", "263.9", "V58.61", "998.2", "560.81" ]

icd9cm

[ [ [] ] ]

[ "54.59", "46.73", "96.07", "99.04", "38.93", "99.15", "99.07" ]

icd9pcs

[ [ [] ] ]

10134, 10204

5371, 7998

331, 380

10469, 10475

4029, 5347

11113, 11458

2434, 2539

8379, 10111

10225, 10448

8024, 8356

10499, 11090

2554, 4010

252, 293

408, 1644

1666, 2221

2237, 2418

5,242

124,531

3688

Discharge summary

report

Admission Date: [**2123-3-16**] Discharge Date: [**2123-3-20**] Date of Birth: [**2070-10-2**] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Latex Attending:[**First Name3 (LF) 7303**] Chief Complaint: Right hip avascular necrosis Major Surgical or Invasive Procedure: Right total hip arthroplasty History of Present Illness: Ms. [**Known lastname 16666**] is a 52 year old female with avascular necrosis of the right hip. She has had persistent pain for years and has failed conservative management. She presents for total hip arthroplasty. Past Medical History: Hepatitis C (liver biopsy in [**2116**] as showing stage III fibrosis) Waldenstrom's macroglobulinemia/lymphoma history of IVDU depression sialolithiasis fine tremor peripheral neuropathy s/p prolonged ICU stay for heroin and benzodiazepine overdose multi-lobar pneumonia (M. cattharalis) Social History: hx for polysubstance abuse, lives with her son Family History: Noncontributory Physical Exam: At the time of discharge: AVSS NAD wound c/d/i without erythema [**Last Name (un) 938**]/FHL/TA/GS intact SILT distally Brief Hospital Course: The patient was admitted on [**3-16**] and, later that day, was taken to the operating room by Dr. [**Last Name (STitle) 5322**] for a right total hip arthroplasty. Please see operative report for details. The patient had significant intraopertaive blood loss due to her underlying coagulopathy and was transfused with PRBCs and FFP. She was transferred to the ICU postop for closer monitoring. She did well there, was hemodynamically stable with a stable Hct, and was transferred to the floor or POD1. The patient was initially treated with a PCA followed by PO pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as lovenox for DVT prophylaxis starting on the morning of POD#1. The drain was removed without incident on POD#1. The Foley catheter was removed without incident. The surgical dressing was removed on POD#2 and the surgical incision was found to be clean, dry, and intact without erythema or purulent drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was stable, and the patient's pain was adequately controlled on a PO regimen based upon recommendation from the chronic pain service. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services or rehabilitation in a stable condition. The patient's weight-bearing status was 50% partial weight bearing with posterior precautions. Medications on Admission: Albuterol, clonazepam, fluticasone nasal, flovent, mso4, mscontin, tramadol, Ca-VitD, benadryl Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right hip avascular necrosis Discharge Condition: Stable Discharge Instructions: experience severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers >101.5, shaking chills, redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your PCP regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not operate heavy machinery or drink alcohol when taking these medications. As your pain improves, please decrease the amount of pain medication. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (e.g., colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may get the wound wet or take a shower starting 5 days after surgery, but no baths or swimming for at least 4 weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by a visiting nurse at 2 weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment at 4 weeks. 8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen, advil, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg twice daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower after POD#5 but do not take a tub-bath or submerge your incision until 4 weeks after surgery. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by VNA in 2 weeks. If you are going to rehab, the rehab facility can remove the staples at 2 weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at 2 weeks after surgery. 12. ACTIVITY: 50% Partial weight bearing as tolerated on the operative leg with posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: Total Hip Protocol 50% Partial weight bearing Posterior precautions Treatments Frequency: Lovenox injections. Wound checks. VNA to remove staples at 2 weeks. Followup Instructions: Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2123-3-31**] 10:00 [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**] Completed by:[**2123-3-20**]

[ "356.9", "202.80", "E878.1", "285.1", "273.3", "571.5", "733.42", "070.54" ]

icd9cm

[ [ [] ] ]

[ "81.51" ]

icd9pcs

[ [ [] ] ]

3567, 3625

1157, 2842

309, 340

3698, 3707

6328, 6636

980, 997

2987, 3544

3646, 3677

2868, 2964

3731, 5334

1012, 1134

6144, 6212

6234, 6305

241, 271

5346, 6126

368, 587

609, 899

915, 964

30,541

125,746

31692

Discharge summary

report

Admission Date: [**2112-2-23**] Discharge Date: [**2112-2-25**] Date of Birth: [**2064-11-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: abdominal pain, SOB Major Surgical or Invasive Procedure: Therapeutic paracentesis History of Present Illness: This is a 47 yo M with h/o advanced hepatocellular carcinoma receiving hospice care, DM type II, CHF (EF 40% 10/07), chronic renal failure, and long hospital course in [**10-9**] for eustachian valve MSSA endocarditis c/b paravertebral abscess, ATN, and AIN who presents with worsening abdominal distention and shortness of breath. He recently saw his PCP 11 days ago during which time the patient denied any shortness of breath. He was scheduled for an outpatient therapeutic paracentesis day of admission for abdominal discomfort [**3-5**] abdominal distention and ascites. He reports that his SOB started last week associated w/worsening abdominal distention, also +URI sx of sore throat, nasal congestion and rhinorrhea, nonproductive cough. He has been using supplemental oxygen at home since Sat. He has this available to him through his hospice care but has never had to use it prior to this weekend. He also notes that he had an episode of bloody emesis a few days ago. No diarrhea/BRBPR/melena, some mild constipation. No emesis since the isolated episode. No abdominal pain. No fever/chills. Notes that he's had many friends/family visiting many of whom had colds and some of whom recently had viral gastroenteritides. He denies CP, but endorses worsening SOB and some agitation this AM due to feeling SOB. No HA/dizzyness. . ROS o/w currently negative except for some slightly increased LE edema from baseline. . In the [**Name (NI) **], pt was afebrile w/O2sat of 83% on RA. Labs were significant for WBC 12.5, Na 130, BUN 108, Cr 5.3, and anion-gap 20. A 30 cc diagnostic paracentesis was performed. The pt's code status was verified to be DNR/DNI but he was agreeable to hospitalization in the ICU. He was admitted to the [**Hospital Unit Name 153**] for further care. Past Medical History: Advanced hepatocellular carcinoma DM type 2 CHF (EF 40% in [**11-8**]) h/o eustachian valve endocarditis s/p 6 week course of abxs (initially nafcillin/gent --> ATN, then nafcillin --> AIN, then vancomycin) c/b lumbar paravetebral abscess and possible pulmonary septic emboli HTN Hypercholesterolemia Chronic renal failure [**3-5**] ATN, AIN h/o UGI bleed with ulcers in GE junction, antrum of stomach, and duodenal bulb Social History: Pt lives with wife and 5 children. 25-pack-year h/o smoking, also h/o cocaine use, denies IVDU. h/o alcohol abuse, sober x20+ years. Family History: +DM2, CAD, HTN, no Ca Father - MI in [**2064**] Mother - s/p CABG age 54 Brother - MI d. age 57 Brother - s/p CABG age 46 Physical Exam: T 96.5 BP 92/65 HR 97 RR 19 O2sat90% on 95%FIO2 Pain 0/10 Gen - cachectic, speaks in phrases HEENT - sclera pale, but anicteric, o/p no erythema/edema/lesions old blood noted on gums/lips, poor dentition, MMM Neck - no masses/LAD CV - RRR no MRG Lungs - decreased lung expansion BL, decreased BS at bases bl, no wheezes, rhonchi; dullness to percussion to midway up right and 1/3 up left Abd - distended w/dullness to percussion throughout, site of therapeutic para clean/dry. nontender, +BS. Ext - 1+ BL LE edema, excoriations noted, clean appearing w/o erythema/drainage. Neuro - oriented x 3, CN 2-12 in tact Skin - pale, warm,dry, slightly jaundiced, no rashes Pertinent Results: [**2112-2-24**] 04:31AM BLOOD WBC-8.4 RBC-3.33* Hgb-10.4* Hct-32.0* MCV-96 MCH-31.2 MCHC-32.5 RDW-13.6 Plt Ct-197 [**2112-2-24**] 04:31AM BLOOD Plt Ct-197 [**2112-2-24**] 04:31AM BLOOD Glucose-117* UreaN-114* Creat-5.6* Na-129* K-5.4* Cl-95* HCO3-21* AnGap-18 [**2112-2-24**] 04:31AM BLOOD ALT-33 AST-105* LD(LDH)-262* AlkPhos-164* TotBili-1.0 [**2112-2-24**] 04:31AM BLOOD Albumin-2.8* Calcium-8.1* Phos-7.1* Mg-2.3 [**2112-2-23**] CXR - Worsening bilateral pleural effusions with bibasilar atelectasis Brief Hospital Course: 47 yo M with h/o advanced hepatocellular carcinoma, DM type II, CHF, h/o eustachian valve MSSA endocarditis c/b paravertebral abscess, and chronic renal failure who presents with worsening abdominal distention and shortness of breath. 1) Shortness of breath -Contributing factors include large ascites as well as metabolic acidosis due to uremia and cachexia causing decreased respiratory muscle strength. He was treated with paracentesis and removal of 7.5L of peritoneal fluid which did improve his dyspnea somewhat although he continued to require high flow O2 for symptomatic improvement. Prior to discharge, hospice care set up high flow O2 in the home. In addition, he was given a prescription for morphine and ativan as needed for dyspnea. In addition, he was also discharged on Hyoscyamine for congestion. 2) Abdominal distention/pain - Due to advanced stage hepatocellular carcinoma and associated ascites treated by 7.5L paracentesis. No evidence of SBP (265 WBC with only 26% polys). Continue with pain control with outpt morphine, oxycodone. 3) Advanced hepatocellular carcinoma - Currently followed by [**Hospital3 **] home health care. Oncologist is Dr. [**Last Name (STitle) **]. No new treatment for HCC during this admission. Continue with outpatient hospice. 4) Acute on chronic renal failure - Cr 5.3 on presentation, up from 2.4 in [**12-9**]. Most likely due to pre-renal etiology. He was evaluated by renal consult during this admission but was not interested in dialysis. Renal recommended discharge on Phos Lo for hyperphosphatemia and patient comfort. 4) Hypotension - Likely due to underlying liver disease/hepatocellular ca. Baseline SBPs in 90's. 5) Pleural effusions - likely due to hepatohydrothorax. Would expect some improvement following paracentesis. No further managment. 6) h/o UGI bleed/anemia - With GE jxn, antral, and duodenal bulb ulcers that were non-bleeding on EGD in [**10-9**]. Hct 35.9 on presentation, above baseline of mid 20's to 30. His PPI was continued. 7) DM type 2 - HgbA1c 7.9 in [**10-9**]. Continue outpt regimen of lantus 25 unit qhs and Humalog sliding scale. 8) CHF - Thought to be [**3-5**] ischemic cardiomyopathy, EF 40% on echo [**2111-11-10**]. Has been off of therapeutic medications since starting hospice care. Continuing lasix for patient comfort. 9) Hypercholesterolemia - Continue atorvastatin. 10) h/o MSSA endocarditis - Of eustachian valve (embryologic remnant of valve of IVC) c/b lumbar paravertebral abscess and possible pulmonary septic emboli. s/p 6 week course of abxs. Repeat [**Month/Day/Year 4338**] showed decrease in size of paravertebral abscess. 11) Code - DNR/DNI, verified with pt Medications on Admission: Coreg 3.125 mg [**Hospital1 **] Lasix 100 mg [**Hospital1 **] Atorvastatin 40 mg daily Lantus 25 units qhs HISS Liquid morphine 5-20 mg po q2-4h prn Oxycodone 5-10 mg q6h prn Reglan 10 mg tid prn Pantoprazole 40 mg q12h Calcium carbonate 500 mg [**Hospital1 **] Lactulose 30 ml tid prn Sorafenib 400 mg [**Hospital1 **] (per pt, is not taking) Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Tablet, Delayed Release (E.C.)(s) 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 4. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 5. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO tid prn as needed for constipation. 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:*30 neb* Refills:*2* 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:*30 neb* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 10. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 11. Home O2 6 L of O2 via nasal cannula 12. PhosLo 667 mg Capsule Sig: One (1) Capsule PO tidachs. Disp:*90 Capsule(s)* Refills:*2* 13. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**2-3**] tabs Sublingual every four (4) hours as needed for congestion. Disp:*150 tablets* Refills:*3* 14. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q2-4hrs as needed for pain or dyspnea. Disp:*600 cc* Refills:*3* 15. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.5-1 mg PO every 4-6 hours as needed for anxiety. Disp:*30 ml* Refills:*3* Discharge Disposition: Home With Service Facility: Caritis Good [**Hospital 53775**] Hospice Care Discharge Diagnosis: Primary Diagnosis: Ascites Shortness of breath Acute on Chronic Renal Failure Anion-gap metabolic acidosis Secondary Diagnosis: End stage hepatocarcinoma CHF DM type 2 HTN Hypercholesterolemia Discharge Condition: Stable on 6 L O2 by NC sating in low 90's, discharged home with hospice care Discharge Instructions: You were admitted for worsening shortness of breath and had a procedure called a paracentesis where several liters of fluid were removed from the abdominal cavity. You are being discharged home with resumption of your prior hospice services and home oxygen therapy. We started you on the following new medications for your decreased renal function: 1) Nephrocaps - This is a kidney friendly multivitamin. 2) Phoslo (calcium acetate) - This is a pill to help bring down your high phosphate levels in your blood, which is a result from decreased renal function. Please call your doctor and home hospice services if you experience any of the following: fever, chills, increasing abdominal distention, abdominal pain, shortness of breath, or confusion. Do not call 911 unless instructed to by the home hospice services or you physician. [**Name10 (NameIs) **] you are beginning to experience worsening shortness of breath and abdominal pain, please call Radiology at [**Telephone/Fax (1) 327**] to schedule an outpatient paracentesis. You may also take morphine to help with symptoms of shortness of breath. Followup Instructions: You have the following appts: Provider: [**First Name11 (Name Pattern1) 31804**] [**Last Name (NamePattern1) 31805**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-4-6**] 3:00 Please call radiology at [**Telephone/Fax (1) 327**] if you are beginning to experience worsening abdominal distention and shortness of breath to schedule an outpatient paracentesis. Completed by:[**2112-2-25**]

[ "789.59", "428.0", "414.8", "511.9", "155.0", "272.0", "403.90", "585.9", "428.22", "276.2", "250.00", "584.9" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

8887, 8964

4141, 6841

336, 363

9202, 9281

3612, 4118

10436, 10837

2788, 2911

7236, 8864

8985, 8985

6867, 7213

9305, 10413

2926, 3593

277, 298

391, 2176

9114, 9181

9004, 9093

2198, 2621

2637, 2772

16,286

168,309

48968+48969+48970

Discharge summary

report+report+report

Admission Date: [**2122-10-4**] Discharge Date: Date of Birth: [**2067-1-2**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: The patient is a 55 year old female with a history of bilateral breast cancer, status post bilateral resection with positive bilateral lymph nodes (ER positive with infiltrating ductal/lobular carcinoma), status post Cytoxan and Adriamycin times four cycles, status post Taxol times one cycle. Chemotherapy was complicated by decreased ejection fraction (unclear if this was secondary to Adriamycin or to ischemia). Recent history significant for admission for hyponatremia over the last several months. Recent history is also notable for difficulty breathing on Friday. The patient complained of weakness and had slurred speech. Her husband who is a physician was concerned that the patient may be experiencing hyponatremia as she has had similar episodes in the past. An ambulance was called and it was noted that the patient's blood sugar was decreased at 52. The patient was given D50 in the ambulance. The patient was admitted to the medical floor but on arrival to the floor, she was noted to be hypotensive with systolic blood pressure in the 80s prompting Intensive Care Unit evaluation. Course in the Emergency Department was notable for recurrent hypoglycemia necessitating D50. Head CT was done which was negative for hemorrhages or mass lesions. After admission to the floor, the patient received several fluid boluses of normal saline. A Foley catheter was placed demonstrating drainage of concentrated appearing urine. Broad spectrum antibiotics were begun with Vancomycin, Ceftriaxone and Flagyl. The patient was then transferred to the Medical Intensive Care Unit Service. PAST MEDICAL HISTORY: 1. Bilateral breast carcinoma, core biopsies consistent with infiltrating ductal/lobular carcinoma, grade I to II. On [**2122-10-1**], the patient had bilateral mastectomy and lymph node dissection. Right 1.3 centimeter infiltrating ductal carcinoma grade III with five out of twelve positive lymph nodes. On the left, there was a 1.0 centimeter infiltrating ductal carcinoma grade II with three out of nine positive lymph nodes. Both were ER positive and negative. On , the patient had four cycles of Cytoxan/Adriamycin. On [**2122-2-13**], the patient had one cycle of Taxol complicated by pulmonary edema. The patient also has received Arimidex briefly and Femara on [**4-24**]. On [**2122-2-14**], the patient was admitted to [**Hospital 2725**] Hospital with congestive heart failure and nonsustained ventricular tachycardia and was started on Amiodarone. On [**2122-2-16**], echocardiogram showed dilated left ventricle, akinesis of septum/apex, severe hypokinesis of lateral/posterior walls, ejection fraction of 20 to 25%, moderate to severe mitral regurgitation, tricuspid regurgitation. Echocardiogram from [**2122-2-24**], showed ejection fraction of 20 to 25%. Echocardiogram from [**2122-7-13**], showed ejection fraction of 20 to 25%. 2. Hypertension. 3. Hypothyroidism. 4. Breast reduction in [**2090**], and [**2093**]. 5. Vein stripping of left leg in [**2114**]. 6. Left knee arthroplasty in 04/99. 7. Right parotid tumor. ALLERGIES: Intolerance to Ativan/Klonopin. Morphine and Codeine causes nausea and vomiting. MEDICATIONS ON ADMISSION: 1. Fosamax 10 mg p.o. q.d. 2. Synthroid 0.125 mg p.o. q.d. 3. Kerlone 10 mg p.o. q.d. 4. Zestril 10 mg p.o. q.d. 5. Aldactone 25 mg p.o. q.d. 6. Amiodarone 200 mg p.o. q.d. 7. K-Dur 40 meq p.o. q.d. 8. Vitamin A, Vitamin D. 9. Aromasin 25 mg p.o. q.d. 10. Enteric Coated Aspirin 325 mg p.o. q.d. 11. Calcium 500 mg p.o. q.d. 12. Lasix doses increased just prior to admission, and the patient has also been taking Bumex as well. FAMILY HISTORY: Negative for carcinoma. Father died at age [**Age over 90 **] of myocardial infarction, and mother died at age 50 of acute renal failure. SOCIAL HISTORY: The patient is originally from Persia. No tobacco and no ETOH. She is married with three children. The patient's husband is an ENT physician in the community. PHYSICAL EXAMINATION: On physical examination, the patient is lethargic and agitated. The patient is delirious. Vital signs revealed temperature 97.0, heart rate 80, respiratory rate 24, blood pressure 80/60, oxygen saturation 100% in room air. The patient weighs 73 kilograms. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Mucous membranes are dry. Jugular venous pressure is eight centimeters. Cardiovascular - regular, II/VI systolic murmur at the left sternal border. Pulmonary - crackles at the bases bilaterally. The abdomen revealed postsurgical scar. Positive bowel sounds and nontender. Extremities revealed 2+ pitting edema to thighs. Neurologically, the patient is oriented to name, follows some commands. Lymph - No axillary lymphadenopathy. LABORATORY DATA: Arterial blood gases revealed pH 7.45/25/88 in room air. Chem7 revealed sodium 132, potassium 4.2, chloride 99, bicarbonate 18, blood urea nitrogen 52, creatinine 1.8, glucose 66, calcium 8.7, phosphate 3.9, magnesium 1.8. ALT 37, AST 66, alkaline phosphatase 124, amylase 14, total bilirubin 3.0, direct bilirubin 2.2. On [**5-24**], total bilirubin was 0.9 and on [**4-24**], total bilirubin was 1.6 and [**3-24**], total bilirubin was 3.6. First CK was 43, troponin less than 0.3. Complete blood count revealed a white blood cell count 6.4, hematocrit 33.7, platelets 163,000, neutrophils 84%, bands 14%, lymphocytes 2%, monocytes 1%. Prothrombin time was 15.0, partial thromboplastin time 29.2, INR 1.6. Chest x-ray revealed four chamber cardiomegaly and subsequent atelectasis at the left base. Electrocardiogram revealed normal sinus rhythm, left axis deviation, poor R wave progression, no ischemic changes . HOSPITAL COURSE: In summary, this is a 55 year old female with a past medical history of breast cancer, status post chemotherapy and radiation therapy who presented on [**2122-10-4**], with hypotension and delirium. The patient was diagnosed with breast cancer one year ago. She is status post bilateral mastectomy with five out of twelve positive lymph nodes on the right and three out of nine positive lymph nodes on the left. The patient had four cycles of Adriamycin and one cycle of Taxol which was complicated by pulmonary edema. At that time, it was thought that the patient's congestive heart failure was secondary to Adriamycin resulting in an ejection fraction of 20%. The patient did have wall motion abnormalities on echocardiogram and was to have a cardiac catheterization planned for the future to rule out coronary artery disease, however, the patient has never had documented evidence of coronary artery disease in the past. Since chemotherapy, the patient has had multiple admissions to outside hospitals for hyponatremia and nonsustained ventricular tachycardia. The patient's last chemotherapy was in [**1-22**]. Four days before admission, the patient initiated radiation therapy times four days. She was noted by her family to be lethargic and somnolent. She was also experiencing increased edema. Her husband, who is an ENT physician, [**Name10 (NameIs) 18546**] her dose of Lasix. The patient was then brought to [**Hospital1 69**] by her family. The patient was originally admitted to the floor, however, she was hypotensive and was also found to have increased white blood cell count and 14% bandemia. Antibiotics with Ceftriaxone, Vancomycin and Flagyl were started before blood cultures were sent. The patient was then transferred to the Medical Intensive Care Unit. Upon presentation, the patient was delirious and incomprehensible. She was hypotensive to systolic blood pressure of 80s. The patient responded to multiple fluid boluses and antibiotics were continued. Urine culture was positive for pansensitive E. coli, however, no other source for sepsis was found. 1. Cardiovascular - Congestive heart failure - Atrial fibrillation - The day after admission the patient was found to have a 20 beat run of what was thought to be ventricular tachycardia and then converted to a supraventricular tachycardia. Cardiology fellow was consulted who recommended Adenosine. After Adenosine was initiated, the patient converted to sinus briefly and then a wide complex tachycardia. Lidocaine was given and a drip was started. The patient was shocked at 200 and 350 joules and converted to sinus rhythm. The patient was then bolused with Amiodarone and started on Amiodarone drip. That evening, the patient converted to a wide complex tachycardia and was shocked several more times. The patient was also intubated for lactic acidemia. In total, the patient was cardioverted seven times. Electrophysiology felt that the patient had atrial fibrillation with aberrancy and was recommending continuing the Amiodarone drip. After approximately one week, the Amiodarone drip was changed to p.o. On [**2122-10-11**], at approximately 08:20 a.m., the patient converted from sinus to atrial fibrillation. The patient was continued on p.o. Amiodarone 300 mg p.o. b.i.d. It was decided not to cardiovert the patient since she had not stayed in sinus in the past. Anticoagulation was not started since the patient was thrombocytopenic at the time (platelets nadired to 32,000). There was also high suspicion of HIT antibody positivity in this patient even though the patient was not HIT positive by laboratory results. Anticoagulation will have to be readjusted in the future. On [**2122-10-19**], the patient converted to sinus spontaneously and then to atrial tachycardia with a 2:1 block. The patient was started on Lopressor 12.5 mg t.i.d. Congestive heart failure - Soon after admission, because of hemodynamic instability and uncertainty of whether the patient was experiencing sepsis versus cardiogenic shock, a Swan was placed. Repeat echocardiogram showed no tamponade, 4+ tricuspid regurgitation and 4+ mitral regurgitation with an ejection fraction of 20 to 25%. The patient's SVR was in the 400 range and cardiac index was approximately 2.1. The patient was started on Dobutamine and Levophed. The patient continued to remain hemodynamically unstable and was started briefly on Dopamine and Neo-Synephrine. The patient then improved and eventually all drips, Lidocaine, Levophed, Dobutamine, Dopamine and Neo-Synephrine were discontinued. The Swan was discontinued and diuresis was initiated. The patient was 24 liters positive and had severe anasarca. The patient was extubated on [**2122-10-13**], but had to be reintubated due to respiratory distress. The patient had reaccumulated fluid rapidly in her lungs. Bilateral thoracentesis was done and 500 ccs was removed on the right and 800 ccs was removed on the left. The pleural effusions were consistent with exudates by LDH and had 700 to 1000 white blood cells. However, the team felt that this was still consistent with congestive heart failure. The patient's respiratory status improved postthoracentesis and aggressive diuresis was again initiated with Lasix 120 mg intravenously t.i.d. The patient was extubated on [**2122-10-19**], but did require BiPAP overnight. On [**2122-10-20**], a Lasix drip was started. The patient was also started on Captopril and titrated up to 100 mg t.i.d. and Isordil 40 mg t.i.d. 2. Renal - The patient presented with acute renal failure which improved after the patient's cardiac output improved. Her peak creatinine was 2.6 and continued to improve despite aggressive diuresis. The patient was followed by renal who have since signed off. 3. Infectious disease - No source for the patient's sepsis was ever found and infectious disease was not convinced that the positive urine cultures could be responsible for the patient's septic physiology. The patient was started on Vancomycin and Meropenem for empiric coverage. CT of the abdomen was negative but could not definitively rule out cholecystitis. Infectious disease recommended continue the Vancomycin and Meropenem for a full eighteen day course. The patient did have positive alpha streptococcus in the right pleural fluid but the Intensive Care Unit team felt that this was not a significant pathogen at the time. Of note, the patient's lactic acidosis peaked at 9.0 and it was thought this was most likely due to a low flow state and hypoperfusion. 4. Gastrointestinal - The patient had increased bilirubin at 3.3 which was present on admission and slightly elevated ALT/AST which has been thought to be due to right sided failure. The patient's total bilirubin peaked at approximately 7.6 on [**2122-10-11**], and improved with diuresis. 5. Hematology - The patient was thought to be in low grade DIC during her Medical Intensive Care Unit stay which has since resolved. She was also thrombocytopenic to 32,000 after Swan was placed. HIT antibody was sent which was negative. However, after the Heparin coated Swan was discontinued, the patient's platelets rose to the 140,000. It is, therefore, thought that the patient may be HIT positive. No additional Heparin was given to the patient during the rest of her Medical Intensive Care Unit stay. 6. Endocrine - The patient has hypothyroidism and was maintained on her outpatient Synthroid dose. 7. Neurologic - The patient presented with delirium and lumbar puncture was attempted but was unsuccessful. The patient has been treated with Meropenem which is adequate CFF penetration. Her mental status has improved since admission. 8. Psychiatry - As an outpatient, the patient has noted to be anxious and has been on low dose benzodiazepines, however, these benzodiazepines were avoided during her Intensive Care Unit stay due to her acute renal failure and mental status changes. 9. Vascular - The patient has distal extremity ischemia thought to be due to Levophed use. Vascular surgery was consulted and agree that pressors were probably responsible for her distal ischemia. They, however, recommended a Transesophageal Echocardiogram to rule out embolic event, however, the Medical Intensive Care Unit felt that the probability of emboli was low and a Transesophageal Echocardiogram was not performed. 10. Code - The patient's code status is full. 11. Communication - The patient's husband, Dr. [**Known lastname **], is in close contact. [**Name (NI) **] can be reached at [**Telephone/Fax (1) 102824**] or [**Telephone/Fax (1) 102825**], pager #[**Telephone/Fax (1) 102826**]. 12. Access - The patient had a PICC line placed on [**2122-10-21**]. The rest of the [**Hospital 228**] hospital course will be dictated by the C-Medicine team who has been following the patient since. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2122-11-2**] 16:32 T: [**2122-11-2**] 16:33 JOB#: [**Job Number 102827**] Admission Date: [**2122-10-4**] Discharge Date: [**2122-11-18**] Date of Birth: [**2067-1-2**] Sex: F Service: This resumes the previous discharge summary dictated by the Medical Intensive Care Unit team on this 55-year-old female with a history of breast cancer with adriamycin induced cardiomyopathy, who was admitted to the C Med after discharge from the Medical Intensive Care Unit where she had been treated for fever, hypotension and mental status changes and septic physiology without source. While she was on the floor with C Med team, she had three main issues: 1. Her congestive heart failure medications were adjusted including her ACE inhibitor, beta-blocker, Lasix, Aldactone and digoxin. Towards the end of the stay, as these were being maximized, she had increased BUN and creatinine and some hyperkalemia, as well as hyponatremia associated with over diuresis in the setting of ACE inhibitor and Aldactone. This resulted in part from the patient refusing laboratory draws for a period of time and was correcting at the time of discharge. 2. The patient was evaluated for fever of unknown origin. Multiple cultures were negative and it eventually resolved without treatment and she had been afebrile for over a week by the time she had left. 3. She received Physical Therapy for rehabilitation after deconditioning in the Medical Intensive Care Unit. In terms of nutrition and wound care for wounds resulting from edema and blood draws at arterial blood gas sites. Please see my already typed discharge summary in OMR dated [**2122-11-18**] for further details. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Full code. DISCHARGE MEDICATIONS: 1. Captopril 37.5 mg po t.i.d. 2. Coreg 18.75 mg po b.i.d. 3. Aldactone 50 mg po q.d. 4. Lasix 100 mg po q.d. 5. Magnesium oxide 400 mg po q.d. 6. Amiodarone 200 mg po q.d. 7. Epo 10,000 units Monday, Wednesday and Friday SC. 8. Digoxin 0.125 mg po q.o.d. 9. Synthroid 125 mg po q.d. 10. Protonix 40 mg po q.d. 11. Iron sulfate 325 mg po q.d. 12. Fosamax 5 mg po q.d. 13. Artificial saliva prn. 14. Tums 500 mg po b.i.d. 15. Boost or other nutritional supplements t.i.d. to q.i.d. 16. Fluid restrictions to two liters to be increased to 1.5 liters if weights are increasing. 17. Vitamin E 400 units po q.d. 18. Vitamin D 400 units po q.d. 19. Vitamin C 500 mg po q.d. 20. Multivitamin po q.d. 21. Aromasin 25 mg po q.p.m. with wound care consistent with wet-to-dry dressings q.d. FOLLOW-UP: Daily weights with titration of Lasix, as well as follow-up laboratory studies for electrolytes and renal function. Aggressive Physical Therapy and the family is to initiate outpatient congestive heart failure care with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. DISCHARGE DIAGNOSES: As per prior discharge summary. Also including: 1. Mild stable hyponatremia. 2. Fever of unknown origin. Multiple cultures negative, resolved. 3. Hyperkalemia while slight over diuresed and on ACE inhibitor and Aldactone. Again, see previously typed discharge summary in OMR dated [**2122-11-18**] for further details. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2122-11-22**] 15:39 T: [**2122-11-22**] 15:39 JOB#: [**Job Number 35011**] Admission Date: [**2122-10-4**] Discharge Date: [**2122-11-18**] Date of Birth: [**2067-1-2**] Sex: F Service: This resumes the previous discharge summary dictated by the Medical Intensive Care Unit team on this 55-year-old female with a history of breast cancer with adriamycin induced cardiomyopathy, who was admitted to the C Med after discharge from the Medical Intensive Care Unit where she had been treated for fever, hypotension and mental status changes and septic physiology without source. While she was on the floor with C Med team, she had three main issues: 1. Her congestive heart failure medications were adjusted including her ACE inhibitor, beta-blocker, Lasix, Aldactone and digoxin. Towards the end of the stay, as these were being maximized, she had increased BUN and creatinine and some hyperkalemia, as well as hyponatremia associated with over diuresis in the setting of ACE inhibitor and Aldactone. This resulted in part from the patient refusing laboratory draws for a period of time and was correcting at the time of discharge. 2. The patient was evaluated for fever of unknown origin. Multiple cultures were negative and it eventually resolved without treatment and she had been afebrile for over a week by the time she had left. 3. She received Physical Therapy for rehabilitation after deconditioning in the Medical Intensive Care Unit. In terms of nutrition and wound care for wounds resulting from edema and blood draws at arterial blood gas sites. Please see my already typed discharge summary in OMR dated [**2122-11-18**] for further details. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Full code. DISCHARGE MEDICATIONS: 1. Captopril 37.5 mg po t.i.d. 2. Coreg 18.75 mg po b.i.d. 3. Aldactone 50 mg po q.d. 4. Lasix 100 mg po q.d. 5. Magnesium oxide 400 mg po q.d. 6. Amiodarone 200 mg po q.d. 7. Epo 10,000 units Monday, Wednesday and Friday SC. 8. Digoxin 0.125 mg po q.o.d. 9. Synthroid 125 mg po q.d. 10. Protonix 40 mg po q.d. 11. Iron sulfate 325 mg po q.d. 12. Fosamax 5 mg po q.d. 13. Artificial saliva prn. 14. Tums 500 mg po b.i.d. 15. Boost or other nutritional supplements t.i.d. to q.i.d. 16. Fluid restrictions to two liters to be increased to 1.5 liters if weights are increasing. 17. Vitamin E 400 units po q.d. 18. Vitamin D 400 units po q.d. 19. Vitamin C 500 mg po q.d. 20. Multivitamin po q.d. 21. Aromasin 25 mg po q.p.m. with wound care consistent with wet-to-dry dressings q.d. FOLLOW-UP: Daily weights with titration of Lasix, as well as follow-up laboratory studies for electrolytes and renal function. Aggressive Physical Therapy and the family is to initiate outpatient congestive heart failure care with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. DISCHARGE DIAGNOSES: As per prior discharge summary. Also including: 1. Mild stable hyponatremia. 2. Fever of unknown origin. Multiple cultures negative, resolved. 3. Hyperkalemia while slight over diuresed and on ACE inhibitor and Aldactone. Again, see previously typed discharge summary in OMR dated [**2122-11-18**] for further details. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2122-11-22**] 15:39 T: [**2122-11-22**] 15:39 JOB#: [**Job Number 35011**]

[ "584.9", "428.0", "427.31", "286.6", "276.2", "425.4", "707.0", "038.9", "174.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.04", "99.62", "89.68", "96.72", "34.91", "89.64" ]

icd9pcs

[ [ [] ] ]

20123, 20163

3826, 3966

21309, 21883

20186, 21287

3371, 3809

5980, 16712

4168, 5962

148, 1750

1772, 3345

3983, 4145

23,000

137,658

50539

Discharge summary

report

Admission Date: [**2129-8-9**] Discharge Date: [**2129-8-22**] Date of Birth: [**2082-10-26**] Sex: F Service: CARDIOTHORACIC Allergies: Levofloxacin Attending:[**First Name3 (LF) 3948**] Chief Complaint: Fevers to 101 and increased SOB. Major Surgical or Invasive Procedure: [**2129-8-11**] Flexible bronchoscopy with therapeutic aspiration of secretions. [**2129-8-9**] Flexible bronchoscopy with bronchoalveolar lavage. History of Present Illness: Ms. [**Known lastname 284**] is a 46 year old female with history of breast cancer, thyroid cancer, and Hodgkins status post XRT who first presented with a pleural effusion on [**2129-6-13**]. She had a thoracentesis and thorascopy with pleuradesis on [**2129-6-23**]. She had trapped lung following htis procedure, requiring decortication ([**2129-6-28**]) and chest tube placement. She developed a post-operative fever and was treated for pneumonia with vancomycin/zosyn --> augmentin on discharge (completed [**2129-7-11**]). She re-presented to [**Hospital1 18**] on [**2129-7-29**] with fevers and shortness of breath and was discharged on [**8-7**] with vancomycin for MRSA empyema. . She presented to [**Hospital1 18**] yesterday with fevers to 101, hemoptysis with occasional clots, and increasing shortness of breath. There were blood clots present in her sputum. She denied chest pain, LE edema. . Patient is on anticoagulation with lovenox for mechanical aortic valve which was held last night. She was given Vanco/Zosyn for empiric treatment for pneumonia. She had a bronchoscopy today which showed diffuse bleeding on the right side. A small amount of bleeding that resolved was seen on the left side. . Following bronchoscopy, patient went to bathroom and developed shorntess of breath patient was increased from 4 to 6LNC of oxygen. She was coughing, but denied hemoptysis. She reported shortness of breath. She denied chest pain, nausea, vomiting, abdominal pain, or any other symptoms. Past Medical History: Left lower lobe effusion s/p [**2129-7-29**] Pigtail catheter placement into the left pleural space [**2129-6-23**] Pleuoscopy, drainage left pleural effusion, biopsy [**2129-6-24**] Left video assisted thoracoscopy converted to left thoracotomy, decortication of lung, also placement of pneumoperitoneum catheter. Hodgkin's disease, status post XRT and lymphadenectomy. Breast Cancer s/p bilateral mastectomy & bilateral reconstruction hypothyroidism s/p total thyroidectomy in [**2122**] for bilateral papillary carcinoma. s/p Aortic replacement mechanical [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] for radiation-induced valvular disease in [**2123-8-24**]. Social History: The patient does not smoke. She drinks alcohol occasionally. She is married, but has no children. She owns a gift store. Family History: Family history is negative for breast cancer. Physical Exam: VS: T: 98.2 HR: 106 SR BP: 160/80 Sats: 96% RA General: 46 year-old female in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple, no lymphadenopathy Card: RRR good click, normal S1,S2 no murmur/gallop/rub Resp: decreased breath sounds bilateral GI: benign Extr: warm no edema Incision: well healed, pigtail site no discharge Neuro: non-focal Pertinent Results: [**2129-8-19**] Chest CT: IMPRESSION: 1. Marked improvement of diffuse airspace consolidation and opacity in the right lung, consistent with resolving hemorrhage. 2. Unchanged appearance of left-sided pigtail catheter; little decrease in small left pleural collection, probably hemorrhagic. 3. Improving left lower lobe hematoma. [**8-11**] CTA chest/ abd/ pelvis: There is no evidence of any active bleeding or extravasation of contrast into the pleural space or into the abdomen. Minimal free fluid in the abdomen is of a simple fluid attenuation and is not blood. It is not bloody in nature. [**8-8**] Ct: Worsening of diffuse airspace opacities in the right lung from [**2129-7-31**]. These may represent worsening multifocal pneumonia. However, superimposed edema or hemorrhage can't be excluded. Left lower lobe nodular opacities similar in appearance from prior study. Left loculated pleural effusion is smaller with pigtail catheter centered in the effusion. Assessment for empyema limited without IV contrast. CXR [**8-20**] The right lung base shows a peribronchial area of consolidation that is likely to represent pneumonia. In the retrocardiac lung areas, sparse air bronchograms and a subtle pleural effusion is seen. Here another consolidation could be present. No hilar or mediastinal enlargement. No evidence of pneumothorax. Borderline size of the cardiac silhouette. CXR [**8-8**]: B/l diffuse airspace opacities which may reflect worsed multifocal pna; superimposed pulm edema/hmg cant be ruled out/ no effussions. [**2129-7-31**]. These may represent worsening multifocal pneumonia.However, superimposed edema or hemorrhage can't be excluded. Left lower lobe nodular opacities similar in appearance from prior study. Left loculated pleural effusion is smaller with pigtail catheter centered in the effusion. Labs: [**2129-8-20**] WBC-5.4 RBC-4.19* Hgb-11.6* Hct-35.7* Plt Ct-502* [**2129-8-18**] WBC-6.8 RBC-4.09* Hgb-11.4* Hct-34.5* Plt Ct-501* [**2129-8-12**] WBC-8.5 RBC-3.69* Hgb-10.4* Hct-31.3* Plt Ct-332 [**2129-8-11**] WBC-7.7 RBC-3.01* Hgb-8.7* Hct-24.8* Plt Ct-283 [**2129-8-9**] WBC-17.4*# RBC-2.75* Hgb-7.6* Hct-23.9* Plt Ct-397 [**2129-8-9**] WBC-7.7 RBC-3.03* Hgb-8.0* Hct-26.2* Plt Ct-340 [**2129-8-8**] WBC-10.8 RBC-2.66* Hgb-7.4* Hct-23.0* Plt Ct-390 [**2129-8-11**] Neuts-85.3* Bands-0 Lymphs-10.0* Monos-1.5* Eos-3.1 Baso-0.2 [**2129-8-22**] PT-15.1* PTT-33.3 INR(PT)-1.3* [**2129-8-21**] PT-14.2* PTT-34.8 INR(PT)-1.2* [**2129-8-8**] PT-15.4* PTT-36.4* INR(PT)-1.4* [**2129-8-9**] FacVIII-248* [**2129-8-9**] Fibrino-674*# D-Dimer-1665* [**2129-8-9**] VWF AG-181* VWF CoF-160 [**2129-8-20**] Glucose-89 UreaN-9 Creat-0.6 Na-138 K-4.3 Cl-101 HCO3-28 [**2129-8-8**] Glucose-108* UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-106 HCO3-23 [**2129-8-17**] ALT-367* AST-114* LD(LDH)-326* AlkPhos-237* TotBili-0.4 DirBili-0.1 IndBili-0.3 [**2129-8-11**] ALT-143* AST-113* LD(LDH)-417* AlkPhos-197* TotBili-1.3 [**2129-8-20**] Calcium-9.2 Phos-4.8* Mg-2.3 [**2129-8-11**] Hapto-282* [**2129-8-12**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2129-8-9**] ANCA-NEGATIVE B [**2129-8-12**] dsDNA-NEGATIVE [**2129-8-9**] [**Doctor First Name **]-NEGATIVE [**2129-8-9**] RheuFac-14 [**2129-8-12**] C3-176 C4-33 [**2129-8-12**] HCV Ab-NEGATIVE Cultures: CMV Viral Load (Final [**2129-8-16**]): CMV DNA not detected. VARICELLA-ZOSTER IgG SEROLOGY (Final [**2129-8-16**]): POSITIVE BY EIA. Blood Culture, Routine (Final [**2129-8-17**]): NO GROWTH. GRAM STAIN (Final [**2129-8-11**]): NO ORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2129-8-13**]): OROPHARYNGEAL FLORA ABSENT. SERRATIA MARCESCENS. RARE GROWTH. GRAM STAIN (Final [**2129-8-10**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2129-8-13**]): ESCHERICHIA COLI. HEAVY GROWTH. STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci ESCHERICHIA COLI | STAPH AUREUS COAG + | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R PIPERACILLIN/TAZO----- <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- =>16 R <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2129-8-14**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2129-8-10**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): VIRAL CULTURE (Preliminary): No Virus isolated so Pleural fluid [**6-13**]: Negative Left Lung tissue [**6-23**]: Negative, fungal, AFB, nocardia Brief Hospital Course: Ms. [**Known lastname 284**] is a 46 year old female with a histoy of Hodgkin's lymphoma, breast cancer, thyroid cancer, s/p aortic valve replacement on lovenox, admitted with repiratory distress secondary to hemotpysis, multifocal pneumonia, polymicrobial empyema. . Respiratory failure. Patient was admitted to MICU for increased oxygen requirements and respiratory distress following bronchoscopy. Patient was intubated for airway protection and to manage patient secretions in setting of ongoing signicant hemoptysis. On bronchosopy, it appeared that pulmonary bleed was diffuse. Etiology of hemopysis was thought to be secondary to multifocal pneumonia on top of radiation changes to lung in setting of anticoagulation. WIth treatment of PNA and holding anticoagulation, hemoptysis resolved. Patient intiially failed extubation, but after diuresis, she was able to be successfully extubation. A rheuamtology work up for diffuse alveolar hemorrhage was pursued, but was pending at time of discharge from MICU. Anemia. Patient had hemoptysis that resolved during hospital stay in setting of anticoagulation for mechanical valve. She remained anemic during MICU course requiring 7 units of PRBCs. She was guiaic negative and CT torso did not show any ongoing bleeding or hematoma. . S/p Aortic valve replacement. Patient was anticoagulated with lovenox at home and presented with hemoptysis. Her lovenox was held and her bleeding resolved. She was resumed on heparin drip 4 days into hospital stay with goal PTT Of 50-60. On [**2129-8-18**] the heparin was stopped and she restarted Lovenox bidge to coumadin. On dishcarge her INR was 1.2. She continued her previous coumadin dosing. . Transaminitis. Patient had rising LFTs after episode of prolonged hypotension following intubation. Thought to be due to shock liver, but was evaluated for hepatitis as well. . Empyema. Patient with left pigtail in place until [**2129-8-20**] it was removed. Infectious Disease: Sputum cultlures positive for serratia marscesens. Pleural fluid positive E. coli (sensitive to cefepime) and MRSA. Patient was treated with vanco/cefepime. Infectious disease was consulted and they recommended 14 day course of cefepime and vancomycin and to removed left pigtail. Hematologic/Oncologic: seen on [**2129-8-15**] for hemoptysis and felt hemoptysis is related to infection and is resolving as infection is treated. In addition the lymphocyte predominance is likely related to this infection. She was discharged to home and will follow-up with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) **] and Infectious Disease as an outpatient. Medications on Admission: Meds: levothyroxin 150', lasix 20', toprol 25', Zocor 20', oxycodone 5 mg', tylenol 325 PRN, ASA 81'; Vancomycin Discharge Medications: 1. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. 2. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day): Until INR 2.0 or greater. Disp:*10 * Refills:*2* 3. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day: to maintain INR 2.0-3.0. 4. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day: take with OJ. 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Daily weights and take as previous. Discharge Disposition: Home Discharge Diagnosis: Left lower lobe effusion s/p [**2129-7-29**] Pigtail catheter placement into the left pleural space [**2129-6-23**] Pleuoscopy, drainage left pleural effusion, biopsy [**2129-6-24**] Left video assisted thoracoscopy converted to left thoracotomy, decortication of lung, also placement of pneumoperitoneum catheter. Hodgkin's disease, status post XRT and lymphadenectomy. Breast Cancer s/p bilateral mastectomy & bilateral reconstruction hypothyroidism s/p total thyroidectomy in [**2122**] for bilateral papillary carcinoma. s/p Aortic replacement mechanical [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] for radiation-induced valvular disease in [**2123-8-24**]. Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased chest pain, or shortness of breath, cough. Continue Lovenox until INR 2.0 or greater. Coumadin as previous. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] in 2 weeks Follow-up with Infectious Disease Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] in one month [**Telephone/Fax (1) 457**] on [**2131-9-26**]:30am [**Hospital Unit Name **]/basement, [**Last Name (NamePattern1) 10357**]. Completed by:[**2129-8-23**]

[ "V10.87", "785.52", "V09.0", "V43.3", "038.9", "482.41", "285.9", "510.9", "V10.3", "995.92", "518.81", "201.90", "786.3", "V58.61", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "33.24", "96.04" ]

icd9pcs

[ [ [] ] ]

12285, 12291

8781, 11435

312, 461

13019, 13028

3331, 8415

13299, 13668

2869, 2917

11599, 12262

12312, 12998

11461, 11576

13052, 13276

2932, 3312

8606, 8758

8448, 8570

240, 274

489, 2006

2028, 2714

2730, 2853

42,288

109,368

35331

Discharge summary

report

Admission Date: [**2186-10-13**] Discharge Date: [**2186-11-10**] Date of Birth: [**2137-2-18**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 668**] Chief Complaint: acute kidney injury Major Surgical or Invasive Procedure: [**2186-11-4**]: orthotopic liver transplant History of Present Illness: Mr. [**Known lastname **] is a 49 y.o. M with Hep C cirrhosis who presents for acute renal failure. He had a recent hospitalization at [**Hospital1 18**] [**Date range (1) 80556**] for renal failure with creatinine of 3.0 on admission and urine Na<10. Felt to be due to hepatorenal syndrome due to failed response to fluid challenge. His diuretics were held and he was treated with octreotide, midodrine, and albumin. His creatinine improved to 1.5 upon discharge. . He was seen last week by Dr. [**Name (NI) **] and noted to have increased creatinine to 2.7, as well as new cough with green mucus and hemoptysis (clots). CXR was normal and he was given azithromycin. His sx persisted, so he was seen by his VA provider yesterday, who rx'd him doxycycline. He also had labs redone this week in [**Location (un) 5583**] that showed further increase in creatinine (value not available at this time), which prompted him to be directly admitted from home. . On the floor, he notes increased abd soreness from baseline x1 week, worse with deep breath, although not as severe as his prior SBP. Also notes increased dyspnea from baseline, that he associates with concurrent abd pain. Has has had poor PO intake over the past week. Also notes intermittent sore throat, chronic nausea, chronic diarrhea from lactulose. He denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, chest pain, vomiting, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: HCV Cirrhosis, genotype 1 (with 3.9 x 2.7 mass in the segment VI of the liver could be perfusion abnormality versus a hepatoma seen on [**2185**]) SBP [**6-15**], currently on norfloxacin prophylaxis Esophageal Varicies (distal) [**12-9**]+ noted [**1-15**] endoscopy at OSH Depression/Anxiety Hypertension h/o infectious colitis [**8-/2184**] to [**12/2184**] Nephrolithiasis - prior lithiotripsy Social History: His HCV thought to be [**1-9**] to occupational exposure, patient used to work as dialysis nurse and had a needle stick. Past alcohol use described as occasional wine/cocktail, has not drunk since [**2175**]. He is an ex-cigarette smoker for the last eight years, but prior to this has a 20-pack year history. Denies any illicit drug use, marijuana, intravenous drug use, tattoos, or body piercing. He is married with two children. Family History: He has one brother who has genetic hemochromatosis. He has one sister with thyroid disease and diabetes, and a second sister who has cholesterolemia and hypertension. Both of his parents have had coronary artery disease. His mother succumbed to complications of her coronary artery disease. Physical Exam: Vitals - T: 97.3 BP: 124/71 HR: 73 RR: 16 02 sat: 95RA UOP 1090 GENERAL: Well appearing, NAD HEENT: No icterus, MM dry, neck supple CARDIAC: RRR no m/r/g LUNG: CTAB, except slight crackles at right base ABDOMEN: Soft, distended with ascites. Nontender. +fluid wave. No organomegaly. NABS. EXT: 1+ ankle edema. WWP. NEURO: A+Ox3. CN 2-12 grossly intact. No asterixis. Pertinent Results: On Admission: [**2186-10-14**] WBC-5.3# RBC-2.51* Hgb-8.5* Hct-25.0* MCV-100* MCH-33.8* MCHC-33.9 RDW-17.6* Plt Ct-59* PT-21.4* PTT-59.4* INR(PT)-2.0* Glucose-86 UreaN-46* Creat-3.5* Na-135 K-4.2 Cl-112* HCO3-17* AnGap-10 ALT-33 AST-55* LD(LDH)-174 AlkPhos-93 TotBili-3.9* Albumin-2.1* Calcium-8.0* Phos-3.8 Mg-2.3 On Discharge: [**2186-11-10**] WBC-4.3 RBC-3.19* Hgb-10.0* Hct-27.4* MCV-86 MCH-31.3 MCHC-36.4* RDW-17.5* Plt Ct-38* PT-12.7 PTT-26.4 INR(PT)-1.1 Glucose-84 UreaN-59* Creat-2.1* Na-137 K-3.1* Cl-103 HCO3-26 AnGap-11 ALT-63* AST-31 AlkPhos-32* TotBili-1.2 Albumin-3.4 Calcium-8.7 Phos-3.8 Mg-1.8 tacroFK-4.8* Brief Hospital Course: [**Last Name (un) **]: Creatinine decreased to 2.4. Upon discharge in [**8-16**], was 1.5. Urine Na was less than 10 now 17. Concerning for HRS physiology. s/p blood transfusion. Currently on daily midodrine and octreotide. Anti-GBM negative. Good UOP and high blood pressures. He was diagnosed with a UTI pre surgery. The UA is consistent with infection. Treated with CTX. Received a seven day course . Confusion: This is new as of [**2186-10-31**]. Concern for encephalopathy and asterixis. He was placed on lactulose and rifaxamin until the time of the liver transplant. . HCV Cirrhosis: MELD on admission was 36. H/o decompensation with SBP, encephalopathy, varices, ascites and thrombocytopenia. Para negative for SBP this admission. The patient stayed hospitalized until the time of his liver transplant due to his decompensation. On [**2186-11-4**] the patient received and orthotopic liver transplant. He was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He received routine induction immunosuppresion to include cellcept, solumedrol with taper and prograf which was started on the evening of POD 0. The surgery went well with the only issue recorded as the bile ducts were taken down and re-anastomosed due to evidence of a bile leak. In the post op period the drain output was minimal and the lateral drain was d/c'd prior to discharge. His LFTs never really were elevated and his creatinine came down to 2.1 by day of discharge and his urine output was excellent between one and two liters. POD 1 ultrasound was WNL His prograf was dose adjusted daily based on trough levels. The level was initially high in the mid teens. Labs will be recehecked Monday [**11-13**]. He was ambulating without difficulty although he had c/o pitting leg edema for which he received IV lasix with good response. He will go home on 20 PO daily x three days with re-assessment in clinic of his fluid status. Patient was reminded to only use the lasix for the three days to avoid dehydration. He was tolerating diet and using supplements PRN. He was not sent on insulin as blood sugars were never elevated and fasting levels were excellent. Medications on Admission: Lactulose 30 mL po QID Midodrine 5 mg po TID Nadolol 10 mg po daily (held per Dr. [**Name (STitle) 23173**]) Norfloxacin 400 mg po daily Phytonadione 5 mg po daily Potassium Chloride SR 20 meq po daily Sertraline 50 mg po daily Doxycycline 100mg daily x10 days (started [**10-12**]) Motrin prn Benadryl prn Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day: Follow transplant clinic taper. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA & Hospice Services Discharge Diagnosis: s/p liver transplant Hepatorenal syndrome with acute kidney failure: resolved Discharge Condition: Stable Ambulatory A+Ox3 Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, yellowing of skin or eyes, or other concerning symptoms. Drain and record JP bulb output three times daily and more often as necessary. Bring copy of record with you to transplant clinic appointments. Place a new drain sponge around the drain site daily and as needed. Please call the transplant clinic if the drain output increases significantly, turns bloody, green or develops a foul odor. Drink enough fluids to keep your urine light yellow in color Monitor the incision for redness, drainage or bleeding. [**Month (only) 116**] leave the incision open to air. You may shower. Pat incision dry and place a new drain sponge daily No heavy lifting No driving if taking narcotic pain medication. Driving should only be resumed with your surgeons permission Labs every Monday and Thursday at [**Hospital **] Medical Office Building Lab Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-11-17**] 1:50 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2186-11-17**] 2:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-11-24**] 12:50 Completed by:[**2186-11-10**]

[ "998.11", "584.9", "285.29", "789.59", "490", "300.4", "401.9", "571.5", "070.71", "293.9", "456.1", "572.4", "599.0", "V15.82", "786.3", "E876.2", "287.5", "070.70" ]

icd9cm

[ [ [] ] ]

[ "54.91", "50.59", "00.93" ]

icd9pcs

[ [ [] ] ]

7652, 7722

4064, 6242

286, 333

7844, 7870

3417, 3417

8906, 9327

2720, 3013

6600, 7629

7743, 7823

6268, 6577

7894, 8883

3028, 3398

3746, 4041

227, 248

361, 1833

3431, 3732

1855, 2255

2271, 2704

6,800

142,356

4507

Discharge summary

report

Admission Date: [**2177-12-29**] Discharge Date: [**2178-1-1**] Date of Birth: [**2123-8-12**] Sex: F Service: MEDICAL ICU CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 53 year-old woman with a history of alcoholic hepatitis and recent admission between [**11-12**] and [**2177-11-17**] for alcoholic intoxication/hepatitis/pancreatitis who now presents with one month of worsening abdominal pain and increased abdominal girth. The patient states this has never occurred before. She also complains of nausea and vomiting over the past week with a decreased appetite. She has had decreased bowel movements over the past few weeks and increased abdominal pain with meals and with alcohol consumption. She continues to drink about 1 pint of alcohol a day. The last drink was the morning of admission. She also has had low grade temperatures with chills as well as increased confusion for the past week. She denies any hematemesis, melena, bright red blood per rectum, cough, chest pain, shortness of breath, urinary frequency, dysuria, incontinence, recent loss of consciousness, fall, head trauma. She also denies any previous episodes of ascites, spontaneous bacterial peritonitis, encephalopathy or variceal bleeding. PAST MEDICAL HISTORY: Alcoholic hepatitis, alcoholic pancreatitis, alcoholic ketoacidosis. Depression with suicidal ideation. Right total hip replacement secondary to AVN, breast cancer status post right mastectomy, status post radiation therapy and chemotherapy in [**2171**], question of hemachromatosis, status post cholecystectomy. MEDICATIONS ON ADMISSION: Folate, thiamine, multivitamin, Oxycodone, Effexor, Trazodone, BuSpar. ALLERGIES: Terazol, Darvocet, Celebrex, Vioxx, Ampicillin and Erythromycin. SOCIAL HISTORY: The patient lives in an [**Hospital3 **] facility. She drinks approximately one pint of alcohol per day and smokes approximately one pack of cigarettes per day. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 99.1, pulse 111, respiratory rate 18, blood pressure 100/54, O2 sat 100% on room air. In general, the patient is lying in bed, lethargic, confused, but conversant. HEENT pupils are equal, round and reactive to light. Scleral icterus. Oropharynx clear. Mucous membranes are slightly dry. Sublingual icterus. Neck full range of motion. No lymphadenopathy. No bruits. Chest decreased breath sounds at right base. Cardiovascular examination regular rate and rhythm. No murmurs. Rectal dark brown OB positive stool. Abdominal examination tense distended abdomen, decreased bowel sounds, mild diffuse tenderness, positive shifting dullness, positive fluid wave. Extremities no edema. Skin with spider angiomata, positive umbilical veins, jaundice. Neurological examination disoriented to time, positive asterixics, good strength and sensation throughout. LABORATORY DATA ON ADMISSION: White blood cell count 12.3, hematocrit 33.6, platelets 183, MCV 110, polys 86, lymphocytes 6%, sodium 139, potassium 2.7, chloride 99, bicarb 27, BUN 8, creatinine 1, glucose 74, calcium 8.5, magnesium 1.4, phosphorus 4, INR 1.7, PTT 41.2. ALT 20, AST 57, amylase 126, lipase 141, total bili 3.3, alcohol level 103, serum tox screen negative. Ammonia level 79. Head CT negative. IMPRESSION: The patient is a 53 year-old woman with likely alcoholic cirrhosis who presents with mental status changes, alcoholic intoxication versus hepatic encephalopathy and increased abdominal girth/pain times one month. HOSPITAL COURSE: 1. Gastrointestinal: Alcoholic cirrhosis/ascites/hepatic encephalopathy - the patient was placed on Lactulose 30 cc q.i.d. to titrate to four to five bowel movements per day. She was also given vitamin K for her elevated INR. She was placed on clears for possible alcoholic pancreatitis. On the night of admission the patient complained of increased nausea and was tachycardic to the 120s. She then vomited a small amount of bright red blood and 300 to 350 cc of coffee grounds, which cleared after nasogastric lavage with 500 cc of normal saline. A right femoral line was placed under sterile conditions and the patient was given Ativan for her nausea and vomiting. Intravenous fluids were started on GI fellow was contact[**Name (NI) **]. The MICU team was called to evaluate the patient for a transfer to the MICU. The patient underwent the paracentesis in the Medical Intensive Care Unit. Aspirate was not consistent with spontaneous bacterial peritonitis, however, she was continued on prophylactic antibiotics for SBP. She also underwent an esophagogastroduodenoscopy, which showed no esophageal varices, so the Octreotide that she was placed on was discontinued. She was initially on a Protonix drip and this was changed to b.i.d. The paracentesis she had was also therapeutic in that 5 liters were removed, however, it quickly accumulated within one to two days and may have contributed to her hypotension. Abdominal CT was done and was negative for ascites. A repeat paracentesis was held off for the time being. She was maintained on NPO status and was hydrated aggressively. Her hematocrit remained stable and her pancreatitis by laboratory data seemed to be resolving. 2. Pulmonary: On [**12-30**] the patient was intubated secondary to worsening metabolic acidosis and compensatory hyperventilation. She had lactic acidosis on admission. Her metabolic acidosis was thought to be most likely secondary to her alcoholic ketoacidosis. It was difficult to control her acid base status even on the ventilator. As her respiratory rate was very high in the 30s and 40s and she was also developing hypoxia requiring increased FIO2. On chest x-ray she was seen to have pleural effusion right greater then left. It was thought to be either secondary to fluid overload versus pneumonia secondary to aspiration. She is producing increased secretions. She was on Levofloxacin, Vancomycin and Flagyl both for SBP prophylaxis and for possible treatment for pneumonia. In the end it was decided to paralyze her and change the ventilator setting to AC to decrease her work of breathing and therefore to hopefully decrease her lactic acidosis. She was sedated with Ativan drip and her FIO2 was increased to 100%. Her ETT aspirate was sent for culture and showed 675 white blood cells, 30 polys, 5 bands consistent with infection, although the appearance of it was similar to ascites. 3. Cardiovascular: The patient continued to be tachycardic and hypotension and eventually was placed on neo-synephrine, [**Last Name (un) **] and vaso drips. The etiologies for her hypotension included sepsis from her possible SBP or pancreatitis, blood loss although esophagogastroduodenoscopy was negative for active bleeding, adrenal insufficiency, although her tachycardia could also be secondary to her alcohol withdraw. Her blood cultures returned positive for gram positive coxae. She was already on Vancomycin as well as Levofloxacin and Flagyl for SBP prophylaxis. On [**12-30**] she received 2 units of packed red blood cells and her hematocrit remained stable after that. A right IJ was placed in while this was done she was given fresh frozen platelets and after this was successfully placed her right femoral line was removed. She continued to be hypotensive and none of her pressors were able to be weaned. She became bradycardic with runs of ventricular tachycardia and her blood culture grew gram positive coxae and gram positive rods with beta strep in her urine culture. 4. Infectious disease: Blood culture with gram positive rods, her sepsis may have contributed to her hypotension, however, her white blood cell count decreased to 2.1 reflecting a very poor prognosis. She was on Vancomycin, Levofloxacin and Flagyl. Her right femoral line was discontinued and a right IJ was placed. Beta strep grew in her urine culture. 5. Hematology: She presented with an upper gastrointestinal bleed and with laboratory data consistent with DIC. She was transfused 2 units of blood and after that her hematocrit remained stable. She was given vitamin K for her elevated INR and fresh frozen platelets prior to every procedure. Her platelets decreased to 41 consistent with DIC. 6. Renal: Her renal function remained stable, but she became oliguric likely secondary to her hypotension. She was hydrated aggressively while in the MICU. Her electrolytes were followed closely and repleted as necessary. 7. Endocrine: The patient had elevated blood glucose secondary to her pancreatitis versus her sepsis versus the D5 she was being given for her alcoholic ketoacidosis. She was placed on an insulin drip to maintain her blood sugars below 200. 8. Neurological: The patient was somnolent and unresponsive. She was on both Ativan drip and morphine for sedation. She was paralyzed in order to ventilate her passively. 9. Prophylaxis: Patient with Protonix and Pneumoboots. 10. Code status: The patient was a medical DNR. 11. Communication: The patient's aunt [**Name (NI) 2127**] [**Name (NI) 19236**] and therapist Dr. [**Last Name (STitle) 19237**] were contact[**Name (NI) **] and informed of her poor condition and poor prognosis. They were aware of her medical DNR status and agreed. Her son [**Name (NI) **] was also spoken with by the resident on the team and was aware of her condition. Her visited her prior to her death. On [**1-1**] at 7:00 p.m. the patient passed away and family agreed to withdraw life support. CONDITION ON DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Alcoholic hepatitis. 2. Alcoholic pancreatitis. 3. Sepsis. 4. Alcoholic ketoacidosis. 5. Depression. 6. Breast cancer. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Last Name (NamePattern1) 7069**] MEDQUIST36 D: [**2178-7-6**] 11:53 T: [**2178-7-7**] 09:51 JOB#: [**Job Number 19238**]

[ "276.2", "276.5", "305.00", "785.59", "038.19", "518.81", "577.0", "789.5", "571.2" ]

icd9cm

[ [ [] ] ]

[ "33.22", "45.13", "96.33", "96.04", "54.91", "38.93", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

9621, 9986

1638, 1788

3551, 9536

158, 175

204, 1271

2922, 3533

1294, 1611

1805, 1989

9561, 9600

24,603

168,967

46955

Discharge summary

report

Admission Date: [**2182-10-9**] Discharge Date: [**2182-10-14**] Date of Birth: [**2116-3-28**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1850**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 66 year old woman with a PMH of ESRD secondary to DM, on HD who was in her usual state of health until she presented at HD with altered mental status and hypotension. She initiated HD about 2 weeks ago, dialyzing M,W,F. She was then sent to the OSH ED for evaulation of her hypotension. At the [**Hospital6 **] she was found to have a WBC of 41.7 with 94 segmented neutrophils. Her labs were also notable for a HCT of 29.4. Also of note, she had an alk phos of 1023. At the OSH ED, she received 2 L NS, 3.375 mg zosyn, and 1 gm vancomycin after blood and urine cultures were sent. She was started on dopamine for a blood pressure of 53/45. Arrangements were made for transfer to our ED. The patient notes that she has not taken her medications for two days because she ran out of some of them. She also states that she is in chronic stable back and abdominal pain. The pain starts in the right flank and radiates to the right UQ and axilla. MRCP done to evaluate this was negative for stones but a biopsy of the liver showed mucinous adenocarcinoma on [**2182-9-12**]. . ROS: + night sweats, fatigue, anorexia, nausea, emesis x 1. denies CP, hematemesis or hematochezia Past Medical History: NIDDM CHF PNA gallstones CRI, secondary to DM and chronic NSAIDS, now on HD through RIJ, although patient noncompliant with regimen CHF liver CA: primary cholangiocarcinoma or pancreatobiliary carcinoma Hurthle cell adenoma chronic back pain on narcotics from lumbar disk disease diabetic retinopathy s/p laser treatments Social History: lives with her son but there is a question of protective services per notes. Smoker. Denies EtOH or illicits. Former candystriper. Her dog and cat need to be euthanized and this is stressing her out. Her mom is also at home and sick. . Family History: noncontributory Physical Exam: Vitals - T BP 90/38 on dopa HR 104 RR Gen- pleasant, cooperative, son and his friend sitting at her side [**Name (NI) 43653**] dry MMM Neck- supple, no LAD Cor-tachy, regular, III/VI murmur best heard at LUSB Pulm- CTAB but poor effort Back- mild TTP at costophrenic angle Abd- TTP localizing to RUQ, no rebound, no guarding, soft Ext- hands cold, legs with 2+ edema to thighs Neuro- A+O x 3, CN II-XII individually tested and intact, strength lower extremities [**4-23**] but poor effort Pertinent Results: [**2182-10-9**] 08:35PM WBC-46.5* RBC-3.63* HGB-9.6* HCT-32.7* MCV-90 MCH-26.4* MCHC-29.3* RDW-17.7* [**2182-10-9**] 08:35PM NEUTS-90* BANDS-6* LYMPHS-2* MONOS-1* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2182-10-9**] 08:35PM PLT COUNT-153 [**2182-10-9**] 08:35PM CK-MB-NotDone cTropnT-0.13* [**2182-10-9**] 08:35PM LIPASE-15 [**2182-10-9**] 08:35PM ALT(SGPT)-52* AST(SGOT)-139* LD(LDH)-872* CK(CPK)-81 ALK PHOS-1054* TOT BILI-0.7 [**2182-10-9**] 08:35PM GLUCOSE-147* UREA N-54* CREAT-5.7* SODIUM-138 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-19 [**2182-10-9**] 08:42PM LACTATE-2.2* [**2182-10-9**] 09:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR ............ [**2182-10-9**] RUQ: 1. Diffusely enlarged liver with multiple masses consistent with tumor. 2. Decompressed gallbladder with wall thickening. 3. Intrahepatic biliary dilatation. Further evaluation with MRCP or ERCP is recommended. ............... [**2182-10-9**] CXR IMPRESSION: Small right effusion with associated atelectasis. If there is a persistent concern for pneumonia and lateral view would be recommended to fully exclude right lower lobe pneumonia ........... [**2182-10-10**] ECHO Conclusions: 1. The left atrium is moderately dilated. 2. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. 3. The aortic valve leaflets are mildly thickened. 4. The mitral valve leaflets are mildly thickened. ............. CT chest/abd/pelvis [**2182-10-11**] IMPRESSION: 1. Large, diffuse infiltrating mass within the right lobe of the liver with possible peritoneal carcinomatosis. Enlarged retroperitoneal lymph nodes, left adrenal mass and multiple lung nodules consistent with metastatic disease. 2. Small, bilateral pleural effusions. 3. Intrahepatic biliary dilatation, likely from the obstructing tumor. ............ [**2182-10-11**] EKG Sinus tachycardia. Right axis deviation. There is a late transition with anterior and anterolateral and lateral ST-T wave changes consistent with possible right ventricular hypertrophy or ischemia. Compared to the previous tracing of [**2182-10-9**] right axis deviation is new and the ST-T wave changes are more prominent. .................. CT Chest/Abd/Pelvis: 1. Large, diffuse infiltrating mass within the right lobe of the liver with possible peritoneal carcinomatosis. Enlarged retroperitoneal lymph nodes, left adrenal mass and multiple lung nodules consistent with metastatic disease. A contrast-enhanced study is recommended. If renal function precludes this, consider MRI. 2. Small, bilateral pleural effusions. 3. Intrahepatic biliary dilatation, likely from the obstructing tumor. Brief Hospital Course: A/P 66 y.o. with ESRD on HD with markedly elevated WBC and hypotension of unclear etiology. . # hypotension: Mrs. [**Known lastname **] presented with persistent hypotension of unclear source. She was not previuosly dialyzed. Sepsis was considered from HD line or intraabdominal process. Pancytopenia in presence of leukocytosis concerning for hematologic malignancy. She had daily blood cultures, none of which grew anything by the time of this summary. Cultures from the OSH did not grow anything. Her diltiazem was held. She required 2 pressors, and was still somewhat hypotensive. She was treated with vanco, levo, flagyl for a possible line infection. Renal was consulted and it was decided not to pull her HD line in case she needed dialysis. CT of the abdomen showed a large mass in the right lobe of her liver, with possible peritoneal and lymph node involvement. Over the course of her short stay her blood pressure remained low. He son [**Name (NI) **] was consulted and she was made DNR/DNI. He flew up from [**State **] to see her and to talk with his family about CMO. Shortly after his arrival Mrs. [**Known lastname **] died of cardiac arrest. . # leukocytosis: Mrs. [**Known lastname **] had an elevated WBC count of unclear source. As discussed above all cultures were negative, and she received empiric antibiotic treatment with vanc, levo, flagyl. A TTE evaluation for vegetations (she had a murmur) was negative. Hematology/oncology was consulted, and felt that she had incurable disease with a grim prognosis. In her condition on admission there was no possible treatment option. This was discussed with her son [**Name (NI) **], and contributed to his decision to make her DNR/DNI. . # ESRD: Mrs. [**Known lastname **] had been on HD for the last 2 weeks prior to admission. There was no indication for acute HD although she missed a few dialysis appointments. However, her HD line was left in place in case she did need HD during her stay. Given her clinical deterioration though, she was not dialysed. . #Coagulopathy - Mr. [**Known lastname **] had an elevated PTT and PT which was thought to possible be due to liver disease, or her large tumor burden. DIC panel was negative. . # DM: Mrs.[**Known lastname 99593**] sugars were controlled with a RISS. . # hepatic mucinous adenocarcinoma: Hematology/oncology was consulted, and felt that she had incurable disease with a grim prognosis. In her condition on admission there was no possible treatment option. LFTs were followed and were elevated throughout, particularly AST and Alk Phos. Her pain was controlled on her home regimen of oxycodone. . # prophylaxis: Mrs. [**Known lastname **] was on a PPI, SQ heparin, and a bowel regimen . # full code on admission, then DNR/DNI, then expired before family decided on CMO. . # access: Mrs. [**Known lastname **] had a LIJ, L A-line . # Dispo: Mrs. [**Known lastname **] died Monday [**10-14**] at 9PM of cardiac arrest, thought to be secondary to her malignancy. An autopsy was declined by her family. Medications on Admission: epo [**Numeric Identifier **] 3 x week phoslo 2 TID prozac 20 mg QD diltiazem 120 QD albuterol flovent lipitor 20 mg zemplar 4 mcg 3 x week oxycontin 20 mg [**Hospital1 **] oxycodone 5 mg PRN Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**] Completed by:[**2182-10-17**]

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Discharge summary

report

Admission Date: [**2193-3-26**] Discharge Date: [**2193-4-29**] Date of Birth: [**2126-4-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation and Mechanical Ventilation Bronchoscopy x2 Internal jugular central line placement Swan Ganz catheter placement PICC line placement, removal and replacement History of Present Illness: 66F with morbid obesity, COPD on 2-3L at baseline, OSA, obesity hypoventialtion, recurrent aspiration PNA initially presented to [**Hospital1 **] with SOB and s/p fall and now transferred here in shock, intubated for hypoxic respiratory failure, with A flutter with RVR. . Pt intubated prior to admission so history obtained mostly from medical records and confirmation with sister. She had been having SOB x2-3 days. Unclear if she had also been having cough or fevers. [**3-26**] she had an unwitnessed fall with associated dizziness and then called out to her [**Age over 90 **] y.o. mother whom she lives with for help. She appeared to have hit her head though it was unclear if she had LOC. She was brought to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by EMS. Prior to arrival she was noted to be tachycardic to 150s which was felt to be SVT. She received adenosine 6 mg then 12 mg with little effect. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] she was started on dilt drip and digoxin 0.5mg without effect. She was also quite dyspneic and she was started on BiPAP. She clinically worsened and was noted to be altered so she was intubated. Pt was a difficult intubation d/t size, anatomy, was successfully tubed w/ 2nd attempt. She also uncerwent head CT and C-spine CT for her fall which were negative except for old C2 fracture and cervical stenosis/DJD. Her pupils unequal in size, both reactive, R->3 to 2, L->5-3/4. Because of the unequal pupils her head CT was repeated which again did not show ICH or mass effect. There was also concern for PE so she received one dose of lovenox and then transferred to [**Hospital1 18**]. . In the ED, initial VS were: Pulse: 150, RR: 24, BP: 142/75, Rhythm: Atrial Fibrillation, O2Sat: 89, O2Flow: 100 fio2. Her initial ABG was 7.32/51/72/27. Her lactate was normal and her first set of troponins was normal. Cardiology performed a limited bedside echo which showed small RV with good contractility, no suggestion of PE per report from ED. She was given Vanc/zosyn and admitted to the MICU. . On arrival to the MICU, patient's VS. HR150 BP 120/102. Shortly after admission her BP dropped to systolic in 60s with HR persistently 150s. EKG showed ventricular rate of 150, rhythm appeared either sinus tach or flutter with 2:1 conduction. She was given 6mg IV adenosine which slowed the vent rate and demonstrated flutter waves. She received 1L NS bolus and digoxin 0.25. Her blood pressure repsoned well and slowly her HR decreased to 90-100s. . Of note she has been hospitalized twice ([**Month (only) 404**] then [**Month (only) 958**]) this year for falls complicated by hypoxia. The most recent time she was treated with levo/flagyl for presumed aspiration PNA. . Past Medical History: hemorrhoids - since age 20 COPD - on 2.5 L oxygen during exertion osteoarthritis obstructive sleep apnea on CPAP ?CHF - EF unknown h/o colon polyps - [**11-13**] polypectomy s/p tonsilectomy s/p appendectomy Social History: h/o tobacco use, occasional EtOH. Divorced. Lives with [**Age over 90 **] year old mother. Family History: h/o colon CA Physical Exam: ADMISSION EXAM: General: Morbidly obese woman, intubated and sedated, withdrawing to pain and flashlight HEENT: Small abrasion over forehead, dried blood in nostril, Sclera anicteric, dMM, L pupil 5->4, R 3->2 Neck: Unable to appreciate JVD because of body habitus. CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Intubated with transmitted vent sounds throughout, no wheezes or crackles heard on anterior exam. Abdomen: Obese, soft, non-distended, bowel sounds present, not withdrawing to palpation GU: foley in place Ext: somewhat cool but appearing well perfused, b/l LE edema. DISCHARGE EXAM: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 37.1 ??????C (98.7 ??????F) HR: 90 (77 - 97) bpm BP: 103/39(43) {90/39(43) - 141/107(112)} mmHg RR: 15 (14 - 28) insp/min SpO2: 96% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 126.5 kg (admission): 147.7 kg Height: 65 Inch General: Morbidly obese woman in NAD, mildly agitated at times but readily reirectable with encouragment and prn seroquel, able to mouth words ??????I feel cold?????? when not using pass?????? muir valve, and fully able to express needs with valve in place NEURO: opens eye to voice. Moves all 4 extremities to command, tracks, mouths words HEENT: Sclera anicteric, PERRL, conjugate gaze Neck: trach in place. Obese neck. CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Anterior/lateral exam only. Less coarse breath sounds, no wheezes, no crackles, Posterior: scattered rhonchi, improved with deep breathing Abdomen: Obese, soft, nondistended, mild TTP in the LLQ, bowel sounds present GU: foley in place draining yellow urine Ext: well perfused w/palpable DP/PT pulses, positive LE edema Pertinent Results: ADMISSION LABS: [**2193-3-26**] 07:23PM WBC-10.2 RBC-4.29 HGB-11.9* HCT-40.1 MCV-94 MCH-27.8 MCHC-29.7* RDW-16.3* [**2193-3-26**] 07:23PM NEUTS-91.4* LYMPHS-6.9* MONOS-1.0* EOS-0.4 BASOS-0.3 [**2193-3-26**] 07:23PM PT-12.5 PTT-34.8 INR(PT)-1.2* [**2193-3-26**] 07:23PM PLT COUNT-289 [**2193-3-26**] 07:22PM GLUCOSE-167* LACTATE-1.1 NA+-141 K+-4.5 CL--105 TCO2-25 [**2193-3-26**] 07:23PM GLUCOSE-174* UREA N-8 CREAT-0.5 SODIUM-144 POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-15 [**2193-3-26**] 07:23PM cTropnT-0.01 [**2193-3-26**] 10:22PM LACTATE-1.5 [**2193-3-26**] 08:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2193-3-26**] 08:30PM URINE RBC-15* WBC-11* BACTERIA-FEW YEAST-NONE EPI-1 [**2193-3-26**] 07:37PM TYPE-ART PO2-72* PCO2-51* PH-7.32* TOTAL CO2-27 BASE XS-0 . OTHER PERTINENT LABS [**2193-4-13**] 03:11PM BLOOD ESR-124* [**2193-4-13**] 02:31AM BLOOD CRP-78.3* [**2193-3-27**] 02:14AM BLOOD [**Doctor First Name **]-NEGATIVE [**2193-3-29**] 02:52AM BLOOD RheuFac-9 [**2193-4-12**] 03:02PM BLOOD C3-162 C4-36 [**2193-3-27**] 02:14AM BLOOD ANCA-NEGATIVE B [**2193-4-9**] 02:44AM BLOOD TSH-5.5* [**2193-4-10**] 02:39AM BLOOD Free T4-1.1 [**2193-4-9**] 02:44AM BLOOD Cortsol-22.0* [**2193-4-13**] 02:31AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND [**2193-4-8**] 02:16AM BLOOD B-GLUCAN-146 pg/mL (positive = > 80 pg/mL) [**2193-4-8**] 02:16am BLOOD ASPERGILLUS ANTIGEN 0.1 (NEGATIVE) [**2193-3-27**] 02:14AM BLOOD ANTI-GBM IgG <1.0 (negative) . DISCHARGE LABS . MICRO [**2193-4-13**] IMMUNOLOGY CMV Viral Load-PENDING [**2193-4-13**] Rapid Respiratory Viral Screen & Culture-PENDING; Respiratory Viral Antigen Screen-PENDING [**2193-4-13**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY; LEGIONELLA CULTURE-PRELIMINARY INPATIENT [**2193-4-11**] STOOL C. difficile DNA amplification assay-FINAL; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL [**2193-4-10**] CATHETER TIP-IV WOUND CULTURE-FINAL [**2193-4-10**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2193-4-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [**2193-4-9**] URINE URINE CULTURE-FINAL [**2193-4-9**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2193-4-7**] URINE URINE CULTURE-FINAL [**2193-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [**2193-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-5**] URINE URINE CULTURE-FINAL [**2193-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-4**] CATHETER TIP-IV WOUND CULTURE-FINAL [**2193-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-3**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-4-3**] CATHETER TIP-IV WOUND CULTURE-FINAL [**2193-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-31**] CATHETER TIP-IV WOUND CULTURE-FINAL [**2193-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-30**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY [**2193-3-29**] BLOOD CULTURE NOT PROCESSED [**2193-3-29**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-29**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-28**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2193-3-27**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL INPATIENT [**2193-3-27**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; Immunoflourescent test for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL CULTURE-FINAL; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL [**2193-3-27**] MRSA SCREEN MRSA SCREEN-FINAL [**2193-3-27**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL [**2193-3-27**] URINE Legionella Urinary Antigen -FINAL [**2193-3-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; FUNGAL CULTURE-FINAL {YEAST} [**2193-3-26**] MRSA SCREEN MRSA SCREEN-FINAL [**2193-3-26**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC GRAM POSITIVE COCCUS(I)}; Anaerobic Bottle Gram Stain-FINAL [**2193-3-26**] URINE URINE CULTURE-FINAL [**2193-3-26**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), STAPHYLOCOCCUS EPIDERMIDIS, ANAEROBIC GRAM POSITIVE COCCUS(I)}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL . STUDIES . EKG [**3-26**] Probable atrial flutter with 2:1 block. Low voltage throughout. Since the previous tracing of [**2187-5-11**] atrial flutter is new. Low voltage is new. The axis is now more leftward. Clinical correlation is suggested. . [**2193-3-27**] TTE ECHO The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the apex (clip [**Clip Number (Radiology) **]) and possibly the basal inferior wall (clip [**Clip Number (Radiology) **]). The remaining segments contract normally (LVEF = 55-60 %). 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. There is no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small posterior pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional systolic dysfunction suggestive of CAD, but preserved global systolic function. No definite valvular pathology or pathologic flow identified. Small posterior pericardial effusion. . [**2193-3-29**] TEE ECHO Findings Patient was intubated in the ICU and sedated with a versed and fentanyl drip. The GE junction was not crossed. LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Good RAA ejection velocity (>20cm/s). Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No masses or vegetations on aortic valve. No AR. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Mild [1+] TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Informed consent was obtained. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was under general anesthesia throughout the procedure. Local anesthesia was provided by benzocaine topical spray. Results Left pleural effusion. 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. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm, non-mobile) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of intracardiac thrombus or endocarditis seen. Mild mitral regurgitation. Complex, non-mobile atheroma in the descending aorta. . IMAGING . CXR [**3-26**] Single AP portable view of the chest was obtained. Endotracheal tube is seen terminating approximately 4.6 cm above the level of the carina. Nasogastric tube is seen, coursing below the level of the diaphragm, distal tip not well seen. There are diffuse bilateral airspace opacities worrisome for severe pulmonary edema. Cardiac silhouette is mildly enlarged. No large pleural effusion or pneumothorax is seen, although the right costophrenic angle is not fully included on the image. . CXR [**3-28**] New right transjugular Swan-Ganz catheter ends in the right pulmonary artery (best seen on the digitally augmented view). Mild-to-moderate interstitial pulmonary abnormality is already cleared from the left lung, improving on the right. Heart size normal. No pneumothorax or appreciable pleural effusion. Nasogastric tube passes into the stomach and out of view. Right PIC line ends in the mid-to-low SVC. . [**4-5**] CT TORSO CT CHEST: 64-row MDCT was performed from the thoracic inlet to the base of the lung following administration of 150 mL of intravenous contrast. The endotracheal tube is in good position above the carina. Tip of the NG tube is in the distal stomach. There is adequate opacification of the thoracic aorta and pulmonary arteries. There is no evidence of aneurysm or dissection. No central filling defects are seen in the main pulmonary arteries. There is a 19 x 15 mm right hilar node, series 2, image 25. A second, smaller right hilar node is seen measuring 11.6 mm, series 2, image 26. There are bilateral pleural effusions, right greater than left. There is associated atelectasis at both lung bases. The upper lobes are relatively clear. There is a small pericardial effusion, series 2, image 37 measuring an average of 10 Hounsfield units consistent with simple fluid. The visualization of the abdominal organs is somewhat limited by streak artifact secondary to the patient's body habitus. However, within these limitations, the liver, spleen, adrenal glands, pancreas, and gallbladder are unremarkable. Both kidneys enhance in a normal fashion. There are no renal masses. Evaluation of the right lateral subcutaneous soft tissues is precluded secondary to streak artifact from the patient's side abutting the CT gantry. However, along the left lateral abdominal wall, there is an area of subcutaneous edema measuring approximately 4 x 9 x 20 cm. The wall of this collection does not enhance, and findings are more consistent with subcutaneous edema rather than an abscess. However, attention to this area on subsequent imaging studies is recommended to ensure that an abscess is not forming. CT PELVIS: 64-row MDCT was performed from the iliac crest to the symphysis pubis following administration of oral and intravenous contrast. In the subcutaneous fat of the anterior abdominal wall, left greater than right, are several subcutaneous soft tissue densities. These all measure less than 2 cm and most likely represent site of prior injection. The colon is visualized from the cecum to the rectum and is moderately distended and fluid filled. However, the small bowel is not dilated. The bladder is decompressed with a Foley catheter. BONE WINDOWS: There is narrowing of the L2-3 disc space. There is narrowing of several mid thoracic disc spaces as well. However, there are no lytic or blastic lesions. IMPRESSION: 1. Several nonspecific findings including bilateral pleural effusions with associated lower lobe atelectasis, small pericardial effusion, and fairly extensive inflammatory changes in the subcutaneous fat of the left abdominal wall. 2. Distended completely fluid-filled colon without evidence of small bowel dilatation. Question if the patient has diarrhea to explain the fluid-filled colon. However, the wall of the colon does not appear to be thickened and does not demonstrate any abnormal enhancement. . [**2193-4-13**] CXR POST-PICC PLACEMENT FINDINGS: The PICC line has been re-positioned and the tip is now in the mid SVC. Again seen is pulmonary vascular re-distribution and alveolar infiltrate, right greater than left. Compared to the films from earlier the same day, the appearance of the right lung is slightly worse. . [**2193-4-11**] EEG - IMPRESSION: Abnormal EEG due to a slow and disorganized background rhythm and due to bursts of bifrontal slowing. These findings indicate an encephalopathy involving both cortex and subcortical structures. The most common causes of encephalopathy are metabolic, infectious or medication-related. There were no prominent areas of focal slowing but encephalopathies can obscure focal findings. There were no clear epileptiform discharges . [**2193-4-14**] CT TORSO - IMPRESSION: 1. Mild interseptal thickening, might represent pulmonary congestion. No pericardial or pleural effusion is seen on current examination. 2. Subsegmental atelectasis in the apical segment of the left lower lobe and in both lung bases, infection cannot be definitely ruled out. 3. Small and large bowels are within normal limits. 4. No intra-abdominal source for fevers is identified. . CXR [**2193-4-22**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged evidence of minimal interstitial fluid overload. Minimal atelectasis at the right lung base. Borderline size of the cardiac silhouette. No overt pulmonary edema. No pleural effusions. No pneumonia . CXR [**2193-4-23**]: IMPRESSION; In order to differentiate recent widening of left upper mediastinum due to engorged mediastinal vessels which appears reasonable as reflected by interval worsening mild pulmonary edema vs acute aortic pathology, erect view is recommended for further evaluation. . CXR [**2193-4-24**]: IMPRESSION: Views of the torso centered at the diaphragm and in the left upper abdominal quadrant show a nasogastric feeding tube, absent. The wire stylet, ending in the mid stomach. Volumes are still low and mediastinal widening is most likely due to vascular engorgement. Aside from right basal atelectasis there is no focal pulmonary abnormality. Pulmonary edema which was present on [**4-17**], not recurred. Tracheostomy tube in standard placement. . ECG's: Cardiovascular Report ECG Study Date of [**2193-4-24**] 12:07:58 PM Sinus tachycardia. Poor R wave progression, likely a normal variant. Cannot exclude a prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2193-4-22**] the rate has increased. Other findings are similar. . Cardiovascular Report ECG Study Date of [**2193-4-22**] 11:44:32 AM Sinus rhythm at upper limits of normal rate. Borderline low limb lead voltage. Considerable baseline artifact. Since the previous tracing of [**2193-4-21**] no significant change. . Cardiovascular Report ECG Study Date of [**2193-4-21**] 6:22:26 PM Sinus tachycardia. Compared to tracing #1 there is no significant diagnostic change. . Lab Results on Discharge: [**2193-4-25**] 03:21AM BLOOD WBC-10.0 RBC-3.54* Hgb-9.4* Hct-31.3* MCV-88 MCH-26.5* MCHC-30.0* RDW-16.2* Plt Ct-428 [**2193-4-26**] 03:35AM BLOOD PT-23.8* PTT-38.7* INR(PT)-2.3* [**2193-4-29**] 03:36AM BLOOD Na-140 K-3.0* Cl-94* [**2193-4-15**] 02:24PM BLOOD ALT-14 AST-24 AlkPhos-59 TotBili-0.8 [**2193-4-28**] 05:18AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 [**2193-4-15**] 02:24PM BLOOD Lipase-21 [**2193-4-4**] 03:14AM BLOOD Hapto-338* [**2193-4-22**] 12:43PM BLOOD Type-[**Last Name (un) **] Temp-37.3 PEEP-10 pO2-41* pCO2-53* pH-7.38 calTCO2-33* Base XS-4 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 66yo female with history of morbid obesity, COPD on 2-3L at baseline, OSA, obesity hypoventialtion, recurrent aspiration PNA who initially presented to [**Hospital1 **] with SOB and s/p fall and transferred to [**Hospital1 18**] in shock, and intubated for hypoxic respiratory failure, with A flutter with RVR. She was cardioverted and anticoagulated following the procedure for the prescribed amount of time. BAL revealed blood on aspiration x3 consistent with diffuse alveolar hemmorhage. Patient had a prolonged ventilator course with dense delirium. She received a trach and was weaned to trach collar. She was taken off of sedation and had gradual but steady improvement in delirium to the point of being cooperative in her care and not agitated. She was discharged for continued recovery at a rehab facility. . ACUTE CARE: 1. Shock: Patient presented in shock of unclear etiology but most likely septic versus cardiogenic. She did have evidence of diffuse alveolar hemorrhage and ARDS presumed to be from pneumonia though this was not clear. She was started on pressors and broad spectrum antibiotics (Vanc/Zosyn/Levofloxacin). Her blood cultures grew two bottles of coagulase negative staphylococcus though her sputum cultures did not grow any pathogenic organisms. Her body habitus and high PEEP requirement made hemodynamic monitoring difficult and she persistently required pressors so a swan ganz catheter was placed for further hemodynamic monitoring. Her atrial flutter was believed to be decreasing her cardiac output so she was cardioverted after TEE did not show and thrombus or vegetations. After cardioversion, fluid resucitation, and antibiotics she was able to be weaned off pressors. She completed a 10 day course of antibiotics on [**4-4**]. . 2. Hypoxic Respiratory Failure/Pneumonia: She has limited baseline pulmonary function becasue of her COPD on 2-3L, OSA, and obesity hypoventilation. The etiology of her acute decompensation is of unclear etiology. CXR showed diffuse bilateral alveolar reticular opacities and had ARDS by large A-a gradient and PaO2/Fio2 ~72. Her bronchoscopy showed DAH though vasculitis labs were negative. The most likely etiology was believed to be pneumonia leading to ARDS and DAH. Because of her large body habitus she required significant amount of PEEP to maintain adequate oxygenation. Multiple attempts were made over 2 weeks to wean her from the vent, which were unsuccesful. She was treated with a course of vancomycin, levofloxacin and zosyn for a total of 10 days. Repeat bronchoscopy was performed [**4-13**] and demonstrated blood-tinged sputum, suggestive of recurrent or ongoing DAH. Eventually her vent settings were weaned and she successfully underwent a tracheostomy on [**2193-4-17**]. She was weaned from the vent after tracheostomy and was tolerating trach collar at time of discharge. She was discharged on fluticasone and ipratropium and albuterol inhaled. Salmetrol was held for potential QT-prolonging interaction with seroquel, which she is on for delirium. . 3. Fluid overload: Patient was about 7L positive for length of stay fluid balance. She was being diuresed with good effect on 60mg PO BID with potassium repletion on discharge. More agressive diuresis had resultes in creatinine bumps. She was discharged on the above lasix dosing and potassium repletion to be followed and titrated to effect on discharge. . 4. Atrial Flutter: Patient presented in atrial flutter with 2:1 conduction. Her rhythm was more apparent after she was given adenosisne which demonstrated clear flutter waves. She was started on digoxin for rate control though her rate persisted in the low 100s. Because it was believed that her rhythm was contributing to her persisttent pressor requirement, cardiology was consulted for cardioversion. A TEE was performed which did not show any clot and she was started on heparin and succesfully cardioverted. She was then started on warfarin and amiodarone. Heparin was stopped when her INR was therapeutic. She was planned to receive one month of anticoagulation after her cardioversion. She failed digoxin and was continued on amiodarone, however this was discontinued out of concern for continued drug fever. Patient remained rate controlled on low dose metoprolol which was discontinued after patient remained in sinus rhythm for greater than 2 weeks after cardioversion. Warfarin was continued for anticoagulation and titrated for therapeutic INR for the prescibed duration post-cardioversion. . 5. GPC Bacteremia: [**1-12**] initial blood cultures grew coagulase negative staph. She was already started on vancomycin for her PNA as above. Her cultures were sensitive to vancomycin. Surveillance cultures remained negative. She underwent a TTE and a TEE which did not show any vegetations. She did not have any indwelling vascular access on admission. The PICC line that was placed on the day after admission was removed. Later her central line and arterial line were removed and cultures of the catheter tips were negative. She completed a 10 day course of antibiotics on [**4-4**] and did not have any subsequent positive blood cultures. . 6. UTI: Patient had a positive UA on [**4-15**] and was started on ceftriaxone. She received 3 day course, but urine culture returned negative . 7. Fever - patient developed persistent low grade fever on the night of [**5-9**]. Temperature mainly rose in the PM and overnight. Persistent fever, curve trending up for a few days. Source unclear. Only positive micro dat was initial blood culture from [**2193-3-26**] showing coagulase negative staph. Prior to arrival she did not have any central lines, unclear source of bacteremia. PICC line was placed on day of admission and was later removed and culture negative, RIJ (cordis) placed later while on vanc and was susbequently pulled with negative culture tip as well. Now has only PICC, placed here. No evolution of her CXR, no diarrhea, no nasal mucus, skin intact. Vanco/Zosyn course completed [**4-4**]; she did appear to improve on ABX but not entirely afebrile, but fever curve worsening. CT torso performed on [**4-5**] was unrevealing of any infectious source. Sputum gram stain was notable for yeast and GPCs. Fungal cultures were unremarkable. ID was consulted given persistent fever without identifiable cause. Felt pt most likely suffering from drug fever, with seroquel most likely culprit medication. It was stopped, and pt again spiked a fever above 101, making that hypothesis unlikely. UA then showed moderate leukocytes, and patient was started on ceftriaxone. Urine culture was negative, but patient did complete a 3 day course of ceftriaxone. Fever curver continued to be monitored and patient remained afebrile for several days prior to discharge. . 8. S/P fall: Pt had hx multiple falls prior to admission. On presentation to the OSH the nature of her fall was unclear so she underwent CT head and c-spine. Her CT head did not show any changes though her C-Spine film did show an old C2 fracture. Spine surgery evaluated the film and did not recommend further workup. After treatment with albuterol and ipratropium at the OSH she was noted to have an enlarged L pupil so a repeat head CT was performed which again did not show any acute changes. On admission here she had persisitently enlarged L pupil though this resolved by the following day. This was believed to be from incidental exposure of the eye to albuterol/ipratropium at the OSH. . 9. Altered mental status - patient was intermittently agitated throughout the course of her ICU stay. Psychiatry was consulted in the setting of acute agitation and inability to wean from vent and patient was trialed on seroquel and haldol alternating. Seroquel was eventually used primarily with haldol prn, but patient continued to become delirious at night, requiring extra sedation. Antipsychotics were weaned as tolerated and benzodiazepines were avoided. QTc was monitored daily while patient was on antipsychotics. On day of discharge, she was requiring seroquel QHS and with a prn daytime seroquel dose that she was not requiring. . CHRONIC CARE: . 1. COPD: Patient is on 2-3L of home O2 at baseline. In the settin of her acute respiratory illness, her home medications were held and she was switched to standing albuterol and ipratropium nebs. She was discharged on fluticasone MDI (she had been on salmeterol/fluticasone at home prior to admission, and only the inhaled glucocorticoid was continued on discharge). She was also discharged on standing ipratropium and albuterol nebs. . 2. DEPRESSION: Patient's home venlaxine was held and she was placed on duloxetine with increased dosing while in the hospital. . 3. CHRONIC PAIN: Given patient's AMS, sedating medications were held and she was given tylenol for pain. She had only a complaint of mild cramping abdominal pain associated with tube feeds during her stay. . . . . TRANSITIONS IN CARE: . 1. FOLLOW-UP: patient requires follow-up with PCP and with pulmonology following discharge 2. MEDICATION CHANGES: STOP: celebrex, venlafaxine, tramadol, percocet, ambien, tiotropium, gabapentin, vitamin D tablets, omeprazole, advair START: ipratropium 6 puffs inhaled 4 times daily albuterol sulfate 6 puff inhaled every six hours as needed for shortness of breath or wheezing seroquel 100mg by mouth nightly seroquel 25mg by mouth four times daily as needed for agitation potassium chloride 40meq by mouth twice daily lasix 60mg by mouth twice daily fluticasone 110mcg, 2 puffs inhaled twice daily CHANGE: duloxetine to 60mg by mouth daily 3. CONTACTS:[**Name2 (NI) **], Sister [**Name (NI) **] [**Name (NI) 1637**] [**Telephone/Fax (1) 97016**] (home); work [**Telephone/Fax (1) 97019**] 4. OUTSTANDING CLINICAL ISSUES: -patient will require titration of psychiatric and pain medications stopped on this admission for altered mental status as mental status clears -on discharge, patient was positive approximately 7 liters estimated for fluid balance. She had bumps in creatinine with more agressive diuresis, but was continued on lasix 60 PO BID for moderate diuresis with good effect, but requirement for potassium supplementation. She should be monitored for creatinine, fluid status, and potassium at least daily on discharge -patient's chronic pulmonary medications may need adjustment as she is transitioned to a home regimen, keeping in mind the QT-prolongation associated with salmeterol and seroquel -patient requires close follow-up with pulmonology Medications on Admission: venlafaxine 75 Daily tramadol 50 mg QID Oxycodone-acetaminophen 5 mg-325 mg [**12-10**] Tablet(s) Every 4-6 hrs, PRN Ambien 10 mg QHS cholecalciferol (vitamin D3) 1,000 unit Tab Oral omeprazole 20 mg daily fluticasone-salmeterol 500 mcg-50 [**Hospital1 **] tiotropium bromide 18 mcg mupirocin 2 % Ointment Topical gabapentin 800 mg Tab Oral QHS gabapentin 400 mg Tab Oral daily duloxetine 30 mg Cap, delayed release Oral 2 daily fluticasone 0.05 % Topical Cream Topical PRN Celebrex 200 mg Cap Oral daily Discharge Medications: 1. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation QID (4 times a day). 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed for congestion. 7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 9. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not administer more than 4 gm of acetaminophen daily. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID (2 times a day) as needed for constipation. 12. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 13. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day) as needed for agitation. 14. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day). 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 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. Outpatient Lab Work Please monitor daily electrolytes, particularly monitoring potassium and creatinine while having lasix diuresis and potassium repletion 19. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] at [**Hospital 1263**] Hospital Discharge Diagnosis: PRIMARY: Hypoxic respiratory failure, diffuse alveolar hemmorhage, Shock, Delirium Secondary: Chronic Obstructive Pulmonary Disease, Obesity Hypoventilation Syndrome, Depression, Chronic Pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 1637**], You were admitted to the hospital after having fallen at home. You developed severe shock and repiratory distress and required a prolonged recovery period in the intesive care unit which was complicated by you developing delirium. You had a tracheostomy tube placed to allow you to breath with the ventilator, and you slowly recovered ability to breath, and your mental status improved. In the course of your stay, your heart entered an abnormal rhythm and had to be shocked back to a normal rhythm as well. Please make the following changes to your medications: STOP: celebrex, venlafaxine, tramadol, percocet, ambien, tiotropium, gabapentin, vitamin D tablets, omeprazole, advair START: ipratropium 6 puffs inhaled 4 times daily albuterol sulfate 6 puff inhaled every six hours as needed for shortness of breath or wheezing seroquel 100mg by mouth nightly seroquel 25mg by mouth four times daily as needed for agitation potassium chloride 40meq by mouth twice daily lasix 60mg by mouth twice daily fluticasone 110mcg, 2 puffs inhaled twice daily CHANGE: duloxetine to 60mg by mouth daily Followup Instructions: Please have your rehab facility arrange an appointment for your with your PCP on discharge. Department: Pulmonary You will need to be seen by Pulmonary in 16-30 days after your hospital discharge. The Pulmonary Department will contact you with your appointment date and time. If you do not hear from the Pulmonary Department in 2 business days please call the office number listed below. Phone: ([**Telephone/Fax (1) 513**]

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icd9cm

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Discharge summary

report+report

Admission Date: [**2116-1-10**] Discharge Date: Date of Birth: [**2067-9-11**] Sex: M Service: MEDICAL CHIEF COMPLAINT: Hematemesis. HISTORY OF THE PRESENT ILLNESS: This is a 48-year-old man with a history of severe atherosclerosis, peripheral vascular disease status post right below knee amputation and mesenteric ischemia, who underwent revascularization for his mesenteric ischemia with onset of an episode of hematemesis on the day of admission. He vomited times two prior to being admitted. The patient has also had episodes of bright red bleeding per rectum and maroon-colored stools over the last two days with subsequent nausea and vomiting. He was seen at [**Hospital3 15402**] on [**12-27**] through the 15th. He had an upper GI scope, which reportedly was inconclusive, secondary to poor visualization and surgical changes, but consistent with normal. He has no previous history of GI bleed. He has been on Lovenox for his hypercoagulable state, which he self discontinued three to four days prior to admission. He discontinued his aspirin. The patient was seen in the emergency room. A nasogastric lavage was done with only scant blood return. He had a large amount of retained food in the stomach, but there was no clear site for bleeding. He was hemodynamically stable. The hematocrits were monitored. PAST MEDICAL HISTORY: 1. Peripheral vascular disease status right below knee amputation, status post aortobifemoral bypass graft, status post right femoral popliteal bypass graft. 2. History of peptic ulcer disease. 3. Gastroesophageal reflux disease. 4. History of pericarditis. 5. History of mesenteric ischemia, status post right hemicolectomy and small bowel resection, hypercoagulable state. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin, which was discontinued. 2. Lovenox, had been discontinued. SOCIAL HISTORY: The patient is on disability. He has not had alcohol for the last 17 years. He does smoke one pack per day of cigarettes. He lives alone. PHYSICAL EXAMINATION: Examination revealed the blood pressure of 122/86, pulse rate 119, respirations 20, 94% oxygen saturation on room air. The patient was sleeping easily and comfortable in no acute distress. He felt lightheaded. HEENT: Unremarkable. CARDIAC: Regular rate and rhythm with tachycardia. Chest was clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended with normal bowel sounds. RECTAL: Examination was guaiac negative. LABORATORY DATA: Labs obtained included the following: CBC, 13.9. hematocrit 36.8, platelet count 260,000, INR 1.1, BUN 28, creatinine 1.5, potassium 5.4, differential on the white count was normal. Repeat hematocrit two hours later was 31, felt secondary to hemodilution post two liters normal saline. HOSPITAL COURSE: The patient was admitted to the medical service. He was made NPO. Gastroenterology was requested to see the patient. He underwent an upper endoscopy, which showed a graft erosion through the duodenal wall with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15532**] esophagus. Biopsy was obtained. Pathology results are pending. The patient was begun on empiric antibiotic therapy of Ampicillin 2 grams q.6h.; Ceftizoxime 1 gram q.24; Flagyl 500 mg q.8h. General Surgery was consulted and Vascular Surgery was consulted. The patient complained of left first toe pain and ischemic changes. He underwent, on [**2116-1-11**] exploratory laparotomy with removal of the [**Doctor Last Name 4726**] Tex graft and duodenotomy closure with a jejunostomy and duodenostomy. He received one unit of packed cells. Fluconazole was begun on [**1-12**] for UTI. He was transferred to the SICU on [**1-13**]. Tube feeds were begun and the Department of Nutrition was consulted for appropriate nutritional management. The patient was begun on Impact with fiber, goal-infusion rate 80 cc per hour. On [**1-14**], the patient complained of abdominal pain. CBC, Chem 7 and LFTs were obtained, which were normal. The tube feeds were held with improvement in her symptoms. He was begun on TPN. Tube feeds were restarted over the next 48 hours. The patient required PICC line placement for long-term antibiotics. On [**1-17**], the NG tube was clamped and then discontinued. On [**1-18**], the patient had nausea, vomiting, and had emesis of 500 cc and the NG tube was replaced. The patient, at that time, had a temperature maximum of 101.6. Blood and urine cultures were obtained. The CBC revealed normal white count. CT of the abdomen was obtained on [**1-30**] and there was no intra-abdominal fluid collection. On [**2-2**], the NG tube was clamped again. Residuals were checked. The patient had an episode of emesis and the NG tube was placed to suction. Tube feeds were changed at this time to ProMod with fiber. He received a second unit of packed cells on [**2116-1-25**]. He underwent an upper GI with small-bowel follow through on [**1-27**]. There was still some ileus, which remained. He was continued on his suction. Hematology/oncology consultation was placed regarding the history of hypercoagulability. Recommendations were that he probably has hemosiderins and antiphospholipid antibodies. Anticoagulation should be continued. The hemosiderin should be treated with vitamin B 12, B complex and folate. The patient should followup with the hematology clinic upon discharge for long-term monitoring. Their number is [**Telephone/Fax (1) 15533**]. On [**1-28**] the NG tube was clamped again. There were no residuals. He was placed to drainage. On [**1-29**] because of persistent ischemic left toe pain and progressive ischemic changes of the toe and the foot, he underwent an arteriogram, which demonstrated occluded infrarenal aorta, occluded celiac SMA and a BF graft. There was a distal flow in the foot on the affected side. He underwent ultrasound of the upper extremities to determine patency of the subclavian arteries and axillary veins and arteries. They were patent. On [**1-31**] he underwent a left axillary to left common femoral artery bypass graft with PTFE and a left femoral to AK popliteal with PTFE. Ultrasound was done at the bedside. The graft was patent. The patient remained hemodynamically stable. He was transferred from the PACU to the VICU for continued monitoring and care. The patient was transferred out of the VICU on [**2-2**] to regular nursing floor. The nasogastric tube was removed on [**2-3**] and he was again on clear sips, which he tolerated. On [**2-5**], regular diet was begun. PO intake would be monitored. Tube feeds will be continued until the p.o. intake was adequate. Department of physical therapy was requested to see the patient regarding independence of his mobility and home safety. PHYSICAL EXAMINATION: Wounds were clean, dry, and intact. Left first toe remained improved with circulation, but still dusky and discoloration was noted. Stool for C. difficile was sent prior to discharge. This was pending at the time of dictation. MEDICATIONS ON DISCHARGE: 1. Roxicet 1 to 2 tsp q.4 to 6h.p.r.n.for pain. 2. Folate 1 mg q.d. 3. Thiamine 100 mg q.d. 4. Flagyl 500 mg q.8h. 5. Levofloxacin 500 mg q.d. 6. Fluconazole 200 mg q.d. 7. Percocet 30 mg q.d. 8. Lopressor 25 mg b.i.d. hold for systolic blood pressure less than 110, heart rate less than 55. 9. Multivitamin tablet with B complex q.d. 10. Reglan 10 mg a.c. and h.s. ADDENDUM: Regarding tube feeds and follow-up evaluations will be made in an addendum discharge on the day of discharge. DISCHARGE DIAGNOSES: 1. Upper GI bleed secondary to graft erosion of the duodenum, status post exploratory laparotomy with removal of [**Doctor Last Name 4726**] Tex graft with a duodenotomy with closure and a jejunostomy and duodenostomy. 2. Postoperative ileus resolved. 3. Blood-loss anemia transfused, corrected. 4. History of hypercoagulable state, treated with Lovenox 100 b.i.d. 5. Ischemic left toe status post angioplasty, status post left axillofemoral with PTFE and left femoral AK popliteal with PTFE. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2116-2-5**] 11:07 T: [**2116-2-5**] 11:40 JOB#: [**Job Number 15534**] Admission Date: [**2116-1-10**] Discharge Date: [**2116-2-10**] Date of Birth: [**2067-9-11**] Sex: M Service: ADDENDUM CONDITION ON DISCHARGE: The patient was discharged in stable condition eating and tolerating a regular diet. Tube feeds were discontinued. He will need no caloric supplements. Wounds were clean, dry, and intact. The left great toe was mildly dusky in color. DISCHARGE INSTRUCTIONS: VNA will be requested for dressing changes. He has dressings to the sacral area, Duoderm with normal saline dressing q.d., Bacitracin to left great toe b.i.d., J-tube dressing, dry sterile dressing, q.d. J-tube care is to irrigate J-tube with normal saline 50 cc solution q.d. The right duodenostomy tube is not to be irrigated but should have a dry sterile dressing. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2116-2-18**]. The patient should follow-up with the [**Hospital **] Clinic in two weeks and with General Surgery in two weeks. The PICC line was removed prior to discharge. DISCHARGE MEDICATIONS: The patient's antibiotics will be continued until [**2116-2-26**]. These consists of Flagyl 500 mg q.8 hours, Levofloxacin 500 mg q.24, Fluconazole 200 mg q.d. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2116-2-10**] 12:00 T: [**2116-2-10**] 12:03 JOB#: [**Job Number 6225**]

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icd9cm

[ [ [] ] ]

[ "39.49", "46.39", "54.59", "88.48", "46.73", "45.01", "96.6", "99.15", "45.16" ]

icd9pcs

[ [ [] ] ]

7655, 8591

9532, 9968

7136, 7634

1836, 1910

2861, 6857

8879, 9508

6880, 7110

141, 1353

1375, 1810

1927, 2068

8616, 8854

21,850

167,660

14851

Discharge summary

report

Admission Date: [**2115-7-19**] Discharge Date: [**2115-7-29**] Date of Birth: [**2071-4-4**] Sex: F HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 7716**] is a 63 year old female who unfortunately suffered a boating accident on the day of admission, [**2115-7-19**]. According to the patient, the patient fell on her back after her boat hit a wave. almost immediately developed numbness for her thighs down. PAST MEDICAL HISTORY: Not significant. PAST SURGICAL HISTORY: Removal of fatty tumor from the abdomen. MEDICATIONS ON ADMISSION: Celexa. SOCIAL HISTORY: The patient smokes [**12-12**] to 1 pack per day. Alcohol, the patient drinks one drink per week. PHYSICAL EXAMINATION: The patient is alert and oriented times three, temperature 95.4, pulse ranges from 66 to 100, blood pressure 142/63, respiratory rate 16, oxygen saturation 97% on room air. Eyes, pupils equal, round and reactive to light, tympanic membranes clear. Cervical spine, nontender. Chest, clear to auscultation. Heart, regular rate and rhythm. Abdomen is soft and nontender. Extremities, warm, no edema. Femoral, dorsalis pedis and popliteal pulses are 2+ bilaterally. Rectal examination reveals absence of tone, no blood. There is no neurological deficit in the upper extremities and examination of the lower extremities reveals absence of sensations below the knees, absence of flexion in knees, ankles and hips bilaterally, no clonus and negative Babinski/deep tendon reflexes. LABORATORY DATA: Radiology on admission revealed severe burst fracture of T12 with kyphosis. No fracture of cervical spine, pelvis. Computerized tomography scan of thoracolumbar spine showed burst fracture of T12 vertebral body with retropulsion of fracture fragments, compromising the central canal. Hematocrit on admission was 36.1. HOSPITAL COURSE: On admission the patient was thoroughly evaluated by Dr. [**Last Name (STitle) 363**]. The patient's condition was very serious. It was explained to the patient and family that the operative intervention was required as soon as possible. The risks of the operation were discussed and consent was given by patient. The patient underwent anterior vertebrectomy of body of T12, T11-L1 fusion, anterior plus anterior instrumentation from T11 to L1. The procedure was done on the day of admission, [**2115-7-19**]. The patient required a blood transfusion, 4 units of packed red blood cells, 1 unit of fresh frozen plasma. The patient tolerated the procedure well and was transferred to the floor. The patient continued to be anemic after the surgery and required transfusion with another unit [**2115-7-22**]. The pain was well controlled with Percocet. After the surgery the patient regained motion of the hips and knees. She also regained sensations all the way to the ankles bilaterally, however, she continued to be unable to move her ankles and had diminished sensations in the legs and no sensations below the ankle joints. The patient was taken to surgery on [**2115-7-23**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. She had fusion of T8 to L2 for kyphosis to the laminectomy of T11 and T12, multiple laminotomies and instrumentation from T8 to L2. The epidural catheter was placed. The patient tolerated the procedure well. Postoperatively she was fitted with an TLSO brace. Hemovac and epidural were removed on postoperative day #2. The patient was transferred from bed to chair using a sliding board. At this time of this dictation the patient was accepted by [**Hospital3 4419**] Center for acute care/rehabilitation. The patient is somewhat anxious, however, she is very motivated to succeed. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Out of bed with assistance on physical therapy and TLSO brace. The patient is discharged to [**Hospital3 4419**] Center. DISCHARGE DIAGNOSIS: 1. Status post multiple laminectomies, infusion of T2 to L2 and instrumentation from T8 to L2 with autograft on [**2115-7-23**]. 2. She is to have removal of a fatty tumor from the abdomen. MEDICATIONS ON DISCHARGE: 1. Acetaminophen 325 mg p.o. q. 4-6 hours prn 2. Cefazolin 1 gm q. 8 hours 3. Diphenhydramine 25 mg p.o. q. 6 hours prn 4. Docusate sodium 100 mg p.o. b.i.d. 5. 45 ml prn p.o. q.d. 6. Folic acid 1 mg p.o. q.d. 7. Milk of magnesia 30 mg p.o. q. 6 hours 8. Ondansetron 2 mg intravenously q. 6 hours 9. Oxycontin standard release 30 mg q. 12 hours p.o. 10. Oxycontin acetaminophen (Percocet) one to two tablets p.o. q. 4-6 hours prn [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**] Dictated By:[**Last Name (NamePattern1) 4307**] MEDQUIST36 D: [**2115-7-26**] 16:08 T: [**2115-7-26**] 16:20 JOB#: [**Job Number 43595**]

[ "806.25", "737.10", "E835.3" ]

icd9cm

[ [ [] ] ]

[ "77.99", "81.04", "81.05" ]

icd9pcs

[ [ [] ] ]

3916, 4109

4135, 4857

571, 580

1859, 3721

501, 544

719, 1841

150, 436

459, 477

597, 696

3746, 3895

6,089

142,109

20544

Discharge summary

report

Admission Date: [**2158-9-18**] Discharge Date: [**2158-9-30**] Date of Birth: [**2108-6-2**] Sex: Service: CHIEF COMPLAINT: Progressive shortness of breath on exertion with increasing fatigue over the past two years. HISTORY OF PRESENT ILLNESS: This is a 50 year old male with a history of aortic coarctation, status post two surgeries as a child who underwent routine echo with his cardiologist in [**2157-12-10**] and discovered [**Year (4 digits) 1192**] to severe mitral regurgitation at that time. The patient was referred for cardiac magnetic resonance scan in [**2158-4-10**] which revealed a coarctation with [**Year (4 digits) 1192**] to severe mitral regurgitation with partial flailed posterior leaflets. The patient was referred to Dr. [**Last Name (STitle) 1290**] for surgical evaluation. Cardiac catheterization done in [**2158-8-10**] showed a 70 percent proximal right coronary artery, 70 percent left main, 80 percent proximal left anterior descending, 80 percent proximal circumflex with coarctation of the aorta and occluded left subclavian artery. Echo from [**2158-7-11**] showed an ejection fraction of 55 percent with 1 plus aortic insufficiency, 4 plus mitral regurgitation with partial flailed leaflet, mild tricuspid regurgitation with [**Year (4 digits) 1192**] pulmonary systolic hypertension and an asymmetric left ventricular hypertrophy. PAST MEDICAL AND SURGICAL HISTORY: Coarctation of the aorta. Hypertension. Coarctation surgery at the age of 5 and also at the age of 6. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg q. Day. 2. Propanolol 80 mg four times a day. 3. Enalapril 10 mg twice a day. 4. Triamterene. 5. Hydrochlorothiazide three times a day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father died at age 49 of a myocardial infarction. Mother is alive at age 83; however, she does suffer from angina. SOCIAL HISTORY: Occupation: Equipment repair man at a waste water treatment plant. Lives with two sons in [**Hospital1 54957**], [**Name (NI) 1727**]. No tobacco. Alcohol: Five to six beers per week times 30 years. No other recreational drug use. Magnetic resonance scan in [**2158-4-10**] showed moderately increased left ventricular cavity size with hyperdynamic left ventricular systolic function. Ejection fraction of 80 percent. Effective forward flow of 40 percent. Coarctation originating after take-off of the left subclavian artery, 135 mm from the aortic valve. Coarctation extended 64 mm with narrow origin and 5 mm and distal diameter of 9 mm. Descending aorta 16 mm at level of diaphragm. [**Year (4 digits) **] to severe mitral regurgitation with partial flail of P1 and P2 segments of posterior leaflets, mild aortic insufficiency and mildly dilated left atrium. PHYSICAL EXAMINATION: Heart rate 68, sinus rhythm; blood pressure 208/102 on the right and 110/80 on the left. Height 6'; weight 167 pounds. General: No acute distress. Appears stated age. Skin: Well hydrated. No rashes or lesions. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Normal mucosa and dentition with partial upper dentures. Neck is supple with no lymphadenopathy. Positive carotid pulsations bilaterally with no jugular venous distention. No thyromegaly. Chest is clear to auscultation bilaterally. Left thoracotomy scar that is well healed. Heart: Regular rate and rhythm. S1 and S2 with a 3/6 systolic ejection murmur, heard best at the apex, radiating to the left axilla. Abdomen: Soft, nontender, nondistended, with normoactive bowel sounds. Extremities are warm with no edema or cyanosis or varicosities. Neurologic: Cranial nerves 2 through 12 grossly intact. No motor or sensory deficits. Pulses: Femoral 1 plus on the right; non palpable on the left. Dorsalis pedis non palpable bilaterally. Posterior tibial non palpable bilaterally. Radial 2 plus bilaterally. Chest x-ray shows cardiomegaly with no effusions. The patient was seen on preadmission testing and was admitted as a post surgical admit on [**2158-9-18**]. At that time, he was brought to the operating room. Please see the operating room report for full details. In summary, the patient had an ascending to descending aorta graft with a 30 mm gel-weave graft and mitral Annuloplasty with a 28 mm [**Doctor Last Name 405**] band and a quadrangular resection. He underwent coronary artery bypass graft times four with saphenous vein graft to the posterior descending artery, saphenous vein graft to the left anterior descending, saphenous vein graft to the obtuse marginal one with sequential graft to obtuse marginal two. The patient's bypass time was 248 minutes with a cross clamp time of 232 minutes. The patient tolerated the operation and was transferred from the operating room to the cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in sinus rhythm at 112 beats per minute with a mean arterial pressure of 68. He had Propofol at 20 mcg per kg per minute. Upon arrival in the cardiothoracic Intensive Care Unit, the patient was noted to have high output from his chest tube as well as tachycardia. He was given multiple blood products as well as Protamine with resolution of chest tube bleeding. His tachycardia did respond to volume and Esmolol drip. He remained sedated and intubated throughout the operative day. He remained hemodynamically stable throughout that period. On postoperative day number one, the patient's sedation was discontinued. However, following this, the patient desaturated. A chest x-ray showed that he had some degree of pulmonary edema. He was treated with diuretics with a good effect; however, the patient continued to require mechanical ventilation. By postoperative day number two, the patient was able to be weaned from mechanical ventilation to pressure support and he was successfully extubated. Over the next two days, the patient was weaned from his cardioactive intravenous medications including Labetalol drip and placed on oral antihypertensives. However, during this transition, the patient experienced episodes of atrial fibrillation for which he was begun on Amiodarone, with no effect, and the patient was ultimately cardioverted on postoperative day number six to a sinus rhythm. On postoperative day number seven, the patient remained hemodynamically stable and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient had an uneventful hospital course with the exception of a persistent fever. It was felt to be due to a phlebitis, caused by an old intravenous site. The patient was treated with intravenous Kefzol with resolution of the fever as well as the phlebitis. On postoperative day number 12, it was decided that the patient would be stable and ready for discharge to home on the following morning. At the time of discharge, the patient's physical examination is as follows: Temperature of 100; heart rate 68; sinus rhythm; blood pressure 160/70; respiratory rate of 18; oxygen saturation 95 percent on room air; weight 78 kg. White count 13.2; hematocrit of 32.4; platelets 375. INR of 1.9. Sodium of 135; potassium of 4.6; chloride of 99; C02 27; BUN 17; creatinine 0.8; glucose 98. Neurologic: Awake, alert and oriented. Pulmonary: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm with normal sinus rhythm. Abdomen is soft, nontender, with normoactive bowel sounds. Extremities are warm with no edema. Sternum is stable with small amount of bloody drainage from the distal portion of the sternal wound. No erythema. The patient's condition, at the time of discharge is good. He is to be discharged to home with visiting nurses. DISCHARGE DIAGNOSES: Coarctation of the aorta. Hypertension. Status post mitral valve Annuloplasty with a 28 mm [**Doctor Last Name 405**] band and a quadrangular resection. Status post coronary artery bypass grafting times four with saphenous vein graft to the posterior descending artery; saphenous vein graft to the left anterior descending; saphenous vein graft to obtuse marginal one with sequential jump to obtuse marginal two. Ascending to descending aortic bypass with a 30 gel-weave graft. Atrial fibrillation. CONDITION ON DISCHARGE: Good. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: He is to be discharged home with visiting nurses. He to follow-up with Dr. [**Last Name (STitle) **] for an INR check on Monday, the 22nd. Further dosing of Coumadin is to be assumed by Dr. [**Last Name (STitle) **]. He is to have follow-up with Dr. [**First Name (STitle) **], his cardiologist, in one to two weeks. Follow-up with Dr. [**Last Name (Prefixes) **] in four weeks. DISCHARGE MEDICATIONS: 1. Coumadin, take as directed. Target INR is 2 to 2.5. 2. Percocet 5/325 one to two tabs q. Four hours prn. 3. Colace 100 mg twice a day. 4. Aspirin 81 mg q. Day. 5. Atenolol 100 mg q. Day. 6. Keflex 500 mg q. Six hours for seven days. 7. Amiodarone 400 mg twice a day times six days and then 400 mg q. Day times one week and then 200 mg q. Day times one month. [**Doctor Last Name **] [**Last Name (Prefixes) **], MD [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2158-11-23**] 18:49:32 T: [**2158-11-24**] 08:23:11 Job#: [**Job Number 54958**]

[ "780.6", "747.10", "451.84", "401.9", "424.0", "427.31", "999.2", "E879.8", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.05", "88.72", "39.61", "36.14", "89.68", "38.45", "99.62", "99.04", "35.12" ]

icd9pcs

[ [ [] ] ]

1773, 1890

7835, 8340

8826, 9455

1563, 1756

2804, 7813

144, 238

267, 1537

1907, 2781

8365, 8803

7,454

115,114

912

Discharge summary

report

Admission Date: [**2127-7-10**] Discharge Date: [**2127-7-15**] Service: UROLOGY Allergies: Tylenol / Advil Attending:[**First Name3 (LF) 6157**] Chief Complaint: kidney stone Major Surgical or Invasive Procedure: cystoscopy with retrograde placement of a ureteral stent History of Present Illness: HPI: This is a [**Age over 90 **]M with h/o of prostate hyperplasia s/p TURP x2, presents from home c/o diffuse abd pain that radiated to the RLQ. A CTU revealed and 4mm obstructing R ureteral stone + hydro. On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: TURP 5 years ago at JPVA and reTURP on [**2124-9-15**] Bladder stone HTN R femoral hernia H/O levo resistent enterococcus uti BPH ? of PNA on CXR + tob use On CXR, appears to have COPD although no documented PFT's. Social History: live alone, not married, smokes cigars, no drug use, some EtOH Family History: n/c Physical Exam: In the ED, VS 96.6, HR 90, BP 210/92, RR16, 92% RA. . General: Elderly Male, mild distress HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: LCTA Cardiac: RR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: AAOX3, responds to questions and follows commands. Pertinent Results: [**2127-7-13**] 04:30AM BLOOD WBC-4.4 RBC-3.78* Hgb-11.3* Hct-33.2* MCV-88 MCH-30.0 MCHC-34.2 RDW-13.9 Plt Ct-122* [**2127-7-12**] 03:11AM BLOOD WBC-5.2# RBC-3.90* Hgb-11.8* Hct-34.0* MCV-87 MCH-30.2 MCHC-34.7 RDW-14.2 Plt Ct-122* [**2127-7-11**] 06:40AM BLOOD WBC-12.9* RBC-4.41* Hgb-13.3* Hct-37.1* MCV-84 MCH-30.1 MCHC-35.7* RDW-13.8 Plt Ct-170 [**2127-7-10**] 10:15PM BLOOD WBC-17.2* RBC-4.30* Hgb-12.9* Hct-37.1* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.1 Plt Ct-189 [**2127-7-9**] 06:45PM BLOOD WBC-13.1*# RBC-4.91 Hgb-14.5 Hct-41.4 MCV-84 MCH-29.5 MCHC-34.9 RDW-13.4 Plt Ct-271 [**2127-7-13**] 04:30AM BLOOD Plt Ct-122* [**2127-7-13**] 04:30AM BLOOD PT-12.7 PTT-26.3 INR(PT)-1.1 [**2127-7-13**] 04:30AM BLOOD Glucose-104 UreaN-39* Creat-1.1 Na-145 K-4.3 Cl-112* HCO3-24 AnGap-13 [**2127-7-12**] 04:29PM BLOOD Glucose-140* UreaN-40* Creat-1.2 Na-142 K-4.1 Cl-109* HCO3-25 AnGap-12 [**2127-7-12**] 03:11AM BLOOD Glucose-127* UreaN-43* Creat-1.4* Na-141 K-3.7 Cl-109* HCO3-22 AnGap-14 [**2127-7-11**] 01:26PM BLOOD Glucose-117* UreaN-44* Creat-2.0* Na-141 K-3.7 Cl-106 HCO3-23 AnGap-16 [**2127-7-11**] 06:40AM BLOOD Glucose-139* UreaN-43* Creat-2.4* Na-139 K-3.7 Cl-105 HCO3-21* AnGap-17 [**2127-7-10**] 10:15PM BLOOD Glucose-152* UreaN-37* Creat-2.2*# Na-138 K-3.7 Cl-105 HCO3-21* AnGap-16 [**2127-7-9**] 06:45PM BLOOD Glucose-135* UreaN-18 Creat-1.1 Na-143 K-3.8 Cl-107 HCO3-25 AnGap-15 [**2127-7-13**] 04:30AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2 . MICRO [**2127-7-11**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT [**2127-7-10**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; ANAEROBIC BOTTLE-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)} INPATIENT . Imaging: CT abd/pelvis [**7-9**] 1. 4-mm obstructing right ureteral stone with right-sided hydronephrosis and stranding around the right kidney. 2. 5-mm right lower lobe pulmonary nodule. In the absence of a known malignancy, followup in one year is recommended to ensure stability. 3. Markedly enlarged and heterogenous prostate. 4. Normal-appearing appendix within a right femoral hernia. 5. Cholelithiasis, without evidence of cholecystitis. Brief Hospital Course: In the ED, patient received CXT 1gm IV, Toradol 30mg IV, Pepcid, morphine and admitted to urology. Patient received IV hydation during HD#1, with plan for going to OR for cystoscopy. During that day, patient was noted to be increasingly tachypnic and hypoxic, Sats 96% on 2L NC. Medical consultation was obtained but patient declined further evaluation since he didn't wnat, "anymore pills." Was noted to be speaking in full sentences, and ambulating to BR without significant distress. VS at that time: TM99.5, Tc 98.1, RR27, and noted to have L>R bibasilar crackles. no CVAT. . Patient taken to the OR in am HD2 for cysto and stenting. No complications, but given the tachypnea, patient remained intubated and transfered to the [**Hospital Unit Name 153**]. . He spent two days in the ICU, extubating on POD1. On POD2 pt was transferred to the floor where the remainder of his hospital course was unremarkable. Pt's cultures grew out probable coag negative staph 4/4 bottles from the evening of HD1 and the morning of HD2/POD0. No other blood cultures were positive. An ID consult was obtained and a PICC was placed for a total of 14d of vancomycin. On POD3 pt failed a void trial. Pt was transferred to rehab on POD4, afebrile, tolerating a regular diet on room air. He is to finish a total of 14 days of vanco and return to Dr. [**Last Name (STitle) 4229**] in the clinic for follow up. Medications on Admission: Milk of Magnesia 30 ml PO Q6H:PRN Codeine Sulfate 15-30 mg PO Q4H:PRN pain Morphine Sulfate 2-4 mg IV Q4H:PRN Docusate Sodium 100 mg PO BID Pantoprazole 40 mg IV Q24H Ipratropium Bromide Neb 1 NEB IH Q6H Levofloxacin 500 mg IV Q24H Tamsulosin HCl 0.4 mg PO HS Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: Do not give within 6 hours (before or after) the dose of Levofloxacin. Disp:*qs ML(s)* Refills:*0* 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day): take while an inpatient at rehab. Disp:*90 syringe* Refills:*2* 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. Disp:*60 Capsule(s)* Refills:*2* 6. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) piggyback Intravenous Q 12H (Every 12 Hours) for 10 days: Please check a trough in 3 days. Disp:*20 piggyback* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 MDI* Refills:*2* 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation QID (4 times a day). Disp:*1 MDI* Refills:*2* 11. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for 2 days. Disp:*6 Tablet(s)* Refills:*0* 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Bacitracin 500 unit/g Ointment Sig: One (1) application Topical twice a day: Please apply to glans of penis while pt has foley [**Last Name (un) **] or prn. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: Obstructing stone of the R ureter with sepsis secondary to UTI with obstruction. Discharge Condition: stable Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 4229**] in his office in two week's time. His office number is: [**Telephone/Fax (1) 4230**]. You also have an appointment with Dr. [**Last Name (STitle) **] as follows: [**Name6 (MD) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2127-7-17**] 1:30 Completed by:[**2127-7-15**]

[ "584.9", "401.9", "591", "600.00", "038.19", "592.1", "486", "496", "599.0", "995.92" ]

icd9cm

[ [ [] ] ]

[ "59.8", "38.93", "87.74" ]

icd9pcs

[ [ [] ] ]

7880, 7945

4178, 5577

235, 294

8070, 8079

1941, 4155

8631, 8997

1274, 1279

5889, 7857

7966, 8049

5604, 5866

8103, 8608

1294, 1922

183, 197

322, 938

961, 1178

1194, 1258

7,901

198,859

30672

Discharge summary

report

Admission Date: [**2157-4-18**] Discharge Date: [**2157-4-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Upper GI bleed, C. Diff Colitis Major Surgical or Invasive Procedure: EGD PICC History of Present Illness: Pt was admitted to [**Hospital3 **] on [**2157-4-9**] for septic shock [**1-28**] C.Diff colitis. Pt received pressors and hydrocortisone initially for BP mgmt. He was treated with po vancomycin and IV flagyl, and also got vancomycin enemas when he developed an ileus. Abdominal CT [**4-13**] showed diffuse colonic submucosal edema and pericolonic fat stranding, ascites, and bilateral lower lobe consolidations w/ effusions. Repeat abd CT [**4-17**] showed no improvement. Surgery was following closely and considering sub-total colectomy w/ end-ileostomy given severity of disease despite maximal medical tx. . On [**2157-4-17**], routine labs showed a Hct of 20.2 from 35.1 2 days prior. On questioning pt admitted to noticing black tarry stools x several days. Upper endoscopy showed a 1.5x1.5cm lower esophageal ulcer at the GE jxn. Cautery of the lesion was ineffective [**1-28**] bleeding, and so was injected with epinephrine. Pt received 5U PRBCs--> Hct 29.8. He was transferred to [**Hospital1 18**] for upper endoscopy and management of bleeding esophageal ulcer. . On arrival to [**Name (NI) 153**], pt was hemodynamically stable. He reports having recent dark, tarry stools and complains of abdominal pain [**1-28**] healing zoster but none otherwise. He denies nausea, vomiting, chest pain, SOB, dysphagia, dizziness, or fatigue. Past Medical History: Recent hospitalization for pneumonia ([**Date range (1) 72694**]) Zoster, c/b post-herpetic neuralgia Sick Sinus Syndrome, s/p pacemaker [**2150**] Gout HTN Hypercholesterolemia Hiatal hernia c.diff colitis Cholecystectomy Social History: Lives with wife [**Name (NI) **] in [**Name (NI) **]. Smoked 1ppd x 15-20 years, quit in [**2115**]. Drinks 1.5 ounces hard alcohol daily. Denies other drug use. Until [**2-/2157**] hospitalization for pneumonia, was working full time in an equipment store. Family History: Non-contributory Physical Exam: T 98.1, 111/64, 77, 18, 97 HEENT: PERRL, EOMI. Dry MM. Neck: Supple, no lymphadenopathy Lungs: mild expiratory wheezes bilaterally. No rales or rhonchi. Chest: RRR, nl S1/S2, no m/r/g Abd: Soft, non tender, +distension, +BS Healing R low thoracic zoster. Midline scar from prior appy. No HSM appreciated. Extrem: 2+ pulses, WWP. Neuro: AOx3, moving all 4 extremities Pertinent Results: [**2157-4-18**] 05:20PM WBC-19.9* RBC-3.80* HGB-11.8* HCT-33.8* MCV-89 MCH-31.0 MCHC-34.9 RDW-16.2* [**2157-4-18**] 05:20PM NEUTS-75.0* BANDS-3.0 LYMPHS-11.0* MONOS-9.0 EOS-1.0 BASOS-0 ATYPS-1.0* [**2157-4-18**] 05:20PM PLT SMR-NORMAL PLT COUNT-220 [**2157-4-18**] 05:20PM PT-12.9 PTT-31.5 INR(PT)-1.1 [**2157-4-18**] 05:20PM GLUCOSE-86 UREA N-21* CREAT-0.6 SODIUM-132* POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-10 [**2157-4-18**] 05:20PM ALT(SGPT)-15 AST(SGOT)-28 LD(LDH)-238 ALK PHOS-44 AMYLASE-135* TOT BILI-0.6 [**2157-4-18**] 05:20PM LIPASE-79* . [**2157-4-18**] CXR: Small right-sided pleural effusion. . [**2157-4-19**] CT CHEST: No evidence of extravasation of contrast. Moderate bilateral pleural effusions with underlying compressive atelectasis. Ectasia of the ascending aorta. Ascites. . [**2157-4-20**] UNILAT UP EXT VEINS US: No evidence of deep venous thrombosis involving the left upper extremity. . [**2157-4-20**] UNILAT LOWER EXT VEINS LEFT: No evidence of deep venous thrombosis in the left lower extremity. . [**2157-4-18**] EGD: Esophagus: Excavated Lesions A single 20mm ulcer with overlyign organizing clot was found in the lower third of the esophagus extending from 29cms to 34cms from the incisors. The GE junction was noted at 38cms. No evidence of active bleeding was noted. Three punctate small ulcers were noted on the opposite wall. The distal esophagus was tortous. Mucosa: Localized linear erythema of the mucosa was noted in the antrum. These findings are compatible with gastritis. Duodenum: Normal duodenum. Other findings: No fresh blood or coffee ground material was noted in the stomach. Impression: Ulcer in the lower third of the esophagus Erythema in the antrum compatible with gastritis No fresh blood or coffee ground material was noted in the stomach. Otherwise normal EGD to second part of the duodenum . [**2157-4-19**] 10:41 am SEROLOGY/BLOOD Source: Line-rsc tlcl. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2157-4-20**]): NEGATIVE BY EIA. . [**2157-4-22**] 11:46 am URINE Source: Catheter. URINE CULTURE (Final [**2157-4-23**]): YEAST. 10,000-100,000 ORGANISMS/ML.. . [**2157-4-23**] 6:14 pm URINE Site: CATHETER Source: Catheter. URINE CULTURE (Final [**2157-4-25**]): YEAST. 10,000-100,000 ORGANISMS/ML. . [**2157-4-22**] 11:46AM URINE Color-Amber Appear-SlCloudy Sp [**Last Name (un) **]-1.025 [**2157-4-22**] 11:46AM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-MOD [**2157-4-22**] 11:46AM URINE RBC-583* WBC-120* Bacteri-MOD Yeast-MANY Epi-0 [**2157-4-23**] 06:14PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.020 [**2157-4-23**] 06:14PM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM [**2157-4-23**] 06:14PM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE Epi-0 . [**2157-4-24**] 06:41AM BLOOD WBC-10.3 RBC-3.36* Hgb-10.9* Hct-32.5* MCV-97 MCH-32.4* MCHC-33.4 RDW-16.2* Plt Ct-190 [**2157-4-24**] 06:41AM BLOOD Plt Ct-190 [**2157-4-24**] 06:41AM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-135 K-3.8 Cl-102 HCO3-28 AnGap-9 . [**2157-4-25**] 07:03AM BLOOD WBC-9.2 RBC-3.63* Hgb-11.7* Hct-34.9* MCV-96 MCH-32.2* MCHC-33.5 RDW-16.4* Plt Ct-207 [**2157-4-25**] 07:03AM BLOOD Plt Ct-207 . Brief Hospital Course: 1) C. DIFF COLITIS: Pt had been on flagyl and vanco at OSH with improvement. His symptoms had mostly resolved by arrival here. He was continued on PO flagyl and PO vanco here. Abd pain and diarrhea resolved. Both were continued for 2 weeks. . 2) Esophageal Ulcer: The esophageal ulcer was cauterized and injected. EGD was repeated here and did not show any active bleeding. Pt was kept on high dose PPI and Hct was stable. Received call from OSH that there was concern there could have been esophageal perforation during EGD. A chestCT was done here which did not show any evidence of this. . 3) ANASARCA: Pt had peripheral edema, ascites, and pleural effusions. It was likely due to fluids received during sepsis and hypoalbunemia. He was started on lasix for diuresis 4) COPD Pt improved with inhaled steroids and bronchodilators. Medications on Admission: Home meds: HCTZ 12.5mg daily, ASA 81mg daily, Quinapril 20mg daily, Avacor 500mg daily, Probenecid 500mg daily . MEDS on transfer: Protonix 80mg IV q8h Lyrica 75mg po bid Flagyl 500mg IV q8h Vancomycin 500mg po qid Vancomycin 500mg pr q6h Combivent 2 puffs tid standing and q4h prn Flovent 4 puffs inh [**Hospital1 **] Albuterol 2.5mg/3ml neb q4h prn TPN Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO bid (). 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 6. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation twice a day. Disp:*1 MDI* Refills:*2* 7. FOLEY Foley Care with Leg Bag per protocol Voiding Trial in 1 week Discharge Disposition: Home With Service Facility: SouthShore VNA Discharge Diagnosis: C diff colitis Upper GI bleed from esophageal ulcer Anasarca Chronic Obstructive Pulmonary Disease Discharge Condition: Good Discharge Instructions: 1. Take medication as prescribed. 2. Follow up as below. 3. Please seek medical attention for fevers, increasing shortness of breath, chest pain, diarrhea, abdominal pain, blood in your stool. Followup Instructions: 1. You have an appointment scheduled with Dr. [**Last Name (STitle) **] on Monday [**2157-5-2**] at 4:30. [**Telephone/Fax (1) 53156**] 2. You have an appointment scheduled with a urologist to discuss your urinary retention. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2157-5-30**] 2:30

[ "401.9", "496", "782.3", "274.9", "008.45", "553.3", "535.40", "530.21", "272.0", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

8026, 8072

5998, 6843

294, 304

8214, 8220

2639, 5975

8464, 8846

2217, 2235

7249, 8003

8093, 8193

6869, 6982

8244, 8441

2250, 2620

223, 256

332, 1680

1702, 1926

1942, 2201

7000, 7226

5,054

192,336

14910

Discharge summary

report

Admission Date: [**2115-7-2**] Discharge Date: [**2115-7-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Transferred for stenting of right mainstem bronchus Major Surgical or Invasive Procedure: Intubation Bronchoscopy with bronchial stent removal. History of Present Illness: 80 yo man w/ h/o Stage 3B lung cancer (s/p chemo, XRT, and stent placement [**5-12**]), COPD on home O2, CAD (multivessel disease and 80% LM stenosis), A fib, and LLE DVT who presents from OSH with obstructed right sided bronchus with post-obstructive pneumonia for possible stenting. On [**6-28**] the patient underwent bronchoscopy which showed tumor occluding the stent which was partially removed. After this procedure, the patient went into respiratory distress in the PACU and required intubation. He was also noted to have ST elevations on EKG in leads V2 and V3. STAT echo revealed EF of 25%, decreased from 60% in [**2115-5-8**]. The patient was admitted to the MICU at the OSH for further management. . On transfer to the MICU, the patient was hypotensive to the 70's systolic which responded to IV fluid bolus. Cardiology was consulted regarding his ST elevations and recommended medical management with addition of plavix for his left main disease. Eventually, the patient was also started on low dose metoprolol and captopril after his blood pressure stabilized. The following morning, his ST elevations had normalized. Cardiology felt that his previous changes were due to myocardial stunning. During his OSH MICU course, he was also found to have focal neuro deficits (left ptosis, left facial droop) so a head CT was done. This study revealed an old right parietal infarct with moderate chronic small vessel infarcts without evidence of enhancing lesions. . The patient was transferred to [**Hospital1 18**] for possible stenting of his right sided bronchial occlusion. He was hemodynamically stable on arrival, and denied CP, SOB, abdominal pain, headache, or dizziness. CXR was done showing complete whiteout of the right lung [**1-9**] to post-obstructive pneumonia. He was started on Vanco and Zosyn for treatment of pneumonia. Chest CT the following day revealed bilateral pleural effusions (R>L), complete RUL/RML/RLL collapse with apparent obstruction of the bronchial stent within the right main stem bronchus. Past Medical History: - Stage 3B Lung Cancer: dx [**2114-10-8**]; s/p 8 courses of chemo; s/p XRT; s/p stent in right bronchus [**5-12**]; s/p 5 therapeutic bronchoscopies (for reocclusion of stent) - COPD on home O2 - CAD: s/p cath [**2114-11-22**] showing multivessel disease, LM 80% - A FIB: started on digoxin 3 weeks prior to admission - s/p LLE DVT: [**2109**] and [**2114-12-8**] (s/p hernia repair); treated with coumadin and plavix in the past - s/p CVA x 2 - s/p hernia repair - s/p left eye surgery for ptosis (3.5 yrs ago) - s/p cataract surgery Social History: Lives at home with his wife. [**Name (NI) **] social support. 60 pack year smoking history. Family History: CAD CVA - sister and father [**Name (NI) **] cancer - brother (smoker) Physical Exam: 98.4 - 112 - 95/44 - 13 - 99% (AC: 500/14/5/0.35); 79 kg Gen: Elderly man, intubated, awake and alert, appears comfortable HEENT: ETT in place, PERRL, anicteric, bilateral corneal arcus, +left ptosis, MMM Neck: right IJ in place, supple, no LAD, no JVD Lungs: course breath sounds, CTA on the left, decreased breath sounds on the right, no w/r/r Heart: irreg irreg, distant HS, no M/R/G Abd: NABS, soft, NT, ND, no palpable masses Ext: warm, dry, [**12-9**]+ pitting edema Neuro: CN II-XII intact with exception of mild left facial droop Rectal: guaiac negative brown stool Pertinent Results: OSH LABS: WBC=5.0; Hct=23.8; plts=154 Na=135; K=4.0; Cl=110; CO2=22; BUN=9; Cr=0.8; glucose=163 INR=1.0 ABG = 7.44/31/87 CK = 30-->26-->25; CKMB = 4.3-->4.6-->3.9; Trop 0.45-->0.88-->0.64 . PORTABLE CXR @ OSH ([**7-2**]): improvement in vascular congestion and slight alveolar fluid from yesterday. Persistent opacification of the right hemithorax. . CT CHEST @ OSH ([**6-29**]): 1) Large right sided pleural effusion and moderate size left sided pleural effusion. 2) Complete collapse of the RUL, RLL, and RML with apparent obstruction of bronchial stent within the right main stem bronchus and soft tissue mass in the azygoesophageal recess likely representing patient's known lung cancer. 3) Emphysematous changes throughout the LUL w/ septal thickening which may be due to scarring, atelectasis although no lymphangitic spread of disease cannot be entirely excluded. 4) Areas of compressive atelectasis within the LLL. Incidental note is made of infrarenal AAA (2.9 x 2.4 cm). . LABS ON ADMISSION TO [**Hospital1 18**]: [**2115-7-2**] 11:09PM WBC-6.4 RBC-3.33*# HGB-9.7*# HCT-29.3*# MCV-88 MCH-29.3 MCHC-33.2 RDW-16.9* [**2115-7-2**] 11:09PM PLT COUNT-164 [**2115-7-2**] 11:09PM PT-13.0 PTT-30.2 INR(PT)-1.1 [**2115-7-2**] 11:09PM GLUCOSE-94 UREA N-9 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12 [**2115-7-2**] 11:09PM ALT(SGPT)-9 AST(SGOT)-15 ALK PHOS-52 TOT BILI-0.4 [**2115-7-2**] 11:09PM CALCIUM-7.7* PHOSPHATE-2.5* MAGNESIUM-1.9 Brief Hospital Course: Pt bronched [**7-3**], showing right main bronchus stent frayed at distal end, blocking RUL and with thick secretions distally. Left bronchus was patent. Overnight [**7-3**], patient was was hypotensive; did not respond to IVF bolus and PRBCs. Low dose Dopamine started with improvement of BP. ~20 min after dopamine started, patient went into RVR. Dopamine stopped. Amiodarone started, patient still tachycardic and hypotensive. At this point, patient underwent synchronized cardioversion (200 and then 300 joules), did not convert to NSR, but rate became more controlled in low 100's. Levophed started for BP control, subsequently weaned off [**7-4**], converted to NS on amiodarone drip. Pt never weaned off mechanical ventilation through his hospital course. Spontaneous breathing trials were poorly tolerated. In addition, his cardiovascular function was tenuous. He had acute drop in blood pressure with cardiac enzyme leak on [**7-11**] and throughout his course remained intermittently hypotensive and also bradycardic at times. Per family request pressor were not given. It became clear given the patients invasive lung cancer and severe coronary artery disease that the prognosis was extremely poor. On [**2115-7-12**] a family meeting was held. The outcome of this was that pt would remain intubated but would also still be DNR and would be given no escalation in care including pressors or antiarrhythmics. The family asked whether it would be possible to send pt home on ventilator so that he may spend his last days at home. Such arrangements were made but required that the patient undergo tracheostomy. Unfortunately the patient was never sufficiently hemodynamically stable that this procedure could safely be performed. On [**2115-7-19**] another family meeting was held. It was explained that tracheostomy was not possible to perform safely and that the patient would probably spend the remainder of his days in the hospital. The daughters decided that care should move toward comfort measures only. Efforts were made to pursue care such that the patient would remain alive over the weekend so that he may have visitors. Of note the patient was noted to disseminated multi-drug resistant Klebsiella infection by blood culture, sputum culture, and urine culture. No antibiotics wore started. Comfort measure only care was instituted in full on [**7-22**] with the goal of making the patient comfortable. The patient went into respiratory failure on the evening of [**7-23**] and expired that night. Attending was duly notified. The family was notified. Autopsy was declined. In summary Mr [**Known lastname 24642**], is an 80 year-old gentleman with a history of stage 3b terminal lung cancer, atrial fibrillation and severe coronary artery disease who presented with hypoxic respiratory failure requring intubation that was secondary to total R bronchial obstruction and post-obstructive pneumonia. It became clear that efforts to treat his disease proved futile in the setting of his terminal disease, and eventually the patient placed in comfort measure only care and passed away. Medications on Admission: ASA 325 po daily Plavix 75 mg PO daily Digoxin 0.125 mg PO daily Lopressor 12.5 mg PO BID Captopril 3.125 mg PO TID Lipitor 20 mg PO daily Combivent MDI 2-4 puffs q4h Nexium 40 mg PO daily Colace 100 mg PO BID Heparin 5000 units SC daily Zosyn 2.25 grams IV TID Vancomycin 1 gm IV Q24H Ativan 0.5mg IV/PO Q4-6 prn Discharge Disposition: Expired Discharge Diagnosis: Stage IIIb lung cancer Post-obstructive pneumonia Hypoxic respiratory failure Severe coronary artery disease with 95% occlusion of L Main artery and 3 vessel disease. Clostridium difficile colitis. Extended spectrum beta-lactamase resistant Klebsiella Pneumonia bacteremia Atrial fibrillation. Discharge Condition: Expired. Followup Instructions: Autopsy declined. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "414.01", "197.2", "041.3", "V12.51", "486", "427.31", "996.59", "V58.61", "428.0", "008.45", "162.8", "496", "785.51", "518.84" ]

icd9cm

[ [ [] ] ]

[ "96.05", "33.91", "96.72", "00.17", "96.6", "98.15", "34.91", "99.04", "33.22" ]

icd9pcs

[ [ [] ] ]

8815, 8824

5317, 8451

313, 368

9161, 9171

3812, 5294

9194, 9340

3129, 3202

8845, 9140

8477, 8792

3217, 3793

222, 275

396, 2443

2465, 3002

3018, 3113

26,445

190,207

52079

Discharge summary

report

Admission Date: [**2141-8-12**] Discharge Date: [**2141-8-24**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a [**Age over 90 **] year old male who presented to ED with fever and chills that began at 4PM on the day of admission. He had been in rehab since his discharge from [**Hospital1 18**] on [**7-4**]. His BP at the nursing home was 75/50. He has had a decreased PO intake for the last weeks or so. He admitted to SOB while in the ED, denied any abdominal pain, nausea, vomiting, or diarrhea. Upon arrival to [**Hospital1 18**] ED his BP was 118/63 and temp was 102.4, and he was started on the sepsis protocol. He was given 5L NS which increased his BP to 134/64. He was started on levoquin, flagyl, and ceftriaxone. He was agitated while in the ED and received 4 mg haldol with some relief. Upon arrival in the ICU he stated he was feeling slightly better. He denies SOB, chest pain, abdominal pain. He does not recall having fevers, but does admit to chills. He is very thirsty. His only pain is in his feet. He reports that prior to admission he was not feeling well, had a poor appetite and decreased PO intake. Past Medical History: 1. Colon Ca s/p resection with no follow up 2. Partial Large Bowel Obstruction ([**2133**]) 3. Crohn's disease s/p hemicolectomy 4. Heart Block s/p PM-[**2130**] 5. Pseudogout 6. mechanical fall s/p R-ORIF 7. B12 deficiency, monthly shots at VA 8. Left atrial myxoma Social History: 1) + TOB hx, quit 60-70 years ago after the war 2) drinks 2-3 drinks occasionally 3) lives alone in the Michaelangelo House in the [**Hospital3 4414**] 4) World War II veteran (Guadal Canal) Family History: non-contributory Physical Exam: On admission: V.S.- 96.0 70 (paced) 90/41 20 100% NC Gen - elderly man, resting in bed, very thirsty repeating "water" HEENT - PERRLA, mm dry, OP clear Neck - IJ in place, full movement of neck, supple CV - distant heart sounds Pulm - CTAB anteriorly, no w/c/r Abd - + BS, soft, NT, ND Ext - no peripheral edema Skin - black pressure sores B heels Neuro - grossly intact, able to move all 4 extremities Pertinent Results: 18.5 > 10.7/34.3 < 219 MCV-72 N:70 Band:18 L:8 M:3 E:0 Bas:0 Atyps: 1 PT: 14.6 PTT: 30.8 INR: 1.4 142 111 49 ------------< 107 5.5 18 2.0 7.52/20/121 HCO3 17 ----> 7.39/24/245 HCO3 15 Lactate:3.8 --> 2.6 --> 2.1 --> 1.5 Urine: Hazy, 1.015, moderate leuks, lrg blood, neg nitrite, >50 RBC, >50 WBC, many bacteria Urine culture: Proteus mirabilis, pansensitive CK: 286 MB: 4 Ca: 9.0 Mg: 1.5 P: 3.3 ALT: 36 AP: 437 Tbili: 1.0 Alb: 3.2 AST: 44 LDH: Dbili: TProt: 7.2 [**Doctor First Name **]: 102 Lip: 103 [**2141-8-16**] 03:44AM BLOOD WBC-5.6 RBC-3.54* Hgb-8.0* Hct-26.2* MCV-74* MCH-22.5* MCHC-30.4* RDW-18.2* Plt Ct-132* [**2141-8-19**] 07:00AM BLOOD WBC-5.1 RBC-3.82* Hgb-8.5* Hct-28.5* MCV-75* MCH-22.3* MCHC-29.9* RDW-19.5* Plt Ct-144* [**2141-8-24**] 07:15AM BLOOD WBC-6.6 RBC-3.85* Hgb-9.0* Hct-29.1* MCV-76* MCH-23.3* MCHC-30.8* RDW-20.9* Plt Ct-129* [**2141-8-12**] 06:40PM BLOOD Neuts-70 Bands-18* Lymphs-8* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2141-8-15**] 04:32AM BLOOD Neuts-85.9* Bands-0 Lymphs-11.2* Monos-2.2 Eos-0.4 Baso-0.1 [**2141-8-14**] 05:13AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-1+ Target-OCCASIONAL Fragmen-OCCASIONAL [**2141-8-14**] 05:13AM BLOOD Glucose-88 UreaN-29* Creat-1.2 Na-139 K-3.6 Cl-111* HCO3-17* AnGap-15 [**2141-8-17**] 12:40PM BLOOD Glucose-114* UreaN-33* Creat-1.6* Na-142 K-5.0 Cl-113* HCO3-20* AnGap-14 [**2141-8-24**] 07:15AM BLOOD Glucose-76 UreaN-21* Creat-1.2 Na-141 K-4.3 Cl-101 HCO3-31 AnGap-13 [**2141-8-12**] 06:40PM BLOOD ALT-36 AST-44* CK(CPK)-286* AlkPhos-437* Amylase-102* TotBili-1.0 [**2141-8-19**] 07:00AM BLOOD CK-MB-8 cTropnT-0.08* [**2141-8-13**] 02:29AM BLOOD CK-MB-7 cTropnT-0.07* [**2141-8-13**] 03:02PM BLOOD Albumin-2.3* Calcium-7.3* Phos-4.0 Mg-2.2 [**2141-8-21**] 06:35AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.6 [**2141-8-24**] 07:15AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.7 [**2141-8-16**] 03:44AM BLOOD calTIBC-144* Ferritn-263 TRF-111* [**2141-8-13**] 05:50AM BLOOD Cortsol-32.8* [**2141-8-12**] 11:29PM BLOOD Type-ART pO2-245* pCO2-24* pH-7.39 calHCO3-15* Base XS--8 [**2141-8-14**] 08:09AM BLOOD Type-ART Temp-36.1 O2 Flow-2 pO2-79* pCO2-24* pH-7.42 calHCO3-16* Base XS--6 Intubat-NOT INTUBA [**2141-8-17**] 10:25AM BLOOD Type-ART pO2-61* pCO2-30* pH-7.38 calHCO3-18* Base XS--5 [**2141-8-19**] 12:19AM BLOOD Type-ART pO2-62* pCO2-37 pH-7.34* calHCO3-21 Base XS--5 [**2141-8-12**] 07:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD Brief Hospital Course: 1) SEPSIS: [**Age over 90 **] year old male admitted with fever and confusion due to sepsis secondary to recent UTI, likely urosepsis. Pt was treated with levofloxacin for a 10 day course. Urine cultures came back positive for pansensitive Proteus mirabilis, blood cultures showed gram-negative rod. C. Diff. toxin negative. A double coverage was not considered necessary as the pt was improving. The pt was initially presented with a respiratory alkalosis and a metabolic acidosis. He was rehydrated aggressively with LR and additional sodium bicarbonate. Electrolytes were repleated accordingly. Once the metabolic acidosis resolved only LR was used. The pt's CVP and urine output were monitored. The uriine output increased moderately over time but never exceeded 60ml/h. The Creat remained stable st the pt's baseline of 1.2. He was thought to have a certain degree of chronic renal failure. As the pt became more tachypneic on [**8-15**] and had intersitial and alveolar infiltrates on X-ray, while his the BP was normal and the urine output did not increase, rehydration was decreased. . 2) ACUTE RENAL FAILURE: Most likely a mixed pre-renal and pre-ATN picture. FENA <1% [**2141-8-18**], with spun urine with granular casts and white and red cells. Patient had a mixed gap and non-gap acidosis, as well as a respiratory alkalosis, most likely secondary to temporary ARF. Renal function improved gradually, with Cr increasing up to 1.7 and then decreased down to a baseline of 1.2. Patient is leaving with a foley catheter in place. He has had good response to Lasix. . 3) CONGESTIVE HEART FAILURE: Patient had a moderate degree of heart failure, likely secondary to fluids given in the ICU. Echo revealed and EF>55% and patient has responded well with Lasix. . 4) ANEMIA: Most likely anemia of chronic disease, particularly given Fe/TIBC of [**1-9**]. Once pt has stabilized s/p sepsis, it would be worthwhile to re-run iron studies. Drop in Hct was likely hemodilutional given large amount of IV NS that was used for resuscitation. However the stool guaiac was positive and an outpatient f/u should be done, especially in the context of a previous hx of colon ca. Iron studies showed an anemia of chronic disease. No transfusions were done. . 5) ELEVATED ALKALINE PHOSPHATASE: --Old GGT level highly elevated at 181 from [**6-11**], thus making a bone etiology less likely. Elevated alk phos most likely secondary to a EtOH use and hepatic disorder. Patient could be evaluated as an outpatient with RUQ U/S and possibly even liver biopsy. While AST was recently elevated at 44, ALT NL, as were total protein. . 7) THROMBOCYTOPENIA: Initially platelets dropped from 219 to 111 but then stabilized around 130. As the pt is on heparin some component of HIT Type II was suspected. HIT Type I seemed to be unlikely as the PTLs never dropped below 100 although heparin was continued. Given that Plt > 100, the patient has no increased risk of bleeding. This might have been a part of the patient's septic reaction. Recommend monitoring as an outpatient. . 8) Elevated INR: INR up to 1.7 on Hospital Day #2. VitK was given and INR normalized. . 9) MS CHANGE and DIFFICULTY WITH SPEECH: Per patient's nephew (who does not live with the patient), the patient was functioning well, mobile in the neighborhood and very social prior to these two hospitalizations. However, it seems likely that the patient has had a slowly progressive dementia. Previous head CT's showed chronic microvascular disease; an EEG at prior hospitalization showed normal activity for his age. . 10) PAIN: Patient had complained of back pain, which was treated well with Tylenol. --Given sedentary state, patient must be monitored for decubitus ulcers; on past admission had a stage 2 decubitus ulcer, as well as bilateral stage 1 heel ulcers. Feet bilaterally are in cushioned braces to protect his skin ulcers. Maintained an occlusive or semipermeable membrane around the ulcers to keep a moist environment around the wound. Medications on Admission: Vitamin B12 Folate Vitamin D Thiamine Calcium ASA Senna Zyprexa PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Simethicone 80 mg Tablet, Chewable Sig: 0.25 Tablet, Chewable PO BID (2 times a day) as needed. Disp:*30 Tablet, Chewable(s)* Refills:*0* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. Disp:*30 Tablet(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO q6hr prn as needed. Disp:*500 ML(s)* Refills:*0* 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for congestion. Disp:*1 inhaler* Refills:*1* 13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*1 Nebulizer* Refills:*0* 14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*60 Cap(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 20847**] Home - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnoses: 1) Urosepsis 2) Acute Renal Failure 3) Congestive Heart Failure 4) Delirium Discharge Condition: Stable, afebrile, breathing comfortably on 3L O2 by nasal canula. Discharge Instructions: We recommend that your physicians follow your health closely and that in particular, they monitor your fluid intake and urine output and adjust your diuretics as needed. We suggest that they check your electrolytes and CBC twice a week, at least initially. CXR's might also be warranted. We also recommend that the nursing staff encourage free water intake by mouth and that overall eating and drinking are encouraged. Nursing staff will need to care for your foot ulcers and maintain a tight seal over them and keep you in boots that protect your feet. Followup Instructions: Your primary care physician and the physicians at your nursing home should monitor your health closely. If you have any recurrence of fevers, pain with urination, signs of worsening congestive heart failure, or any other problems, you should call your PCP or return to the emergency department. Completed by:[**2141-8-24**]

[ "038.9", "V10.05", "584.9", "555.9", "276.8", "276.3", "707.07", "287.4", "428.0", "276.2", "263.9", "266.2", "599.0", "V45.01", "995.92", "E934.2", "285.29" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10752, 10830

4848, 8848

223, 229

10968, 11035

2292, 4825

11641, 11967

1829, 1847

8966, 10729

10851, 10947

8874, 8943

11059, 11618

1862, 1862

178, 185

257, 1314

1876, 2273

1336, 1604

1620, 1813

60,003

157,046

54570

Discharge summary

report

Admission Date: [**2164-10-10**] Discharge Date: [**2164-10-15**] Date of Birth: [**2087-5-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 812**] Chief Complaint: Chief Complaint: conjunctivitis Reason for MICU admission: tachypnea Major Surgical or Invasive Procedure: None History of Present Illness: 77M with CAD, systolic CHF, brought to ED with bilateral conjunctivitis and O2 requirement. Patient is a poor historian, but per notes he was noted to have bilateral conjunctivitis with painless erythema two days ago and started on cipro eye gtts plus warm compresses. Then noted to have increased drainage, particularly from left eye. Last night he was also noted to desat to 76% which improved to 96% on 2L and also reported dyspnea on exertion. Sent to ED for further evaluation. . In the ED, initial vs were: T98.8 69 131/82 32 100 on NRB. RR has remained in the 28-34 range with some accessory muscle use. 90% RA and 99% on 3L. Patient with bilateral conjunctivitis but EOMs full and painless and eyes in general without pain; per ED no concern for orbital cellulitis. CXR with R sided effusion which looked somewhat worse than prior, ?pneumonia or failure. Patient was given vanco and levofloxacin and ceftriaxone. Received 250 cc NS. . In the MICU, patient confused about reasons for coming to the hospital but does note that his eyes have been "stiff". No visual difficulties or pain in the eyes. Denies shortness of breath, cough, chest pain. + orthopnea. Unsure about edema or weight gain. . Review of systems: (+) Per HPI. Also recently completed ampicillin course for UTI. (-) Denies headache, cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, abdominal pain. No recent change in bowel or bladder habits. No dysuria. . Past Medical History: - CAD - CHF, EF 20% in [**8-/2163**]; also with mod PA HTN - paroxysmal Afib without anticoagulation - HTN - Hyperlipidemia - h/o bladder CA - h/o prostate CA - h/o colon polyps - Dementia, reported as Alzheimer type; recent cognitive decline Social History: Resident at [**Location (un) **] Hourse. Worked in pharmacy when young; now retired. Sister also lives in [**Name (NI) **] (is health care proxy) and helps with his care; niece in close proximity. Stopped smoking in [**2144**]; smoked for 40 years. Family History: Noncontributory Physical Exam: General: Alert, pleasant, moderately tachypneic when awake with pursed lip breathing. HEENT: Marked bilateral bulbar and tarsal conjunctival erythema with L>R yellow purulent exudate. Denies facial tenderness. Not much periorbital edema. EOMI intact and painless. Bilateral erythema over superior maxillae (at site of nasal cannula). MM quite dry, no clear OP lesions. Neck: supple, JVD to at least 5-6 cm ASA. No adenopathy. Lungs: Diminished anteriorly and posteriorly; R lung fields with more diminished breath sounds particularly at base. Few crackles at L base. Pursed lip breathing. CV: Diminished, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, no clubbing, cyanosis. 2+ bilateral pedal edema. Bilateral lower legs wrapped. Chronic venous stasis changes. Neuro: Alert, oriented to self and [**Location (un) 86**]. CN II-XII intact. Easily able to read at close and far distances. Pertinent Results: WBC 5.9 Hct 38.1 MCV 93 Plts 173 INR 1.7 Na 144 K3.2 Cl 103 HCO 33 BUN 20 Cr 0.9 Ca 8.7 Mg 2.1 Phos 3.0 CK 17 CE negative x1 ABG 7.43/48/127/33 Lact 1.7 Micro: Blood culture x 2 pending Urine culture pending . Images: CXR: AP upright portable chest radiograph is obtained. Evaluation is limited due to low lung volumes and the patient's chin overlying the lung apices as well as patient's rotation to the right. There is persistent large right pleural effusion with right basilar consolidation. The left lung appears grossly clear. There is mild pulmonary vascular congestion more apparent in the right upper lung. Heart size cannot be assessed. Aorta appears unfolded. No definite pneumothorax is seen. Bones are demineralized. IMPRESSION: Persistent right-sided pleural effusion with right basilar consolidation, likely atelectasis. Increasing congestion notable in the right lung. Evaluation quite limited due to patient's position. . EKG: NSR at 69, incomplete LBBB, normal axis, low limb lead voltage, diffuse TWF; all grossly unchanged from prior. Brief Hospital Course: 77M with CAD, CHF EF 20%, dementia; presenting with conjunctivitis and hypoxemia yesterday, admitted to MICU for sCHF exacerbation. . # Acute on chronic systolic heart failure: EF 20%. Patient demonstrated evidence of volume overload with tachypnea, hypoxia, LE edema, decreased breath sounds, and elevated JVD. Pneumonia was initially considered and he was covered with 24 hrs of Levofloxacin, Vancomycin, and Ceftriaxone, but he had no evidence of leukocytosis or fever and little change in a CXR, so the antibiotics were stopped. A serum BNP was markedly elevated on admission and clinical exam were more consistent with CHF exacerbation. CXR demonstrated a large, simple right pleural effusion. He was treated with supplemental O2, Albuterol nebs, diuresed with IV Lasix, and continued his home dose Metoprolol and Enalapril. His symptoms improved on with this regimen and his effusion demonstrated improvement with serial CXR's. While the cause of his CHF exacerbation is unknown, the patient reports medication compliance and cardiac enzymes were negative x 3 without EKG changes. Despite the absence of clear ischemic event, he was maintained on telemetry throughout this hospitalization without incident. He was discharged on an increased dose of Lasix. . # Bilateral Conjunctivitis: Patient with marked erythema and exudate on admission, most likely bacterial. He received 1.5 days of Ciprofloxacin eye drops and changed to Erythromycin drops QID on admission with subsequent improvement in his symptoms. He completed 7 days of treatment & the patient was without eye pain or significant periorbital edema throughout this admission and his extraocular movements were intact throughout his stay. . # CAD: Patient with negative CE's x 3. Patient continued on his home Metoprolol and a an ASA was restarted, but he was not on a statin on admission and it was not started as an inpatient. He remained on telemetry throughout this hospitalization without incident. . # Hematuria: Patient with an episode of hematuria, thought to be [**1-2**] traumatic Foley placement. Hematuria improved without intervention. . # Dementia. Patient continued on his home Aricept, but Namenda was not given because it was non-formulary. It was restarted at discharge. . # Paroxysmal Atrial fibrillation: Patient remained in sinus rhythm throughout this admission. He was continued on his home Metoprolol 50mg [**Hospital1 **] with adequate rate control. He was started on ASA 325mg in lieu of Coumadin given his history of GI bleed. . # Hypertension: Patient normotensive as an inpatient, but continued on his home Metoprolol 50mg [**Hospital1 **], Enalapril 20mg daily, & Lasix 80mg IV PRN. # Elevated INR: Patient with elevated INR, thought to be nutritional deficiency. Given 1mg Vitamin K with subsequent improvement in his INR from 1.7 to 1.3. . # Code: Patient remained FULL CODE throughout this hospitalization Medications on Admission: enalapril 20 mg daily furosemide 80 mg daily isosorbide 30 mg daily potassium 20 meq daily multivitamin daily B12 500 mcg daily vitamin D3 800 units daily chlorhexidine rinse swish and spit [**Hospital1 **] namenda 5 mg [**Hospital1 **] cipro eye gtts 2 gtts QID x 7 days (started [**10-9**]) metoprolol 50 mg [**Hospital1 **] calcium carbonate 500 mg TID citalopram 20 mg daily aricept 10 mg HS flomax 0.4 mg daily claritin 10 mg daily lidoderm patch to R knee plavix - stopped [**10-5**] ASA 81 mg - stopped [**10-3**] ampicillin 500 mg QID [**Date range (1) 111620**] bisacodyl prn MOM prn [**Name2 (NI) **] prn guiafenesin prn fleet enema prn Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Hypoxia & pulmonary edema secondary to congestive heart failure Bacterial Conjunctivitis Secondary: Coronary artery disease Paroxysmal Atrial Fibrillation Dementia Hypertension Hyperlipidemia Benign Prostatic Hypertrophy Discharge Condition: Breathing comfortably on room air. Vital signs stable. Discharge Instructions: You were admitted to the hospital due to shortness of breath and an infection in your eyes. In the hospital, you were found to have an exacerbation of your congestive heart failure and some excess fluid in your chest. You were treated with oxygen and medication to remove the excess fluid and your breathing improved. You also had a conjunctivitis in your eyes that was treated with an antibiotic. . Medications: Lasix - This medication was INCREASED from 80mg a day to 80mg twice a day by mouth Aspirin - This medication was RESTARTED at 325mg daily. Plavix - This medication CONTINUED TO BE HELD given your history of bleeding while taking this medication. . Please weigh yourself every day. If your weight changes by more than 3 pounds, please call your primary care physician. [**Name10 (NameIs) **], please adhere to a low-salt diet and limit the amount of fluid you drink to less than 1.5 liters a day. If you experience any new shortness of breath, cough, increased swelling in your legs, pain or discharge from your eyes, impaired vision, or pain with moving your eyes, please call your doctor or go the emergency room. Followup Instructions: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Name (NI) 111621**], in [**12-2**] weeks. You can schedule an appointment by calling [**Telephone/Fax (1) 608**]. [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

[ "276.8", "331.0", "372.39", "401.9", "599.70", "427.31", "294.10", "600.00", "799.02", "428.23", "790.92", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8283, 8353

4677, 7585

396, 403

8627, 8684

3587, 4654

9861, 10195

2474, 2491

8374, 8606

7611, 8260

8708, 9838

2506, 3568

1652, 1924

304, 358

431, 1633

1946, 2192

2208, 2458

72,992

186,009

50142

Discharge summary

report

Admission Date: [**2167-2-3**] Discharge Date: [**2167-2-10**] Date of Birth: [**2110-8-10**] Sex: M Service: CARDIOTHORACIC Allergies: Fentanyl Attending:[**First Name3 (LF) 922**] Chief Complaint: persistant AFIB, RCA disease on cath Major Surgical or Invasive Procedure: CABG x2, MAZE, LAA ligation History of Present Illness: The patient is 56-year-old gentleman who was initially sent to me for minimally invasive Maze procedure for paroxysmal atrial fibrillation. The patient had longer and longer episodes of atrial fibrillation and now constitutes persistent atrial fibrillation. One time he was admitted for his minimally invasive Maze procedure and a left atrial clot was noted in his left atrial appendage and he underwent anticoagulation for that with subsequent resolution of his left atrial thrombus. The last time he was admitted to hospital for the minimally invasive Maze procedure, a diagnostic cardiac cath was performed by Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**] due to some atherosclerosis which was noted on the preoperative CT angiogram to evaluate his left atrium. The diagnostic cardiac cath revealed anomalous right coronary artery with a significant lesion within the mid to proximal segment as well as a subtotally occluded first obtuse marginal coronary artery. The decision was therefore made to proceed with concomitant Maze on top of a coronary artery bypass grafting procedure. The patient therefore agreed to proceed Past Medical History: Paroxysmal Atrial Fibrillation [**2159**] Tachybrady Syndrome s/p PPM [**11-4**] Stroke [**1-4**] Upper GI bleed Hepatitis C in the setting of IV drug use Diabetes Hpertension Oesity Social History: He is a prior smoker. He is currently self-employed as an exterminator. He used to use IV drugs but does not use them anymore. Family History: There is a family history of diabetes and early stroke in his mother. Physical Exam: General: well appearing male in NAD. generalized edema noted. VS: 98.5, 126/78, 102, 20, 98% on RA HEENT: unremarkable Chest: CTA bilat. Sternal incision well approx, no redness, no drainage. sternum stable. COR: RRR S1, S2 ABD: soft, round, NT, ND, +bowel sounds, +flatus. Extrem: bilat Extrem edema. Neuro: intact. Pertinent Results: [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 104665**]Portable TTE (Complete) Done [**2167-2-10**] at 11:00:00 AM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2110-8-10**] Age (years): 56 M Hgt (in): 74 BP (mm Hg): 131/76 Wgt (lb): 280 HR (bpm): 80 BSA (m2): 2.51 m2 Indication: Pericardial effusion. ICD-9 Codes: 423.9, 424.1, 424.0, 424.2 Test Information Date/Time: [**2167-2-10**] at 11:00 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Adequate Tape #: 2009W006-0:20 Machine: Vivid [**8-4**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.35 >= 0.29 Left Ventricle - Ejection Fraction: >= 60% >= 55% Aorta - Sinus Level: *4.0 cm <= 3.6 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.2 m/sec TR Gradient (+ RA = PASP): *45 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. AORTA: Moderately dilated aortic sinus. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS. PERICARDIUM: Small to moderate pericardial effusion. Sgnificant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Conclusions The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated The aortic root is moderately dilated at the sinus level. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. The effusion is partially echodense consistent with some degree of organization. Interpretation assigned to [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting physician Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 104666**],[**Known firstname **] [**2110-8-10**] 56 Male [**Numeric Identifier 104667**] [**Numeric Identifier **] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/mtd SPECIMEN SUBMITTED: Atrial Appendage. Procedure date Tissue received Report Date Diagnosed by [**2167-2-5**] [**2167-2-5**] [**2167-2-7**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl DIAGNOSIS: Atrial appendage: Focal muscle hypertrophy, slight mural fibrotic changes. Clinical: Coronary artery disease, coronary artery bypass graft. Gross: The specimen is received fresh in a container labeled with the patient's name, "[**Known firstname 25368**] [**Known lastname 11622**]", the medical record number and additionally labeled "left atrial appendage". It consists of an atrial appendage measuring 4 x 2 x 0.5 cm. There is a 4 cm staple line at the resection margin. The specimen is opened revealing approximately 5 cc of blood but no thrombi. The appendage wall appears unremarkable. Representative sections are submitted in cassette A. Brief Hospital Course: pt was admitted [**2167-2-3**] for heparinization prior to Maze, CABG. A pre-operative ECH was done- see results section. He was taken to the OR on HD#2 [**2167-2-5**] for CABG , Maze. See operative note for details. [**Name (NI) **] pt was admitted to tne Cardiac ICU for invasive monioring. Extubated on POD#1 and transferred from the ICU to the floor. Diuresed, started on lopressor and coumadin. Developed SVT- treated w/ sotalol and lopressor dose increased. Progressed well and passed activity requirements for d/c home w/ VNA follow up. D/C'd to home on 5mg coumadin and INR follow up w/ [**Hospital3 **] coumadin clinic. Medications on Admission: Lisinopril 40/D,Hctz 25/D,Coumadin 5mg/D(LD [**1-30**]),ToprolXL 100/D,Glargine 35u dinner,Humalog SSI(bfst,lunch,HS),VitC,Fish oil. Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous Q PM: resume preop schedule. 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: then decrease 40mg daily for 10 days. Disp:*30 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:*50 Tablet(s)* Refills:*0* 11. Outpatient Lab Work INR check [**2166-2-10**] then as directed. Goal INR 2.0-2.5 12. humalog insulin humalog insilun per sliding scale according to finger stick. Resume preoperative sliding scale schedule Discharge Disposition: Home With Service Facility: [**Hospital3 1280**] Home care Discharge Diagnosis: CABG x2 (SVG>OM, SVG>DRCA),MAZEw/ LAA ligation. [**2-5**] CVA(w/o residua),DM,HTN,obesity,remote IVDA,HepC,SSS(s/p PPM),h/o UGIB,PAF Discharge Condition: good Discharge Instructions: No driving for 4 weeks No lifting more than 10 pounds for 10 weeks. Shower daily, No tub bathing or swimming for 6 weeks. No lotion, creams or powders to incisions Report any fever greater than 100.5 You should have the VNA draw your blood INR and fax the [**Hospital **] coumadin clinic [**Telephone/Fax (1) 6256**] Followup Instructions: Follow up with: Dr. [**Last Name (STitle) 914**] in [**4-1**] weeks Dr. [**First Name (STitle) 1075**] and Dr. [**Last Name (STitle) 83774**] in [**3-3**] weeks Dr. [**Last Name (STitle) 104668**] your PCP [**Last Name (NamePattern4) **] 2 weeks. Completed by:[**2167-2-10**]

[ "250.00", "V70.7", "427.31", "070.54", "292.12", "V58.61", "305.50", "E878.2", "997.1", "414.01", "V12.54", "427.89", "746.85", "V45.01", "401.9", "278.00", "429.89" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.93", "37.33", "37.22", "89.45", "39.64", "88.56", "36.12" ]

icd9pcs

[ [ [] ] ]

9292, 9353

7090, 7720

310, 340

9530, 9537

2319, 7067

9902, 10179

1896, 1967

7903, 9269

9374, 9509

7746, 7880

9561, 9879

1982, 2300

234, 272

368, 1527

1549, 1733

1749, 1880

15,930

148,918

20388

Discharge summary

report

Admission Date: [**2151-9-2**] Discharge Date: [**2151-9-9**] Date of Birth: [**2075-6-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: UGIB Major Surgical or Invasive Procedure: EGD x 2 colonoscopy Central Line Placement History of Present Illness: The patient is a 76y/o F with a PMH of HTN, DM, CHF with EF 25-30%, mesenteric vein thrombosis (on coumadin), Ulcerative colitis and recent C. diff colitis admitted with coffee ground emesis. The patient was sent to ER from her nursing home with reports of a 1 day history of coffee ground emesis. At [**Hospital3 **], she was noted to have melanotic stools on exam. NG lavage with 600cc of coffee grounds. BP noted to be 93/54 pretransfusion with HR 103. HCT 24.2. INR found to be 4.5. She was given 1U PRBC, 2U FFP and Vitamin K 10mg. Repeat BP 158/69, HR 103. She was sent to [**Hospital1 18**] for further evaluation. On arrival to the ED, she was noted to have minimal output from her NG tube. Vitals: T 97.8, HR 115, BP 115/75, RR 18, O2 100% on RA. HCT 25. She was given ciprofloxacin 400mg IV. 1L NS. Pantoprazole gtt was started. 1U PRBC ordered but not given prior to transfer to MICU. On arrival to the MICU, the patient is alert, oriented only to self. She is unable to relate the details of her history of bleeding. Past Medical History: Diverticulitis, status post sigmoid resection in [**Month (only) 205**] of [**2145**] with a diverting colostomy which was reversed in [**2145-11-20**]. Mesenteric Vein Thrombosis [**2146**] Diabetes mellitus HTN Hyperlipidemia Cardiomyopathy - EF 25-30% [**2146**] Mesenteric Thrombosis - on coumadin GI bleeds in past Dementia Anxiety Ulcerative colitis Social History: Lives in [**Location (un) 25576**], most recently in nursing home. No known history of tobacco or EtOH Family History: unknown Physical Exam: Tc: HR:101 BP:175/69 RR:16 100% SP02 NC alert, oriented to person, disoriented to place and time follows commands, HEENT: PERRLA, no JVD, mmm, anicteric, OG tube in place. CVS: RRR, S1S2 clear, no M/R/G RESP: mild inspiratory crackles ABD: +ve bs, soft, non tender, obese EXT: 1+ pitting edema Pertinent Results: [**2151-9-3**] 12:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2151-9-3**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2151-9-3**] 12:00AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 [**2151-9-2**] 11:00PM GLUCOSE-113* UREA N-49* CREAT-0.9 SODIUM-136 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-18* ANION GAP-26* [**2151-9-2**] 11:00PM estGFR-Using this [**2151-9-2**] 11:00PM CK(CPK)-177* [**2151-9-2**] 11:00PM CK-MB-7 cTropnT-0.03* [**2151-9-2**] 11:00PM MAGNESIUM-1.9 [**2151-9-2**] 11:00PM WBC-11.8*# RBC-2.72*# HGB-8.4* HCT-25.3* MCV-93# MCH-31.0# MCHC-33.3 RDW-16.6* [**2151-9-2**] 11:00PM NEUTS-88* BANDS-0 LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-3* [**2151-9-2**] 11:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2151-9-2**] 11:00PM PLT SMR-NORMAL PLT COUNT-365 [**2151-9-2**] 11:00PM PT-19.8* PTT-20.5* INR(PT)-1.8* EGD: Medium hiatal hernia Granularity, friability, erythema and nodularity in the lower third of the esophagus compatible with erosive esophagitis (biopsy) Normal mucosa in the stomach (biopsy) Otherwise normal EGD to third part of the duodenum Colonoscopy: A single sessile 20 mm non-bleeding polyp was found in the ascending colon. Cold forceps biopsies were performed for histology. A single sessile 3 mm non-bleeding polyp of benign appearance was found in the ascending colon. Otherwise normal colonoscopy to cecum Brief Hospital Course: 76 y/o female with HTN, DM, CHF with EF 25-30%, mesenteric vein thrombosis (on coumadin), Ulcerative colitis and recent C. diff colitis presenting with melanotic stools, coffee ground emesis in setting of coagulopathy with INR 4.5 on admission. #1 GI bleed: Pt hemodynamically stable with HCT of 24.2 on admission after 1 unit RBC at outside hospital. Received FFP in [**Hospital 18**] hospital with reversal INR to 1.8 and placed on IV pantoprazole [**Hospital1 **]. Initially the patient was observed in the ICU. A central line was placed for access and blood draws due to poor peripheral access. Serial hematocrits were followed and showed no evidence of active bleeding. An EGD performed on [**9-3**] showed increased granularity, friability, erythema and congestion in the lower third of the esophagus from 25cm to 35cm but no evidence active bleeding. The patient was transferred to the regular medical floor where she was observed for any further bleeding. Colonoscopy performed on [**9-7**] revealed a single sessile 20 mm non-bleeding polyp in the ascending colon which was biopsied. Polypectomy was deferred to outpatient setting secondary to recent active GI bleed. A repeat EGD was also performed for biopsy of erosive gastritis. The patient was discharged on pantoprazole twice daily with instructions to follow up with Dr. [**Last Name (STitle) **] for polypectomy. #2 Anticoagulation for history of mesenteric vein thrombosis in [**2146**]: Patient presented with acute GI bleed in the setting of a supratherapeutic INR. As outlined above, the patient's anticoagulation was reversed using FFP and vitamin K and coumadin was held for the duration of her hospitalization. Upon discharge the patient was not restarted on her coumadin as her colonic polyp was felt to be a significant risk for chronic gastrointestinal bleed. The decision whether to continue longterm anticoagulation is deferred to the patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17863**]. Patients' with IBD are at 3x higher risk for developping pulmonary embolism/ deep venous thrombosis compared to the normal population. Most associated thromboembolic events occur within the portal, mesenteric and retinal veins. 80% of patient's who present with newly diagnosed thromboses have active IBD at the time of diagnosis. #3 Heart Failure: Systolic (EF55%): The patient presented with mild symptoms of volume overload consistent with CHF exaccerbation post transfusion. During her hospitalization, volume status was monitored clinically and she was diuresed as needed with lasix. Upon discharge, patient was euvolemic with no crackles in her lungs and only mild edema in extremities. She was discharged on her home dose of lasix. #4 HTN: In the setting of an acute bleed, the patient's home blood pressure medications were held. Subsequently, the patient was hypertensive with systolic blood pressure in the 170s. She remained asymptomatic with no symptoms of end organ ischemia. Once hemodynamic stability was confirmed, home antihypertensive regimen (lisinopril, norvasc, metoprolol, lasix) was resumed and the patient remained normotensive. #5 Ulcerative Colitis: Patient has history of ulcerative colitis. She was maintained on her home dose of azathioprine and asacol and had no evidence of active disease as confirmed by colonoscopy report. #6 clostridium difficile: Prior to admission, the patient had been started on flagyl on [**8-31**] for clostridium difficile. This regimen was continued and patient was discharged with instructions to complete the entire 14 day course. As per colonoscopy report, the patient did not have severe disease and no psuedomembranous colitis or evidence of toxic megacolone was visible. #7 DM: Patient's home dose of glimeprimide was held throughout hospital course. Despite instituting sliding scale insulin, the patient was hyperglycemic with average glucose ranging 200-220 throughout her hospital stay. Upon discharge, home medical management was reinstituted. #8 Dementia: At mental baseline, the patient was alert and oriented to person only. This was stable throughout her hospital stay. Patient was maintained on her rivastigmine and antidepressive. #9 Reflux disease: On omeprazole at home. Started on pantoprazole [**Hospital1 **] in setting of GIB. Also started of sulfacrate twice daily. #10 FEN: Patient's electrolytes were monitored daily and replaced as needed. Note: patient frequently required potassium replacement: supplementation may need to be provided on a daily basis esp as patient is on lasix Status: Full Code Communication: Son [**Telephone/Fax (1) 54665**] Medications on Admission: Tylenol 650mg po q4 PRN Albuterol 2puff inh QID Amlodipine 2.5mg daily Azathioprine 100mg daily Calcitonin 1 spray daily Colace 200mg [**Hospital1 **] Calcium carbonate 1 tab [**Hospital1 **] Cymbalta 20mg daily Ferrous sulfate 325mg daily Folic Acid 1 mg daily Lasix 20mg daily Gabapentin 300mg TID Glimepiride 1mg daily Insulin lispro SS Latanoprost 0.005% solution 1 drop op QHS Lidoderm patch 1 top daily Lisinopril 20mg [**Hospital1 **] Loperamide 2 mg Q6 prn Magnesium oxide 500mg daily Megestrol acetate 400mg daily Metoprolol tartate 25mg [**Hospital1 **] Flagyl 500mg TID (started [**8-31**]) MOM 30ml PRN MVI daily Omeprazole 20mg daily Percocet 1 tab Q8 PRN Prednisone 10 mg daily Rivastigmine 6mg [**Hospital1 **] Coumadin 3mg daily Vitamin D 50000U Q 2 weeks Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take with meal. 12. Sucralfate 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. 15. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Outpatient Lab Work Pleave have Hct rechecked in 1 week Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: acute anemia erosive gastritis colonic polyp Discharge Condition: alert and oriented x 1, at baseline per family members hemodynamically stable with stable hematocrit at 28 for 24 hours stools are fecal occult blood negative Discharge Instructions: You were admitted with bleeding from your gastrointestinal tract. You have received blood transfusions and have had 2 endoscopies and a colonoscopy with the gastroenterology team. You were found to have several causes for your bleeding, both irritation in your esophagus and a polyp in your colon. Because of this bleeding, your coumadin has been held, please discuss whether or not to restart your coumadin with your primary care physician. [**Name10 (NameIs) 357**] have your primary care physician recheck your hematocrit in one week. You will need to follow up as indicated below with your gastroenterologist Dr. [**Last Name (STitle) **] for treatment of your colon polyp. Please make the following changes to your medication regimen: 1. Please change omeprazole 20 mg by mouth daily to omeprazole 40 mg by mouth twice daily to help prevent acid secretion in your stomach 2. Please start taking sulfacrate by mouth twice daily to help protect the lining in your stomach 3. Please stop taking your coumadin until further notification by your primary care physician Followup Instructions: You should be following up with your gastroenterologist Dr. [**Last Name (STitle) **] within 1 months time for a repeat colonoscopy and removal of your polyp to minimize your risk of further bleeding. His office will be contacting you or your son regarding scheduling this. If you do not hear from them within 1 week, the number at the clinic is [**Telephone/Fax (1) 2799**] Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 17863**] after hospital discharge. You have an appointment on [**2151-9-15**] at 2:00pm. Please call if you have questions or need to reschedule. [**Telephone/Fax (1) 11376**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "45.13", "45.16", "45.25", "38.93" ]

icd9pcs

[ [ [] ] ]

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3870, 8561

318, 362

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129,810

37194

Discharge summary

report

Admission Date: [**2172-11-25**] Discharge Date: [**2172-11-30**] Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11415**] Chief Complaint: Open left femur fracture Major Surgical or Invasive Procedure: [**2172-11-26**]: ORIF Left femur fracture History of Present Illness: Ms. [**Known lastname 83757**] is an 89 year old female who is a resident from the [**Location (un) 38076**] House. She had a noticable bruise on her left leg on [**2172-11-6**] she was taken to [**Hospital6 **] on [**2172-11-10**] and found to have a left open femur fracture. Due to her advanced age her fracture was treated non-operatively and was given 5 days of IV Ancef and on [**2172-11-13**] she was transferred back to her nursing home. On [**2172-11-25**] she was transferred to the [**Hospital1 18**] orthopaedic outpatient clinic. She was seen by Dr. [**Last Name (STitle) 5322**] and it was noted that she continues to have an open fracture. The plan was made to admit for surgical repair. Past Medical History: -HTN -CKD -GERD -Bladder CA -Dementia (etiology unclear) -left THR(20 years ago) -History of multiple vertebral compression fractures -Extremely hard of hearing Social History: Nursing Home Resident ([**Location (un) 38076**] House) Family History: n/a Physical Exam: Upon admission Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: LLE, + opea area, +pulses/sensation Pertinent Results: [**2172-11-28**] 02:54AM BLOOD WBC-13.7* RBC-2.29*# Hgb-6.8*# Hct-20.0* MCV-87 MCH-29.8 MCHC-34.2 RDW-18.5* Plt Ct-181 [**2172-11-27**] 09:20PM BLOOD Hct-19.4* [**2172-11-27**] 12:53PM BLOOD Hct-22.3* [**2172-11-27**] 08:10AM BLOOD Hct-24.9* [**2172-11-27**] 01:16AM BLOOD WBC-18.3* RBC-3.52* Hgb-10.5* Hct-30.3* MCV-86 MCH-29.8 MCHC-34.7 RDW-18.2* Plt Ct-289 [**2172-11-26**] 08:34PM BLOOD Hct-30.4* Plt Ct-257 [**2172-11-26**] 04:55PM BLOOD Hct-29.0* [**2172-11-26**] 03:03PM BLOOD WBC-16.8* RBC-3.18* Hgb-9.2* Hct-28.6* MCV-90 MCH-28.8 MCHC-32.0 RDW-18.5* Plt Ct-343 [**2172-11-25**] 07:50PM BLOOD WBC-11.7* RBC-4.03* Hgb-11.8* Hct-37.0 MCV-92 MCH-29.2 MCHC-31.8 RDW-18.3* Plt Ct-381 [**2172-11-28**] 10:22AM BLOOD PT-66.1* PTT-72.8* INR(PT)-7.6* [**2172-11-27**] 01:16AM BLOOD PT-17.8* PTT-34.1 INR(PT)-1.6* [**2172-11-26**] 08:34PM BLOOD PT-16.3* PTT-34.8 INR(PT)-1.4* [**2172-11-26**] 03:03PM BLOOD PT-20.6* PTT-41.2* INR(PT)-1.9* [**2172-11-25**] 09:30PM BLOOD PT-20.7* PTT-36.9* INR(PT)-1.9* [**2172-11-28**] 02:54AM BLOOD Glucose-67* UreaN-26* Creat-1.1 Na-138 K-3.6 Cl-107 HCO3-19* AnGap-16 [**2172-11-27**] 01:16AM BLOOD Glucose-77 UreaN-24* Creat-0.8 Na-137 K-4.2 Cl-110* HCO3-21* AnGap-10 [**2172-11-26**] 03:03PM BLOOD Glucose-116* UreaN-24* Creat-0.8 Na-138 K-5.0 Cl-110* HCO3-20* AnGap-13 [**2172-11-25**] 09:30PM BLOOD Glucose-101 UreaN-28* Creat-0.8 Na-137 K-5.5* Cl-109* HCO3-23 AnGap-11 [**2172-11-27**] 09:20PM BLOOD CK(CPK)-159* [**2172-11-27**] 12:53PM BLOOD CK(CPK)-94 [**2172-11-27**] 03:51AM BLOOD CK(CPK)-63 [**2172-11-27**] 01:16AM BLOOD ALT-4 AST-17 AlkPhos-224* TotBili-5.3* DirBili-3.7* IndBili-1.6 [**2172-11-28**] 02:54AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.9 [**2172-11-27**] 01:16AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.0 [**2172-11-26**] 03:03PM BLOOD Calcium-6.9* Phos-3.9# Mg-1.7 [**2172-11-25**] 09:30PM BLOOD Albumin-1.6* Calcium-7.9* Phos-2.2* Mg-2.0 Brief Hospital Course: Ms. [**Known lastname 83757**] presented to the [**Hospital1 18**] on [**2172-11-25**] via direct admit from orthopaedic clinic with an open left femur fracture. She was seen by medicine and cleared for surgery. On [**2172-11-26**] she was taken to the operating room and underwent an I&D with ORIF of her left femur fracture. She remained on vasopressors to support her blood pressure and remained intubated and was transferred to the T/SICU for further care. She was weaned off the vasopressors and extubated on [**2172-11-27**]. On [**2172-11-28**] she was transferred out of the T/SICU to the floor. After a family meeting she was made DNR/DNI and comfort care only. She is being discharged to rehab for resumption of hospice services. Medications on Admission: -Fentanyl Patch -Lasix -Fentanyl patch -Ranitidine -Ca+ -Vitamin D Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) 5-15mg dose PO Q2H (every 2 hours) as needed for pain. 4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for nausea. 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for aggitation. Discharge Disposition: Extended Care Facility: [**Location (un) 38076**] House - [**Location (un) 47**] Discharge Diagnosis: Open left femur fracture Discharge Condition: Fair, comfort measures only Discharge Instructions: Continue non-weight bearing on your left leg Comfort care Physical Therapy: Activity: Bedrest (non-weight bearing left leg) Treatment Frequency: Staples/sutures out 14 days after surgery Followup Instructions: As needed. [**Hospital 9696**] clinic phone number is [**Telephone/Fax (1) 1228**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2172-12-1**]

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icd9cm

[ [ [] ] ]

[ "79.35", "79.65", "88.72" ]

icd9pcs

[ [ [] ] ]

4875, 4958

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294, 339

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1558, 3444

5293, 5537

1350, 1355

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1370, 1539

5156, 5206

230, 256

367, 1076

5227, 5270

1098, 1261

1277, 1334

77,686

153,777

41758

Discharge summary

report

Admission Date: [**2163-9-30**] Discharge Date: [**2163-10-17**] Date of Birth: [**2097-10-11**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: collapse with right sided hemiparesis. Major Surgical or Invasive Procedure: ([**2163-9-30**]) MERCI retrieval and thrombolysis of clot in left M1 and M2 vessels. History of Present Illness: The patient is a 65 year old right handed man with a past medical history significant for a.fib (not on Coumadin - has been undergoing cardioversion and ablations, and has been off for at least a month, HTN, HLD, DM - on insulin and oral medications, who presents with a sudden onset of right sided weakness, determined to have a LMCA syndrome at an OSH, given tPA and sent to [**Hospital1 18**] for further evaluation. . Per his family and OSH (he was unable to provide details due to aphasia) he was in his usual state of health this morning and was out shopping for groceries with his wife. At around 12:30 (his wife had just left him) he apparently fell to the ground and collapsed and this was witnessed by a bystander. He did not strike his head and apparently was awake but could not speak. He was noted at the time to be weak on the right side and taken to [**Hospital3 26615**]. He was in the window and was given tPA after consultation with tele-service. He got a total of 77mg of tpa at ~1:45pm and transferred here. The stoke scale there was reported to be in the 20s but the exact number is not available. . Here on examination he continued to have severe deficits, given a stroke scale of 23. He had a CTA which showed a persistent L MCA clot and he was taken to the angio suite for intervention. . NIH Stroke Scale score was 19: 1a. Level of Consciousness: 0 1b. LOC Question: 2 1c. LOC Commands: 1 2. Best gaze: 0 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 4 6a. Motor leg, left: 0 6b. Motor leg, right: 3 7. Limb Ataxia: 0 8. Sensory: 2 9. Language: 3 10. Dysarthria: 1 11. Extinction and Neglect: 0 . Time Code Stroke called: 15:06 Time Neurology at bedside for evaluation: 15:07 Time (and date) the patient was last known well: 12:25 (24h clock) NIH Stroke Scale Score: -19- t-[**MD Number(3) 6360**]: --- Yes Time t-PA was given ------:------ (24h clock) -X- No Reason t-PA was not given or considered: Already given at OSH, completed at [**Hospital1 18**] . I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. . On neuro ROS and general ROS was not available at the time. Per family patient had not had any significant infectious illnesses recently. He did exert himself somewhat last week doing yard work. Past Medical History: - afib: only on ASA not on Coumadin (been off for at least a month) - HTN - DM on insulin - HLD - CAD had a stent at least 1 year ago - s/p cholecystectomy 1 year prior Social History: Lives with his wife. [**Name (NI) **] has an adult son. [**Name (NI) **] quit smoking about 20 years ago, unclear how long a smoking history. Occ EtOH, no drugs. Contact info:(wife) h: [**Telephone/Fax (1) 90709**] and son c" [**Telephone/Fax (1) 90710**] Family History: Father had stroke in his 70s, also with PD. Physical Exam: ADMISSION PHYSICAL EXAM: . Vitals: T: 98.2 P:72 R: 16 BP:142/82 SaO2: 100 . General: Awake and alert, attending to name, but not following commands HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear anteriorly Cardiac: RRR, s1s2, no murmurs heard Abdomen: soft, NT/ND Extremities: normal no c/c/e . Neurologic: -Mental Status: Alert, aphasic, turns to name, didn't make any clear speech. Followed eye opening and closing commands, and one hand squeeze commands, otherwise no others. . -Cranial Nerves: I: Olfaction not tested. II: pupils equal and reactive 3->2. R field cut III, IV, VI:Left visual pref, with encouragement can cross eyes across midline to right VII: right facial droop, lower half of face IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. . -Motor: Normal bulk, tone throughout. Right arm - minimal effort against gravity, slight withdrawal to pain (flexor), no movement in hand, leg slight withdrawal to pain no effort against gravity. Left arm/leg moving spontaneously appear full . -Sensory: Decreased on right side to painful stim, o/w appears grossly intact . -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 trace 0 R 2 2 2 trace 0 Plantar response was up on right, down on left . -Coordination and gait: not tested . DISCHARGE PHYSICAL EXAM: ??????????????????????????????????????? Pertinent Results: ADMISSION LABS: . [**2163-9-30**] 04:10PM WBC-10.6 RBC-3.76* HGB-12.7* HCT-35.5* MCV-94 MCH-33.8* MCHC-35.8* RDW-12.7 [**2163-9-30**] 04:10PM BLOOD Plt Ct-202 [**2163-9-30**] 04:10PM BLOOD PT-12.8 PTT-22.3 INR(PT)-1.1 [**2163-9-30**] 05:47PM GLUCOSE-232* LACTATE-1.8 NA+-134 K+-4.5 CL--104 [**2163-9-30**] 05:47PM TYPE-ART PO2-424* PCO2-36 PH-7.43 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED . Discharge Labs: [**2163-10-17**]: CBC: 10.7/11.4/32/580 PT 22 PTT 27.2 INR 2.0 Chem 10: 139/4.4/103/27/15/0.8/162 Ca 8.2 Phos 3.8 Mg 2.0 . IMAGING: . ECG [**2163-9-30**]: Normal sinus rhythm. Peaked P wave in lead V1. Tall R wave in lead V1 suggests right ventricular pressure overload. No previous tracing available for comparison. . CTA NECK AND HEAD W&W/OC & RECONS [**2163-9-30**]: Large left MCA territory infarction with ischemia involving the entire left MCA territory. Abrupt occlusion at the distal left M1 segment. The appearance on the perfusion map with increased MTT and reduced blood volume suggest irreversible injury. No hemorrhage. . TRANS CATH INFUSION [**2163-9-30**]: [**Known firstname **] [**Known lastname 90711**] underwent cerebral angiography and mechanical and chemical thrombolysis of the left middle cerebral artery and its branches which were successful. . PORTABLE CXR [**2163-9-30**]: The tip of the endotracheal tube projects 5 cm above the carina. Mild-to-moderate pulmonary edema with borderline size of the cardiac silhouette. No pleural effusion. No focal consolidation, no pneumothorax. . EEG [**2163-10-3**]: This telemetry captured no pushbutton activations. Continuous EEG recording showed a mildly slow background at best but with close to normal frequencies posteriorly on the right. Left hemisphere backgrounds were markedly suppressed. Later in the recording there was some bifrontal slowing. There were no epileptiform features or electrographic seizures. The very suppressed background on the left suggests either widespread cortical dysfunction (e.g. with a stroke) or material interposed between the brain and recording electrodes (e.g. subdural fluid). There was no evidence for ongoing seizures. . ECHO [**2163-10-4**]: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Agitated saline contrast study at rest revealed no evidence of intracardiac shunt (though technically suboptimal). No intracardiac mass/thrombus identified. . CT HEAD W/O CONTRAST [**2163-10-4**]: There has been no appreciable change. Again seen is a large recent infarct within the left MCA territory, with confluent hemorrhagic conversion in the left lentiform nucleus and corona radiata, as well as gyriform cortical hemorrhages. There is unchanged blood in the frontal and occipital horns of the left lateral ventricle, and in the occipital [**Doctor Last Name 534**] of the right lateral ventricle. There is unchanged rightward shift of the normally midline structures, and effacement of the left lateral and third ventricles, but no dilatation of the right lateral ventricle. The basal cisterns are not compressed. Brief Hospital Course: *)NEURO: Mr. [**Known lastname 90711**] was transferred to the [**Hospital1 **] from OSH s/p stroke that was treated with TPA. His symptoms included aphasia and right sided hemiparesis. CTA at outside hospital showed the presence of M1 occlusion. Repeat CT at [**Hospital3 **] revealed: . "Large left MCA territory infarction with ischemia involving the entire left MCA territory and abrupt occlusion at the distal left M1 segment. The appearance on the perfusion map with increased MTT and reduced blood volume suggest irreversible injury. No hemorrhage." . At [**Hospital1 **], he underwent clot retrieval by MERCI followed by 2 mg of IA TPA to each M2 branch. All M1 and M2 vessels were opened successfully. He was started on ASA 325 mg daily. He was also maintained on heparin 5000 units TID for anticoagulation and bridged to Coumadin 5 mg daily. . His last CT scan on [**2163-10-4**] showed the presence of a large volume MCA stroke with hemorrhagic conversion as well as intraventricular hemorrhage. The CT on [**2163-10-4**] did not show any signs of local vasogenic edema concerning enough to start on osmotic therapy. . His persistent neurological symptoms include significant right hemiparesis, difficulty following commands, right sided hyper-reflexia, and weak withdrawal to noxious stimuli on the right side. . *)PULMONARY: Upon presentation, Mr. [**Known lastname 90711**] was emergently intubated for airway protection. He subsequently required a tracheostomy because of an inability tolerate secretions and impaired swallow/gag function. During his ICU stay, he developed intermittent fevers and leukocytosis. CXR revealed right pleural effusions and lower lobe opacity consistent with aspiration pneumonia. As patient was transferred from ICU to general floor, he was placed on a VAP antibiotic bundle (vancomycin, tobramycin, cefepime) which helped reduce his fevers and leukocytosis and resulted in clearing of the CXR over the course of 3 days. At that time, an attempt at placing a PMV failed because of significant secretions. The recommendation was to forgo the placement of PMV until patient was further stabilized. . *)CARDIO: Upon admission, blood pressure medications were withheld to allow for autoregulation. A cardiac enzyme assay returned negative. During the first two to three days of ICU stay, he developed a rapid ventricular rate required a bolus of amiodarone over the course of 24 hours. He was subsequently stabilized with regiment of metoprolol and diltiazem which have been carefully titrated to 37.5 mg TID and 90 mg QID respectively. His rhythm remains irregularly irregular. . *)Infectious Disease: Mr. [**Known lastname 90711**] was started on treatment for presumed ventilator associated pneumonia. He continued to have low fevers during the first days of treatment, however all cultures, including blood, urine, and sputum/BAL were negative. Cdiff was also tested and was negative. He was initially on vancomycin, tobramycin, and cefepime per VAP protocol but was then taken off the tobra given the negative cultures. However, due to the continued fevers, we decided to treat for a total 10 day course with vancomycin and cefepime which will be completed on [**2163-10-20**]. . *)ENDO: Diabetes medications were held and patient was placed on insulin sliding scale for better control of blood sugars per stroke protocol. His HgbA1c taken at admission returned a value of 8.3%. His blood sugar control has been complicated during this hospital admission with blood glucose values ranging from 150-300. He was restarted on his metformin, and was also continued on insulin. . All his lipid modifying agents were held out of concern for worsening hemorrhagic process. Additionally, his LDL with a value of 41 is at goal. . *) ABDOMEN: Patient suffered a pneumoperitoneum, thought to be secondary to placement of PEG tube. It was noticed on daily CXRs obtained in the ICU. The patient did not suffer from belly tenderness of peritoneal signs following the noticed pneumoperitoneum, and it has since resolved on repeat x-rays. . *) TRANSITIONAL CARE ISSUES: Mr. [**Known lastname 90711**] suffered a severe stroke to his left brain and his course has been complicated. He has been stabilized and begun to show improvement. However, he remains paralyzed on the right side and has difficulty following commands. His requires comprehensive care outside of the hospital. Of note, he developed aspiration pneumonia while in the hospital, requiring his placement on an antibiotic regiment. This regimen must be completed outside of the hospital, and a close watch on his infectious disease status must be maintained. Mr. [**Known lastname 90711**] will also benefit from appropriate physical therapy to help him regain function where possible. On day of discharge, his INR was 2.0 on the aspirin bridge to Coumadin. We have continued him on both aspirin and Coumadin and his INR will need to be rechecked, the aspirin can be discontinued once his INR is stable between [**2-24**]. Medications on Admission: - Glipizide 10mg qd - Metformin 1000mg [**Hospital1 **] - Altace 5 qd - Lipitor 10mg qd - Atenolol 25mg qd - Lantus 35U qd - Insulin (Humalog) sliding scale - ASA 325qd - Fish oil 1000mg qd - MVI Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: continue until INR therapeutic, goal btw [**2-24**]. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours). 9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q 8H (Every 8 Hours). 10. metoprolol tartrate 5 mg/5 mL Solution Sig: Five (5) mg Intravenous Q6H (every 6 hours) as needed for P > 140 or SBP > 160. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: primary: left middle cerebral artery ischemic stroke with hemorrhagic conversion. secondary: hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Hi Mr. [**Known lastname 90711**], . It was a pleasure to take care of you during your hospital stay. You were admitted because of a stroke affecting your left brain. During your hospital stay you underwent a procedure to remove blockages to arteries in your brain. You have symptoms of right sided weakness and difficulty in speech. Some of these symptoms may improve with time and appropriate rehabilitation. . We have started you on some new medications. These medications include: -Coumadin 5 mg daily. This medication will help thin your blood and prevent the recurrence of stroke. -Antibiotic regiment to treat PNA????????? . If at any time you experience any of the following danger signs below, please contact your primary care physician or seek immediate attention at the nearest hospital. Followup Instructions: Follow-up in [**Hospital 4038**] Clinic at [**Hospital1 18**], [**Hospital Ward Name 23**] Building, [**Location (un) **] : Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2163-12-20**] 4:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "96.72", "31.1", "33.29", "43.11", "88.41", "99.10", "39.74", "00.41" ]

icd9pcs

[ [ [] ] ]

14763, 14833

8531, 12608

345, 433

15044, 15044

4860, 4860

16004, 16379

3285, 3331

13798, 14740

14854, 15023

13578, 13775

15180, 15981

5291, 8508

3964, 4775

3371, 3773

267, 307

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461, 2798

4876, 5275

15059, 15156

2820, 2991

3007, 3269

4800, 4841

5,678

168,080

10906+56173

Discharge summary

report+addendum

Admission Date: [**2106-7-30**] Discharge Date: [**2106-8-11**] Service: CT [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is an 83-year-old gentleman who was admitted on [**2106-7-30**], presenting with acute respiratory distress and angina pain. He had a three year history of dyspnea on exertion, worse over the several weeks prior to admission with the addition of new onset anginal pain with exertion. His cardiac risk factors included smoking and a family history of coronary artery disease. At the time of his initial workup, the patient was noted to have electrocardiogram changes suggestive of ischemia as well as enzyme levels ruling him in for a myocardial infarction. The patient was subsequently admitted. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d. PHYSICAL EXAMINATION: On admission, the patient was afebrile with a blood pressure of 114/60, a pulse of 70, a respiratory rate of 12 and an oxygen saturation of 90% on room air. His jugular venous pressure was at 8 cm. He had bilateral crackles, right greater than left. His heart had a regular rate and rhythm. He had a IV/VI systolic ejection murmur at the left upper sternal border that radiated to his carotids. His abdomen was soft, nontender and nondistended with normal active bowel sounds. His extremities were warm and well perfused. HOSPITAL COURSE: As the patient ruled in for an acute myocardial infarction by enzyme and electrocardiogram criteria, he was admitted and started on an integrelin drip and heparin drip as well as p.o. aspirin and Plavix. The integrelin and heparin drips both needed to be discontinued secondary to developing hematuria. The patient underwent a cardiac catheterization, which revealed 50% occlusion of the left anterior descending artery, 60% occlusion of the left circumflex coronary artery, 90% occlusion of the posterior right coronary artery and 70% occlusion of the mid right coronary artery as well as a critical aortic stenosis with an approximately 80 mmHg gradient. Cardiothoracic surgery was subsequently consulted and the decision was made that the patient should undergo aortic valve replacement as well as coronary artery bypass grafting. The patient's preoperative hospital course was uneventful. He was hemodynamically stable and afebrile. On [**2106-8-3**], the patient underwent uncomplicated coronary artery bypass grafting times one with a saphenous vein graft to the major obtuse marginal artery as well as an aortic valve replacement with a #21 [**Location (un) **] bioprosthesis. The patient tolerated the procedure well and was transported to the cardiac surgery recovery unit intubated and in stable condition. In the unit, the patient was unable to be extubated initially secondary to respiratory acidosis. He was on Neo-Synephrine and nitroglycerin drips for blood pressure control as well as a dobutamine drip. In the early morning of postoperative day #1, the patient had been weaned to CPAP and was subsequently extubated without incident. He was started on Lopressor, the Neo-Synephrine and dobutamine drips were weaned and his nitroglycerin drip was discontinued. On postoperative day #2, the patient was arousable, moving all extremities to command. His chest tubes and Foley catheter were discontinued and his diet was advanced. He was noted to have a wide complex tachycardia and was started on amiodarone. By the end of postoperative day #2, the patient was transferred to the floor in stable condition. On the floor, the patient remained afebrile and hemodynamically stable. The only major issue that the patient had was his delirium, which necessitated the placement of a one-to-one sitter. All sedating medications were held and the patient was frequently oriented with no effect. A psychiatry consultation was obtained, who recommended that the patient be started on low dose Haldol 0.5 mg b.i.d. in an effort to clear up his delirium. This was started on postoperative day #7, at which time his one-to-one sitter was discontinued. He had no events overnight. On the morning of postoperative day #8, the patient's mental status seemed to be intact. The patient was subsequently discharged in stable condition to a rehabilitation facility on postoperative day #8. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. times one week. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times one week. 3. Aspirin 81 mg p.o. q.d. 4. Ibuprofen 400 mg p.o. t.i.d. 5. Protonix 40 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. 7. Percocet one to two tablets p.o. every three to four hours p.r.n. 8. Albuterol nebulizers every four hours p.r.n. 9. Lopressor 25 mg p.o. b.i.d. 10. Captopril 25 mg p.o. t.i.d. 11. Haldol 0.5 mg p.o. b.i.d. 12. Amiodarone 400 mg p.o. t.i.d. times two days, then 400 mg p.o. b.i.d. times seven days, then 400 mg p.o. q.d. DISCHARGE EXAMINATION: The patient was afebrile with stable vital signs. He was in no acute distress. He was alert and oriented times three. He had decreased breath sounds on the left with bilateral wheezing. His heart had a regular rhythm. His belly was soft, nontender and nondistended. His extremities were warm and well perfused. His incisions were clean, dry and intact. DISCHARGE DIAGNOSES: Coronary artery disease. Congestive heart failure. Critical aortic stenosis. Status post coronary artery bypass grafting times one and aortic valve replacement. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3801**] MEDQUIST36 D: [**2106-8-11**] 12:22 T: [**2106-8-11**] 13:27 JOB#: [**Job Number 35465**] cc:[**Wardname 35466**] Name: [**Known lastname 6244**], [**Known firstname **] Unit No: [**Numeric Identifier 6245**] Admission Date: [**2106-7-30**] Discharge Date: [**2106-8-13**] Date of Birth: [**2023-2-27**] Sex: M Service: ADDENDUM: The patient was unable to be placed in rehab on [**2106-8-11**]. Nevertheless, his hospital course remained uneventful, with no changes in his mental status. He did not require the placement of a one to one sitter. It is anticipated that he will have a bed today [**2106-8-13**] and will be discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**] Dictated By:[**Last Name (NamePattern1) 2751**] MEDQUIST36 D: [**2106-8-13**] 08:27 T: [**2106-8-19**] 10:32 JOB#: [**Job Number 6246**]

[ "428.0", "427.31", "780.09", "410.71", "496", "486", "414.01", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.53", "39.61", "99.20", "88.57", "37.22", "36.11", "35.21" ]

icd9pcs

[ [ [] ] ]

5311, 6634

4301, 5290

776, 802

1371, 4278

825, 1353

145, 750

70,698

190,460

55127

Discharge summary

report

Admission Date: [**2183-10-16**] Discharge Date: [**2183-10-28**] Date of Birth: [**2122-11-7**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 46126**] Chief Complaint: Trauma: pedestrian struck Major Surgical or Invasive Procedure: [**2183-10-26**] ORIF Left distal radius fracture History of Present Illness: 60yo woman medflighted from [**Hospital3 **] s/p ped struck. Per report, pt was crossing the street when she was struck by a car moving at high speed. Pt hit the windshield with her face hard enough to spider the glass. No LOC at scene, pt A&Ox2 with full recall of the event at OSH. Pt intubated for airway protection during transfer. Per outside records, pt sustained multiple facial fx, L radial ulnar fx, R SDH, and SAH. Past Medical History: PM: OSA, hyperthyroidism PS: none Social History: supportive partner Family History: noncontributory Physical Exam: PHYSICAL EXAMINATION; upon admission: [**2183-10-16**] HR: 80 BP: 137/60 Resp: 15 O(2)Sat: 100% on the vent Normal Constitutional: Boarded and collared, intubated and pharmacologically sedated. HEENT: Both eyes are nearly swollen shut, the last one being less so in the pupil the left is 1 mm and nonreactive. She has diffuse facial and forehead ecchymoses. She has blood in the mouth. She has blood in the nares. She also has a nasal bridge laceration. There is a lot of swelling and some deformity over both maxillae. Collared Chest: Breath sounds symmetrical Cardiovascular: Heart sounds are normal Abdominal: Soft GU/Flank: Foley catheter is in place and draining clear yellow urine. Extr/Back: Spine is without step-offs. Upper extremities show a deformity in the left wrist area with intact distal pulses. This is a closed injury. She has a tense right thigh ecchymosis which was not present according to the med flight crew earlier. She has a left knee abrasion which is minimal. Distal pulses in both feet are normal. Pertinent Results: [**2183-10-16**] CT Head Stable appearance of right frontal contusions. Bifrontal and probable left occipital subarachnoid blood. Right and possible left subdural hematomas. Multiple calvarial, facial, anterior and middle skull base fractures as above including mildly displaced right frontal bone fracture, all better assessed on prior facial CT. [**2183-10-16**] CT C-spine 1. No fracture or malalignment of the cervical spine. 2. Focal retro-dens density concerning for epidural hematoma - MR may be considered for further characterization. 3. Enlarged thyroid gland with multiple partially calcified nodules. Nonurgent ultrasound should be considered if not already performed. [**2183-10-17**] MR [**Name13 (STitle) 2853**] 1. Abnormal signal at C5-C6 disc space with an associated disc bulge, while this could all be related to degenerative changes, an acute disc bulge cannot be excluded. Otherwise, mild multilevel degenerative changes of the cervical spine. 2. Mild increased signal in the posterior paraspinal soft tissues, which may represent edema, or muscle strain/ligamentous injury. 3. Increased signal along the prevertebral space, which may represent edema in this patient that appears to be intubated and has a nasogastric tube. 4. Enlarged and heterogeneous thyroid gland. Corrrelation with ultrasound is advised if clinically indicated. [**2183-10-17**] R Forearm X-Ray There is no elbow joint effusion. There are no signs for acute fractures or dislocations. Peripheral catheters are seen within the right wrist and right antecubital region. Mineralization is normal. Bony structures are intact. There are mild degenerative changes of the first CMC joint. [**2183-10-17**] pelvis, RLE films There are degenerative changes of both hips, which are mild to moderate. There is some mild joint space narrowing and spurring of both hip joints. No acute fractures or dislocations are seen. There are moderate degenerative changes of the lower lumbar spine with disc space narrowing particularly at L4-L5. Focused imaging of the right femur show no acute fractures. There are some mild degenerative changes of the right knee joint with joint space narrowing medially and laterally. There is some surrounding soft tissue swelling. A Foley catheter is seen. [**2183-10-17**] R ankle 1. No acute fracture. 2. Soft tissue swelling. 3. Corticated densities adjacent to the medial malleolus suggestive of prior avulsion injuries likely of the deltoid ligament. [**2183-10-17**] Left hand, wrist There has been improved alignment of the distal radius fracture with less impaction. There is again seen a transverse facture which has intra-articular extension in joint space. Fine bony detail is limited by the overlying splint material. There is also a small ulnar styloid fracture which is unchanged. Mild degenerative changes of the first CMC joint is seen. There are no bony erosions. [**2183-10-17**] CT Maxillofacial There is a displaced right paramedian fracture of the frontal bone. Known orbitofrontal parenchymal hemorrhages, subarachnoid, intraventricular, and subdural hematomas are evaluated on concurrent NECT. There are comminuted fractures involving the lateral, medial, and anterior walls of the maxillary sinus. The fractures extend into the ethmoids bilaterally. The sinuses, particularly the naris, are filled with blood as are the sphenoid sinuses. The right lateral pterygoid plate is fractured (402B:82). No mandibular fracture is seen. The bilateral nasal bones are fractured. Extraconal hemorrhage extends into the right orbit and orbital fat herniates into the right maxillary sinus (402B:54). The globes appear intact, but there is some suggestion of telecanthus. The greater [**Doctor First Name 362**] of the right sphenoid is fractured. Bilateral diastasis of the frontozygomatic sutures is seen. No definite fracture of the left orbital floor is seen. ET and NG tubes are seen coursing through the oropharynx. Extensive facial soft tissue edema and right lateral frontal subgaleal scalp hematoma are again noted. IMPRESSION: 1. Unilateral right LeFort 1, 2, and 3 fractures as described above. 2. Minimal herniation of right intraorbital fat into the maxillary sinus. 3. Displaced right paracentral frontal bone fracture. 4. Inferior displacement of the right medial inferior rectus muscle, but no definite entrapment. 5. Diastatic frontozygomatic sutures. [**2183-10-17**] Repeat CT Head 1. Stable right orbito-frontal hemorrhagic contusions. 2. Stable right parietal vertex subdural hematoma. No mass effect. 3. Small foci of subarachnoid and intraventricular hemorrhage, unchanged. 4. Extensive facial fractures described on concurrent sinus CT. [**2183-10-21**]: video swallowing: IMPRESSION: No frank aspiration. Penetration with thin and nectar barium consistencies. For further details, please refer to full report by speech and swallow division [**2183-10-22**]: left wrist x-ray: IMPRESSION: 1. Interval placement of fiberglass cast. 2. Slight improvement of intra-articular distal radius fracture with minimal volar displacement. Unchanged ulnar styloid fracture. [**2183-10-22**]: portable abdomen: No evidence of radiopaque metal [**2183-10-23**]: MR abdomen: IMPRESSION: Limited study demonstrating bifrontal hemorrhagic contusion with small subarachnoid hemorrhage, right greater than left. Recommend repeating the study after adequate premedication and sedation. [**2183-10-23**]: MR of orbit: IMPRESSION: Limited study demonstrating bifrontal hemorrhagic contusion with small subarachnoid hemorrhage, right greater than left. Recommend repeating the study after adequate premedication and sedation [**2183-10-23**]: MR of the head: IMPRESSION: 1. Slow diffusion along the optic nerves, left more than right, suspicious for injury to the optic nerve either related to ischemia or edema particularly on the left. 2. Intraparenchymal hematoma in the right frontal lobe as described. Small areas of slow diffusion in the right cerebellar peduncle and left occipital lobe, probably ischemia vs shear injury. 3. Subdural and subarachnoid blood products. 4. Extensive sinus disease with blood products in the maxillary sinuses. 5. Multiple facial fractures. Please refer to CT scan of [**2183-10-17**] for additional details. 6. Other findings as described. Brief Hospital Course: The patient arrived intubated but was moving all extremities in the emergency room and making purposeful movements directed towards the endothracheal tube. Imaging studies done at the OSH showed multiple facial fractures, a SDH, SAH and a left radial fracture. Because of the head injury, the patient was started on keppra. Upon admission to the [**Hospital1 18**], the patient was admitted to the intensive care unit for vital sign and neurological monitoring. She developed an episode of hypotension and required dopamine infusion for cardiovascular support which was weaned off. The patient's hemodynamic status remained stable. A PICC line was placed on HD #2 because of poor iv access. While in the intensive care unit, the patient was maintained on ventilatory support. The neurosurgery service was consulted and recommended a repeat head cat scan which remained unchanged. There was a question of edema and ligamentous injury of C5-C6, as well as within the paraspinal and prevertebral soft tissue. A [**Location (un) 2848**] J collar was recommended with neurosurgical out-patient follow-up. Because of the multiple facial fractures, the plastic surgery service recommended surgical intervention after the swelling subsided. They also recommended follow-up with the opthamology service who closely followed the patient because of a concern for left optic neuropathy. To further evalute this, the patient underwent further testing on the day of discharge. The patient was placed on sinus precautions and started on broad spectrum antibiotics. She was transitioned to amoxicillin prior to discharge. The facial fractures prevented placement of a [**Last Name (un) **]-gastric tube and an oral gastric tube was placed to provide nutrition. The patient's hematocrit decreased on HD #3, likely reatled to fluid shifts, and the patient was given 2 units packed red blood cells. The hematocrit remained stable throughtout the remainer of the hospital course. The patient was successfully weaned and extubated on HD #4 and was making purposeful movements of all extremities. The patient was transferred to the surgical floor. During the hospital course, the patient had bouts of delirium which limited participation in daily care. With the addition of zyprexa, the patient became more oriented to her surroundings and by the time of discharge was alert, oriented, and conversant. On HD # 9, because of prior failed attempts in tolerting oral supplements, a speech and swallow study was done and the patient was cleared for thin liquids and soft ground solids. On HD #10, the patient was taken to the operating room for an ORIF of the left distal radius fracture, left carpal tunnel release, and a tenotomy of the brachioradialis tendon. The operative course was stable with a 20cc blood loss. The patient was extubated after the procedure and monitored in the recovery room. A sling was applied to the left arm for support and the patient was started on oral analgesia for post-operative pain. As part of discharge planning, the patient was evaluated by physical therapy and recommendations made for discharge to an extended care facility. Social worker was available to provide support to the patient and family. The right PICC line was removed prior to discharge. The patient was discharged to a rehabilitation facility on HD #13 with stable vital signs. Her electorlytes normalized and the hematocrit stabilized at 27. Follow-up appointments were scheduled with Neurosurgey, Orthopedics, Plastic surgery, and opthamology. Medications on Admission: methimazole 5', ASA 81', ranitidine OTC Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. Amoxicillin-Clavulanic Acid 875 mg PO Q12H last dose [**2183-11-2**] 3. Artificial Tear Ointment 1 Appl BOTH EYES 6X/DAY 4. Artificial Tears 1-2 DROP BOTH EYES TID 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES [**Hospital1 **] 8. Heparin 5000 UNIT SC TID 9. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR QID:PRN after each bowel movement 10. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain hold for systolic blood pressure <110, hr <60 11. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 12. Methimazole 5 mg PO DAILY 13. Senna 1 TAB PO BID constipation 14. Quetiapine Fumarate 50 mg PO HS 15. OLANZapine (Disintegrating Tablet) 7.5 mg PO QID hold for increased sedation and notify team 16. Aspirin EC 81 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Trauma: bifrontal SAH right subdural hemorrhage suprasellar cistern hemorrhage Right maxillary/frontal/zyg/ethmoid fracture depressed fracture right anterior wall maxillary sinus depressed fracture right orbital floor bilateral nasal bone fractures nondisplaced left zygomatic arch fracture Left distal radial fracture/ulnar styloid fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after you were struck by a car. Initially you were brought to an outside hospital where you had a breathing tube enroute to maintain your airway. You had radiographic images taken and you were found to have a small bleed in your head, facial fractures, a right frontal bone fracture, and a left radial fracture. You also were found to have a ligamentous injury to your neck and had a special collar applied which you will need to wear until your follow-up visit. You were seen by several consulting services who provided your care. You were monitored in the intensive care unit and when your vital signs stabilized, you were transferred to the surgical floor. You have progressed nicely and are now being discharged to a rehabilitation facility where you can further regain your strength and mobility. Followup Instructions: Your contact information and insurance records are incomplete- please call our registration department at ([**Telephone/Fax (1) 22161**] before your first appointment. Department: ORTHOPEDICS When: TUESDAY [**2183-11-4**] at 10:00 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: FRIDAY [**2183-11-21**] at 8:30 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: FRIDAY [**2183-11-21**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Name6 (MD) **] [**Name8 (MD) **], MD Specialty: Opthalmology Location: [**Hospital1 **] Address: [**Location (un) **], [**Hospital Ward Name **] 5, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 253**] We are working on a follow up appointment for you to be seen by Dr. [**Last Name (STitle) **] in neuro-opthalmology. You will be called at rehab with the appt. If you have not heard within 2 business days or have questions, please call the number listed above. Completed by:[**2183-10-30**]

[ "242.90", "300.00", "E849.5", "372.72", "377.39", "430", "802.1", "354.0", "E814.7", "847.0", "801.01", "800.01", "327.23", "432.1", "372.73", "458.9", "802.6", "530.81", "802.4", "780.09", "813.44" ]

icd9cm

[ [ [] ] ]

[ "83.13", "96.71", "79.02", "96.6", "04.43", "38.97", "79.32" ]

icd9pcs

[ [ [] ] ]

13001, 13071

8433, 11988

300, 353

13459, 13459

2001, 8409

14498, 16028

918, 935

12078, 12978

13092, 13438

12014, 12055

13635, 14475

950, 975

235, 262

381, 808

989, 1982

13474, 13611

830, 866

882, 902

46,959

109,201

41336+58437

Discharge summary

report+addendum

Admission Date: [**2124-3-4**] Discharge Date: [**2124-3-10**] Date of Birth: [**2056-9-17**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13565**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 67 year old man man with history of seizure disorder (since [**2088**]) who presented to [**Hospital6 10353**] with a complex partial seizure with secondary generalization. Prior to this episode he had been seizure free for 4 years on Keppra, Dilantin, and Neurontin. He was in his usual state of health until until Friday [**2123-3-4**] around 4:30 PM when his wife found him sitting in his chair smacking his lips and staring into the distance, a similar presentation to his typical seizures (last seen well at 2:30 PM). His wife called the [**Name (NI) 14356**] and his seizure had generalized with shaking when they arrived. He was given Ativan 2 mg in the field with apparent resolution of the seizure. He was transported to [**Hospital6 10353**] where he reportedly had another seizure en route (per wife). On arrival to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **], he was unresponsive with positive gag, right lateral nystagmus, and slow respirations. He was thought to be in status epilepticus, and was given another dose of Ativan 2 mg followed by rapid sequence intubation for airway protection. He was given a total of 14 mg IV Ativan and 400 mEq IV phosphenytoin at [**Hospital1 392**]. He was febrile to 101.4 on arrival and a CBC revealed leukocytosis to 18.5. An LP was done, showing 1 WBC, glucose 98, and protein 63, and a urnialysis was negative. A chest x-ray was done for ET tube placement, which showed no acute cardiopulmonary process. He was transferred to the [**Hospital1 18**] overnight on [**2124-3-4**] at 1AM due to intubation. His wife does not know of any medication changes and states he is compliant with his medications. His primary neurologist is a Dr [**Last Name (STitle) 90003**] at JP VA. He arrived with a bag of medications and it was noted that his Keppra bottle was expired by a few years. Past Medical History: - Seizures: CPS with secondary generalization (since [**2088**]) - Hyperlipidemia Social History: He lives with wife and 23 year old son in [**Name (NI) 392**], MA. He is retired from a company that works with Medicaid. He denies tobacco, alcohol, and illicit drug use. Family History: No family history of seizures. Father died at 41 from "black lung" (coal miner). Mother died at 62 from stroke. Physical Exam: On arrival (intubated): Vitals: T:99.2 P: 90 R: 16 BP:115/68 SaO2:100% on Vent General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, Neck: In C-collar Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, Abdomen: soft, NT/ND. Extremities: no edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Intubated off sedation (propofol) but had received Ativan/dilantin before arrival. Obtunded. -Cranial Nerves: PEERL, Conjugate gaze. + gag with ETT. -Motor: Moving all 4 ext. -Sensory:+ grimace to pain in all 4 ext with withdraw. Plantar response was flexor bilaterally. Pertinent Results: From [**Hospital3 **]: Blood: CBC: 18.4 > 16.3 / 49.0 < 245 N:74 L:16 M:6 E:1 CSF: Tube 1: clear, colorless, 59 RBC, 1 WBC Tube 4: clear, colorless, 0 RBC, 0 WBC, 98 glucose, 63 protein On arrival: [**2124-3-4**] 12:57AM LACTATE-1.7 [**2124-3-4**] 12:57AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-100 PO2-473* PCO2-45 PH-7.39 TOTAL CO2-28 BASE XS-2 AADO2-209 REQ O2-43 -ASSIST/CON INTUBATED-INTUBATED [**2124-3-4**] 01:30AM PT-12.8 PTT-20.4* INR(PT)-1.1 [**2124-3-4**] 01:30AM WBC-11.8* RBC-4.78 HGB-14.5 HCT-41.3 MCV-87 MCH-30.4 MCHC-35.1* RDW-13.3; NEUTS-87.7* LYMPHS-6.1* MONOS-5.7 EOS-0.1 BASOS-0.5 [**2124-3-4**] 01:30AM PHENYTOIN-9.9* [**2124-3-4**] 01:30AM GLUCOSE-135* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15 [**2124-3-4**] 08:14PM PHENYTOIN-17.1 [**2124-3-4**] 09:12AM %HbA1c-5.8 eAG-120 [**2124-3-4**] 08:14PM GLUCOSE-101* UREA N-15 CREAT-1.1 SODIUM-134 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-27 ANION GAP-15 [**2124-3-4**] 08:14PM ALBUMIN-4.0 CALCIUM-8.3* PHOSPHATE-2.8 MAGNESIUM-2.0 Micro: [**2124-3-7**] BLOOD CULTURE: PENDING [**2124-3-7**] URINE CULTURE: PENDING [**2124-3-4**] BLOOD CULTURE: PENDING [**2124-3-4**] BLOOD CULTURE: PENDING [**2124-3-4**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY (STREPTOCOCCUS PNEUMONIAE} [**2124-3-4**] URINE CULTURE FINAL: No growth [**2124-3-4**] MRSA SCREEN MRSA SCREEN-FINAL: Negative [**2124-3-4**] URINE CULTURE-FINAL: No growth [**2124-3-4**] BLOOD CULTURE: PENDING [**2124-3-4**] BLOOD CULTURE: PENDING Brief Hospital Course: [**Known firstname 449**] [**Known lastname **] is a 67-year-old right-handed man with past medical history notable for hyperlipidemia and epilepsy who is currently admitted to the neurology inpatient general service after sustaining a cluster of seizures as an outpatient with subsequent intubation, a short stay in the neuro ICU, and subsequent extubation. # Neurologic: Mr. [**Known lastname **] had been doing very well with no seizures for four years on the combination of Keppra and Dilantin. He was initially brought to an OSH ED after being found by his wife having a complex partial seizure that secondarily generalized. He proceeded to have 2 additional seizures en route to and at the OSH. He was given approximately 14 mg Ativan and loaded with Dilantin and subsequently intubated prior to transfer to the [**Hospital1 18**]. He was extubated in the ICU and ultimately transferred to the general neurology inpatient floor. His Dilantin was increased slightly from 200/300 mg to 300 mg [**Hospital1 **] and his Keppra was increased to 1000 mg [**Hospital1 **] after speaking with his outpatient neurologist Dr. [**Last Name (STitle) 90004**]. There are no obvious infectious metabolic or stress associated triggers that we can elicit from him. He had an LP, which was normal and a head CT which was unremarkable. From a seizure perspective, he has been stable since his initial cluster of seizures that initially brought him in. He was sent home on the higher doses of Keppra and Dilantin as described above and is scheduled to follow up with his outpatient neurologist, Dr. [**Last Name (STitle) 90004**] on [**3-20**], [**2123**]. # Infectious: An initial chest x-ray was concerning for pneumonia. Given his fever and leukocytosis to 18.5 at the OSH he was initially started on ceftriaxone and azithromycin which was changed to Zosyn and Vancomycin due to the concern for possible aspiration. His sputum revealed 4+ gram positive cocci in sputum. A subsequent chest x-ray revealed that the prior imaging showed artifact rather than consolidation. His fevers and leukocytosis resolved and the rest of his infectious workup including LP, urinalysis, and C. diff was negative, so his antibiotics were discontinued. He remained symptom free from an infection standpoint through his hospital course and was afebrile for greater than 24 hours prior to discharge. # Cardiovascular: He remained hemodynamically stable throught his hospital course. He was continued on his home simvastatin 20 mg daily. # Pulmonary: He arrived intubated from the outside hospital and was extubated in the neuro ICU. There was initially concern for possible aspiration pneumonia (above), but repeat chest x-ray revealed no evidence of consolidation, so antibiotics were discontinued as he was exhibiting no signs or symptoms of infection. # Endocrine: He was placed on an insulin sliding scale with a goal blood sugar of 150, during his hospitalization and was adequately controlled with blood sugars between 100 and 150. Please fax d/c summary to outpatient neurologist Dr. [**Last Name (STitle) 90004**] (fax: [**Telephone/Fax (1) 90005**]) Medications on Admission: - Keppra 500mg [**Hospital1 **] - Dilantin 200/300mg - Neurontin 400mg TID - Simvastatin 20 mg PO daily - Vardenafil - Calcium Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. phenytoin sodium extended 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 7. vardenafil Oral Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: GTC Seizure S/P extubation. Intubated at OSH for airway protection. Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were initially admitted to [**Hospital3 **] for seizures. You were intubated there and transferred to the [**Hospital1 18**], where you taken to the intensive care unit. Your seizure medications were changed while in the hospital (see below) after speaking with Dr. [**Last Name (STitle) 90004**]. You remained seizure free while at the [**Hospital1 18**]. We were initially concerned that you had pneumonia so you were started on antibiotics. A later chest x-ray showed that you did not have pneumonia and your fevers resolved, so we stopped the antibiotics. It was a pleasure taking care of you. Medication changes: - Your Keppra was increased from 500 mg twice daily to 750 mg in the morning and 1000 mg at night. - Your Dilantin was increased from 200 in the morning and 300 at night to 300 in the morning and 300 at night. Followup Instructions: Neurologist: Dr. [**Last Name (STitle) 90004**]: [**2124-3-20**] Completed by:[**2124-3-10**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14239**] Admission Date: [**2124-3-4**] Discharge Date: [**2124-3-10**] Date of Birth: [**2056-9-17**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 14240**] Addendum: Keppra 1000 [**Hospital1 **] Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6617**] MD [**MD Number(2) 14241**] Completed by:[**2124-3-10**]

[ "275.41", "275.3", "345.3", "272.4", "518.0", "780.60" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10455, 10670

4883, 8032

314, 321

8885, 8885

3322, 4860

9932, 10432

2562, 2676

8209, 8683

8784, 8864

8058, 8186

9036, 9678

3140, 3303

2691, 3015

9698, 9909

266, 276

349, 2250

8900, 9012

2272, 2356

2372, 2546

50,049

189,969

45778

Discharge summary

report

Admission Date: [**2115-8-31**] Discharge Date: [**2115-9-8**] Date of Birth: [**2043-12-3**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: abdominal pain [**1-14**] sigmoid volvulus Major Surgical or Invasive Procedure: open sigmoid colectomy History of Present Illness: 71 year old male who states that over the past 3 days he has had intermittent crampy abdominal pains and a sensation of bloating. No nausea or vomiting. No fever, chills or night sweats. Has had a watery bowel movement in the last hour. Positive flatus. No blood per rectum. No melena. Bending forward would help alleviate the pain. He had similar pain on [**2115-8-16**] when he was diagnosed with sigmoid volvulus. The sigmoid volvulus was reduced by sigmoidoscopy. The pain in [**2115-8-16**] was much worse. Past Medical History: PMH: Hypertension, Hypothyroidism PSH: Appendectomy, Shoulder Surgeries Social History: Lives by himself. Denies ETOH. Denies tobacco. Family History: non-contributory Physical Exam: PE: VS: 99.5 99.5 122/80 70 18 95 FS 97-119 gen: WA/WD, NAD CV: RRR, no m/r/g, nl S1, S2 pulm: CTA b/l abdomen: NBS, soft, NT, minimally distended extremities: no edema, Pertinent Results: admission: [**2115-8-31**] GLUCOSE-100 UREA N-28* CREAT-1.1 SODIUM-142 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14 ALT(SGPT)-20 AST(SGOT)-25 ALK PHOS-52 TOT BILI-0.6 LIPASE-30 CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.4 WBC-9.1 RBC-4.33* HGB-12.8* HCT-38.4* MCV-89 MCH-29.5 MCHC-33.3 RDW-14.8 NEUTS-73.2* LYMPHS-18.1 MONOS-6.4 EOS-1.7 BASOS-0.6 PLT COUNT-269 PT-12.7 PTT-21.7* INR(PT)-1.1 discharge: ... [**2115-9-4**] UA - positive urine culture - imaging: KUB [**2115-8-31**]: Findings which raise concern for early sigmoid volvulus. KUB [**2115-9-1**]: Similar appearance to the prior study with a distended left upper quadrant air-filled viscus. Lack of additional change might be seen with an ileus. EKG [**2115-9-2**]: Normal sinus rhythm. RSR' pattern in lead V1. Early R wave transition. Left axis deviation. No previous tracing available for comparison. Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment of his recurent abdominal pain. Patient was diagnosed with recurrent sigmoid volvulus in the ED. He was then admitted to ICU for sigmoidoscopy and decompresion of the volvulus by the gastroenterology service. This was performed and patient felt resolution of the abdominal pain for about one hour, after which the abdominal discomfort returned. The KUB was repeated approximatelly 2 hours after the decompression was read as unchanged. At that time, gastroenterology service was reconsulted. They felt there was no more procedures indicated from their service and recommended surgical intervention. Patient was complaining of discomfort, yet was quite comfortable at that time, continued to pass flatus. He was thus transferred to the floor from the ICU and observed on the floor for 2 days. On HD3, he went to the operating room and resection of sigmoid colon was performed. The surgery was non-complicated. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids, with a foley catheter, and morphine PCA for pain control. The patient was hemodynamically stable. Neuro: The patient received PCA morphine with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. 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/GU/FEN: Pre-operatively and 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. ID: The patient's white blood count and fever curves were closely watched for signs of infection. On POD1, patient developed UTI that was treated with levofloxacin. Wound care .... Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions 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 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: Lisinopril 20 mg PO Daily Synthroid 137 mcg PO Daily Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-14**] Drops Ophthalmic TID (3 times a day). Disp:*1 bottle* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Over-the-counter. Tablet(s) 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: sigmoid volvulus 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 [**4-21**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *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: Please call Dr. [**First Name (STitle) **] to set up an appintment in [**1-15**] weeks. You may reach her office at [**Telephone/Fax (1) 2998**]. Please call the [**Hospital **] clinic to schedule a follow up appointment at your earliest convenience at [**Telephone/Fax (1) 253**] Completed by:[**2115-9-8**]

[ "275.2", "368.2", "599.0", "560.2", "401.9", "244.9", "300.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "46.85", "45.76", "45.24" ]

icd9pcs

[ [ [] ] ]

5915, 5973

2223, 5123

356, 380

6034, 6043

1325, 2200

8057, 8369

1102, 1120

5227, 5892

5994, 6013

5149, 5204

6067, 7525

7541, 8034

1135, 1306

274, 318

408, 924

946, 1021

1037, 1086

21,167

141,877

15784

Discharge summary

report

Admission Date: [**2103-11-20**] Discharge Date: [**2103-11-23**] Date of Birth: [**2065-3-29**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old male Portuguese-speaking construction worker who is status post a mechanical fall from 20 feet. The patient landed on his back with positive loss of consciousness x 10 minutes. Once recovered the patient complained of right chest pain, headache and lower back pain. The patient was brought to [**Hospital1 69**] by ambulance in a collar and on a back board. Upon arrival the patient had decreasing mental status and was intubated in the Emergency Department. PAST MEDICAL HISTORY: Denied. PAST SURGICAL HISTORY: Denied. ALLERGIES: The patient has no known drug allergies.. MEDICATIONS: None. SOCIAL HISTORY: He lives in [**Location 2251**] with his wife and one infant child. PHYSICAL EXAMINATION: On admission the patient had a temperature of 96, blood pressure 159/palp, pulse 86, breathing at a rate of 28, 99% saturation. The patient's pupils were equal, round and reactive to light at 3 mm bilaterally. Extraocular movements were full. The patient had a small C-shaped laceration on the right occiput. The patient had the cervical collar in place on his neck. Cardiovascular examination showed a regular rate, no murmurs. Lungs were clear to auscultation bilaterally. The patient was tender over the right chest wall. There was no crepitus. The abdomen was soft, mildly distended, tender to palpation over the right lower quadrant, no ecchymosis appreciated. The pelvis was nontender and stable. Rectal had normal tone and was hemoccult negative. The patient's back examination had no bony step-offs but tenderness to palpation over his thoracic spine. The patient had 2+ distal pulses equal bilaterally. LABORATORY DATA: The patient had a white count of 10.4, hematocrit of 46.9, platelet count 479, sodium 140, potassium of 3.6, chloride 109, BUN 17, creatinine 0.8, glucose 181. The patient's blood gases on admission were pH of 7.38, PCO2 42, PO2 82. The patient's toxicology screen was negative. Urinalysis was negative. The patient received a chest x-ray which was negative; pelvis was negative. The patient was given a head CT which showed a right parietal epidural hematoma. Also noted were fractures of the right parietal and temporal bones, also a fracture through the inferior right mastoid. The patient was given a CT scan of the abdomen, pelvis and chest. Of note the patient had bilateral atelectasis and lung contusions, a right coracoid process fracture of the scapula. CT scan of the abdomen and pelvis was otherwise negative. The patient was given a CAT scan of the cervical spine which was negative for fracture. The patient also received CT scan of the thoracic and lumbar spine, which was negative for fracture. Of note was a very small chip fracture at the end of the 11th and 12th rib. HOSPITAL COURSE: Neurosurgery was consulted to see the patient. As there was no mass effect, ventricular side was preserved, with a small epidural hematoma, it was not believed to be significant enough to require intervention at this time, and would be followed. The patient was started on Dilantin for seizure prophylaxis. The patient was successfully extubated on [**2103-11-21**]. Orthopedic surgery was consulted to follow the patient's shoulder fracture. CT of the right shoulder showed a right coracoid process fracture which was minimally medially displaced. Management for this per orthopedics was four weeks of sling, no active motion. The patient was given a repeat head CT on [**2103-11-21**] per neurosurgery, which showed progression of edema around the left temporal lobe hemorrhagic contusion. The posterior frontal extra-axial hemorrhage was deemed to be stable with no midline shift appreciated. Neurosurgery also advised to repeat the head CT scan again on [**2103-11-22**]. Head CT was repeated which showed the left temporal hemorrhage with adjacent edema stable, no shift, and the right subdural hematoma to be improving with no midline shift, no compression, stable from prior study of [**2103-11-21**], and right subdural improved. The patient was reevaluated on [**2103-11-23**] by neurosurgery. The patient was deemed stable for discharge to home with follow up in one month. The patient was seen again by orthopedic surgery who recommended for his shoulder fracture a sling x 4 weeks and pendulum exercises, passive range of motion only, no active range of motion of the right shoulder or elbow, as arm muscles, biceps and brachialis etc attached to the coracoid process. DISCHARGE DIAGNOSES: 1. Right posterior frontal extra-axial hemorrhage, left temporal lobe contusion. 2. Right coracoid process shoulder fracture. 3. Small chip fracture of the 12th rib on the left side. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg p.o. t.i.d. x 3 days. 2. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n. FOLLOW UP: The patient is to follow up with neurosurgery with Dr. [**Last Name (STitle) 1327**] in one month. The patient should call [**Telephone/Fax (1) **] for appointment. The patient was asked to schedule a head CT scan, noncontrast, prior to the next appointment with Dr. [**Last Name (STitle) 1327**]. The patient is to follow up in trauma clinic in two weeks. The patient is to follow up with orthopedics with Dr. [**First Name (STitle) 1022**] in two weeks at [**Telephone/Fax (1) **] for further evaluation. [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D. [**MD Number(1) 19853**] Dictated By:[**Last Name (NamePattern1) 5924**] MEDQUIST36 D: [**2103-11-23**] 13:15 T: [**2103-11-30**] 11:46 JOB#: [**Job Number 45448**]

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44985

Discharge summary

report

Admission Date: [**2144-9-20**] Discharge Date: [**2144-9-29**] Date of Birth: [**2063-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Hematuria Reason for ICU Admission: Hypotension, requiring pressor Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname 656**] is an 81 yo M with a history CAD s/p CABG, HTN, chronic renal failure (b/l crt 1.4-1.6), s/p elective hip replacement in [**2144-8-26**], which was complicated by cardiogenic shock, VRE bacteremia & PEA arrest, discharged on [**2144-9-11**] to rehab, who was transferred from [**Hospital **] Hospital for evaluation and management of fevers (102.6) & hypotension (reportedly 90/palp). Pt was initially brought to MWH b/c of bloody foley output noted after sustaining foley trauma (pt accidentally tugged on foley while toileting on day of presentation). However, while getting evaluated for the hematuria, he spiked a fever to 102.6 and was noted to have a UTI, for which he got CTX. Decision was made to transfer to [**Hospital1 18**], where he has gotten much of his care, for further eval. . In the [**Hospital1 18**] ED, T 98.9, 73, 82/46, 27, 96% on 2L. His MS was clear. He appeared dyspneic. UA was +. CXR w/o clear consolidation and not significantly changed from prior. He was given Ceftaz/flagyl for UTI. He got 4L IVF & was still hypotensive. R IJ was placed b/c of hypotension in setting of presumed sepsis. CVP reportedly 22. Levophed started for persitent hypotension in setting of nml/elevated CVP. Pt admitted to MICU for further care. . ROS: Pt notes no fever, chills, nausea, vomitting, constipation, diarrhea, melena, BRBPR, chest pain, palpitations, dizziness or lightheadedness change in vision, numbness, tingling, weakness. He does note recent bladder spasms & dysuria over last week. No flank pain. He has also had significant b/l LE swelling since hip repair. He has baseline SOB. Gets SOB after ~30yards, which is reportedly stable. Past Medical History: -R hip degenerative arthritis s/p elective total hip replacement [**2144-8-25**] c/b PEA arrest in setting of cardiogenic shock - Coronary artery disease s/p coronary artery bypass in [**2140**] (SVG to OM, SVG to RCA and LIMA) - EF 45% from [**2144-9-1**] - Hypercholesterolemia. - Chronic renal insufficiency (~1.4-1.6) - Gastroesophageal reflux disease. - Status post lumbar laminectomy in [**2140-2-4**] for spinal stenosis. - MGUS (monoclonal gammopathy of unknown source) - dx'd [**2143**] - Episode of pancreatitis [**6-/2144**] likely from gallstone pancreatitis - s/p chole [**6-11**] - History of a difficult intubation. - Benign prostatic hypertrophy. Also h/o prostatic atypia noted by biopsies from both [**2130-6-29**] andAugust 27, [**2133**] as well as PIN on his subsequent biopsy of [**2137-10-2**] - History of torn cartilage in the right knee. Social History: Pt lives with wife, has 3 children. Is retired and previous occupation as mens apparel businessman and CFO for son's construction buisiness. No tobacco, rare social ETOH, and no other drug use. Family History: F: 1st MI early 60s M: CVA Physical Exam: VS: 97.6, 76, 91/70, 28, 94% on 2.5L NC Gen: appears slightly uncomfortable, tachypneic, a&ox3 HEENT: NCAT, PERRL, sclera anicteric, OP clear, MMM Neck: Supple, no LAD, no JVD CV: RRR S1/S2, no m/r/g Resp: Bibasilar crackles w/ decreased BS partic @ L base Abdomen: Soft, NTND, BS+ Ext: [**3-8**]+ LE pitting edema up to flanks. DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-8**] both upper and lower extremities Skin: Pink, warm, no rashes; R hip wound intact, staples in place Pertinent Results: [**2144-9-20**] 07:40PM BLOOD WBC-20.8*# RBC-3.03* Hgb-8.9* Hct-27.6* MCV-91 MCH-29.4 MCHC-32.2 RDW-16.0* Plt Ct-279 [**2144-9-29**] 09:30AM BLOOD WBC-5.3 RBC-3.65* Hgb-10.9* Hct-33.2* MCV-91 MCH-30.0 MCHC-32.9 RDW-16.4* Plt Ct-240 [**2144-9-20**] 07:40PM BLOOD Neuts-90* Bands-5 Lymphs-1* Monos-1* Eos-0 Baso-2 Atyps-0 Metas-1* Myelos-0 [**2144-9-22**] 03:59AM BLOOD Neuts-87.4* Lymphs-7.0* Monos-3.6 Eos-1.8 Baso-0.2 [**2144-9-20**] 09:09PM BLOOD PT-21.9* PTT-28.6 INR(PT)-2.1* [**2144-9-29**] 09:30AM BLOOD PT-18.1* PTT-31.0 INR(PT)-1.7* [**2144-9-20**] 07:40PM BLOOD Glucose-103 UreaN-24* Creat-1.7* Na-137 K-5.0 Cl-107 HCO3-22 AnGap-13 [**2144-9-29**] 09:30AM BLOOD Glucose-156* UreaN-16 Creat-1.5* Na-140 K-3.7 Cl-101 HCO3-31 AnGap-12 [**2144-9-20**] 07:40PM BLOOD CK(CPK)-35* [**2144-9-21**] 05:52AM BLOOD CK(CPK)-40 [**2144-9-20**] 07:40PM BLOOD cTropnT-0.11* [**2144-9-21**] 05:52AM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-[**Numeric Identifier 96171**]* [**2144-9-21**] 05:52AM BLOOD Albumin-2.7* Calcium-7.1* Phos-4.1 Mg-1.8 [**2144-9-24**] 07:25AM BLOOD calTIBC-159* Ferritn-690* TRF-122* [**2144-9-21**] 08:57AM BLOOD Type-MIX pO2-29* pCO2-36 pH-7.39 calTCO2-23 Base XS--3 [**2144-9-22**] 10:02AM BLOOD Type-CENTRAL VE Temp-35.8 pO2-28* pCO2-38 pH-7.41 calTCO2-25 Base XS--1 Intubat-NOT INTUBA [**2144-9-20**] 07:43PM BLOOD Lactate-1.7 [**2144-9-22**] 04:20AM BLOOD Hgb-9.8* calcHCT-29 O2 Sat-67 [**2144-9-23**] CXR: AP chest compared to [**9-9**] through 19: Mild pulmonary edema minimally improved since [**9-22**] despite increase in volume of moderate right pleural effusion. Aeration at the left lung base has improved, probable small left pleural effusion persists. Heterogeneity in the widespread infiltrative pulmonary abnormality suggests some residual multifocal pneumonia, particularly in the suprahilar right lung. Heart size top normal, unchanged. No pneumothorax. Right jugular line passes to the upper right atrium but the tip is obscured. No pneumothorax. [**9-22**] RUQ U/S RIGHT UPPER QUADRANT ULTRASOUND: The liver echotexture is normal. No focal lesions are seen. There is no intrahepatic biliary ductal dilation. The gallbladder has been removed. The common duct is not dilated. Bilateral pleural effusions are seen, though no ascites fluid is seen on four quadrant assessment. LIVER DOPPLER: The main, right anterior, right posterior and left portal veins are patent with the appropriate direction of flow. The right middle and left hepatic veins are patent, with appropriate waveforms. The main hepatic artery demonstrates a normal waveform as well. The inferior vena cava is patent with normal waveform. IMPRESSION: 1. Bilateral pleural effusions. No ascites fluid detected. 2. Patent hepatic vasculature. [**2144-9-21**] Chest/abd/pelvis CT 1. Areas of patchy consolidation in bilateral lungs, consistent with multifocal pneumonia. Associated bilateral pleural effusions. 2. No evidence of abscess or colitis, however, study is limited secondary to lack of intravenous contrast. 3. Central venous catheter with tip in the superior vena cava. 4. No obvious abscess in the right hip region, however, region unable to be adequately assessed secondary to artifact from right hip replacement. [**2144-9-21**] Echo The left atrial volume is markedly increased (>32ml/m2). The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-5**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2144-9-1**], the findings are similar. [**2144-9-20**] EKG Sinus rhythm with first degree A-V delay Left atrial abnormality Delayed R wave progression with late precordial QRS transition - is nonspecific ST-T wave abnormalities - cannot exclude in part ischemia - clinical correlation is suggested Since previous tracing of [**2144-9-9**], rate faster and further ST-T wave changes present Brief Hospital Course: 81 year-old man with CAD s/p CABG, recent hospitalization for elective hip repair complicated by post-operative cardiogenic shock & PEA arrest, who presents from rehab with septic/cardiogenic shock in setting of Ecoli bacteremia. . # Acute on Chronic Systolic Heart Failure: Pt grossly overloaded--e/o pl effusions, pulm edema, gross LE edema up to flanks, which was present prior to admission & volume resuscitation. Weight was up approximately 20-30lb since he had his R hip repair at the end of [**Month (only) 205**] (his pre-op weight was 175lb and wt on admission to MICU 198lb). BNP 35,000. Suspect he has been overloaded since last hospitalization. EF stable at 45-50% w/ mild global LV hypokinesis. No e/o acute MI. BNP severely elevated at 35,000. We diuresed him steadily at approximately 1 liter per day initially on a lasix drip then IV push lasix then PO lasix 80mg/day. He was 88kg when he was admitted to the floor and was 80kg on the day before d/c, stated that his dry wt. was 79kg before all of these hospitalizations. Beta blocker and lisinopril were held initially due to concern for acute decompensated heart failure and increasing creatinine, but were restarted when his Cr stabilized around baseline and he was diuresing well. . # Shock: Resolved. Pt off of pressors >48hr before admission to the floor. Suspect primary cause was sepsis due to Ecoli bacteremia. WBC trended down & pt afebrile on abx since leaving ICU. Suspect Also, evidence of cardiogenic component to shock w/ low SvO2. However, echo w/o evidence of acute MI & EF stable. We changed his ceftazidime to ceftriaxone and then to oral cefpodoxime to finish out 2 weeks course of antibiotics. Some question as to whether his urosepsis originated from chronic prostatitis and so he was referred to urology. . # Hematuria: was due to foley trauma originally, but then he continued to have hematuria intermittently. He has been scheduled with urology Dr. [**Last Name (STitle) 261**] for [**10-8**] for evaluation of his difficulty urinating, hematuria and history of urosepsis, question of chronic prostatitis as he appeared to have a somewhat positive UA (WBC's) after being on antibiotics for several days with a moderately tender prostate. Pt. was explicitly instructed that he needs to keep this appointment as he may need a workup to rule out malignancy. Hct remained stable and was at a [**Location (un) **] on day of d/c. # Anemia: baseline hct varies, though predominantly in 30s. Was 33.2 on day of d/c Iron studies indicative of anemia of chronic disease. # CRF: stable. Pt.'s Cr remained approximately at baseline for the duration of his admission and was 1.5 on day of d/c. . # s/p R hip replacement: appears to be healing well. Staples removed. Pt. needs to remain anticoagulated for DVT prophylaxis until [**10-24**] on warfarin. Pt. was discharged on 7.5mg warfarin daily for one more dose and then back to 3mg daily. . # Sepsis: pt febrile to 102.6, WBC 20s, RR 20s-30. Has possible urinary source w/ + UA. Blood cultures from OSH grew E.coli resistant to ampicillin/unasyn/flouroquinolones/bactrim but sensitive to sensitive to Cefazolin, CTX, ceftazidime, and Zosyn. Pt. defervesced in the Unit and remained afebrile for his course of treatment on the floor ([**Date range (1) 96172**]). . # Hypotension: Pt & family report baseline BP in 90s-100s. However, pt's BP into the 80s in ED. Pt asx w/ this, mentated clearly & made some urine. Suspect drop in BP may be related to sepsis. However, cardiogenic shock also possible. Trop is elevated at 0.11 (last level was from [**9-3**] & was ~6.0). CK nml. EKG w/ some mild changes in lateral precordial leads, though no evolution. No clear trigger/cause for neurogenic shock or adrenal insufficiency. BP returned to SBP 100s-110s w/ Abx therapy and remained stable while pt. was on cardiology floor, so very likely that sepsis had large contribution to his hypotension in the ED/Unit. . Medications on Admission: Per DISCHARGE PAPERCWORK 1. Calcium Carbonate 1500 mg TID 2. Cholecalciferol 1000unit DAILY 3. Atorvastatin 40 mg DAILY 4. Oxycodone 5 mg PO Q6H as needed for pain. 5. Acetaminophen 1000 mg PO four times a day. 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment PRN (as needed). 7. Aspirin 325 mg DAILY 8. Lidocaine 5 %Adhesive Patch Q24H 9. Trazodone 12.5 mg PO HS 10. Fentanyl 12 mcg/hr every 72 hours as needed for pain. 11. Timolol Maleate 0.5 % DAILY 12. Lisinopril 5 mg PO DAILY 13. Metoprolol Succinate 150 DAILY 14. Ranitidine HCl 150 mg twice a day 15. Tamsulosin 0.4mg 16. Coumadin 4mg [**Name (NI) **] (unclear indication) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed. 7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 16. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 19. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days: Continue until [**10-6**]. Please check urinalysis after stopping. . 20. Tears Naturale Forte Ophthalmic 21. Outpatient Lab Work Daily PT/INR please [**Name8 (MD) 138**] M.D./NP w/ results. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary E. coli urosepsis Acute decompensated heart failure Secondary MGUS (monoclonal gammopathy of unknown significance) Coronary artery disease Benign prostatic hypertrophy Chronic renal insufficiency Gastroesophageal reflux Hypercholesterolemia Discharge Condition: Stable Discharge Instructions: You have been diagnosed with E. coli urosepsis, this will require you to finish a course of oral antibiotics (cefpodoxime) after leaving the hospital. This may have resulted from infection of your prostate and we have scheduled you a follow up visit with your Urologist Dr. [**Last Name (STitle) 261**] on [**10-8**] at 1:00 p.m. We have stopped your oxycodone, lidocaine patch and fentanyl patch because you were no longer having any pain. We have decreased your metoprolol to 50mg once a day, this can be slowly increased in the future by your doctor. We have decreased your dose of Ranitidine to 150mg once daily as needed because your kidney function was low. We have changed your tamulosin to doxazosin. We have increased your coumadin from 4mg to 7.5mg daily because your INR was low, you will need to have your INR checked daily until it is between [**3-8**] and stable and your warfarin adjusted accordingly. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 261**] at 1:00 on [**10-8**] on the [**Location (un) 470**] of the [**Hospital Ward Name **] building ([**Telephone/Fax (1) 4276**] Please check a urinalysis after stopping antibiotics [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2144-11-10**] 10:00 [**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**] [**10-9**] at 3:30pm. Completed by:[**2144-9-29**]

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Discharge summary

report

Admission Date: [**2125-1-12**] Discharge Date: [**2125-1-29**] Date of Birth: [**2053-7-2**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: Cough Major Surgical or Invasive Procedure: Endotracheal Intubation PICC line placement and removal History of Present Illness: 71 yo F with h/o developmental delay, h/o aspiration pneumonia, and other medical issues presents with senior care center because of cough and O2 Sat 88%. . Patient is a poor historian, and unable to tell the events. She is able to confirm with simple yes-no questions. Per ED notes, patient was noted to be coughing while eating. . Initial VS in the ED: 98.2, bp 137/73, hr 112, O2 Sat 100% on 4L. Patient was noted to have diminished breath sounds throughout. CXR showed possible retrocardiac opacity. Patient was given levofloxacin in the ED for possible aspiration pneumonia vs. pneumonitis. She was also given tyelnol rectally. VS prior to transfer: 98.5 114 126/79 18 96%ra . On the floor, patient is demanding to have coffee. She notes stuffy nose and congestion. . Review of systems: (+) Per HPI. (-) Denies fever, chills. Denies headache, sinus tenderness. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - static encephalopathy secondary to motor vehicle accident as a child - History of fall - History of left hip fracture - [**2122-1-4**] history of nursing home admission: Rossscommon - [**2122-12-30**]: Admitted to new group home Bay Cove - History of hypertension - History of schizophrenia: Referred to Psychiatry [**Hospital1 18**] [**2124-1-5**] - History of head injury at 18 months age - Posttraumatic Brain Injury Syndrome/Developmental Delay (315.9): Referred to Cognitive Neurology [**Hospital1 18**] [**2124-1-5**] - PEG/jejunostomy tube: Referred to GI at [**Hospital1 18**] [**2124-1-5**] - Respiratory Failure 2o Aspiration (per old record from Nursing Home) - [**2124-3-22**]: PEG Feeding Tube replacement (v44.1) - History of speech and language pathology evaluation [**Month (only) 1096**], - [**2121**]: Cleared for mechanical soft diet - [**2124-2-14**]: New diagnosis: Diabetes mellitus type 2 - LUE Paresis: [**2124-5-11**]: Ref'd Physiatry: [**Hospital1 **] - chronic bilateral knee pain: degenerative joint disease of medial and lateral compartments: confirmed: plain radiographs [**2121-1-23**] - [**2124-9-6**]: s/p Rehab @ [**Hospital1 **] for extrem, incl cotractures. Has home exercise Rx, brace for hand - 1215/11: Ref'd ortho re shoulder pain/contrx - Adenomatous polyp on colonoscopy [**2117**] [**Hospital1 18**]: [**2124-10-18**]: Referred to GI [**Hospital1 18**] - [**2124-10-18**]: Referral to podiatry [**Hospital1 18**] regarding recurrent wound right fourth toe - [**2124-10-18**] glaucoma in ophthalmology followup Social History: lives in a group home for severe mental retardation and schizophrenia and static encephalopathy secondary to motor vehicle accident as a child and dementia . Physical Exam: Admission Physical Exam: Vitals: 97.6, 122/57, 110, 16, 93% 3L General: Alert, oriented to self, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: no obvious wheeze, rales, or rhonchi, but with poor inspiratory effort CV: RRR, no obvious m/r/g Abd: soft, NT, ND, G tube scars, BS present Extremities: 1+ DP pulses bilaterally, edema up to the thighs bilaterally, contracture of the left hand . Discharge Physical Exam: VS: 97.1, 100s-110s/50s-60s, 80s 20 94% RA GEN: laying in bed, NAD HEENT- poor dentition, L eye cataract present Lungs- BS present b/l today, upper airway sounds heard throughout, BS heard over LUL today CV- S1S2 no m,r,g Abdom- NT, ND, BS+, not TTP Ext- 2+ pitting edema to knees b/l, left arm contracted and flexed Neuro- LE strength 4/5, right hand grip strength 5/5, pt wheelchair bound for several yrs following multiple falls Pertinent Results: Admission Labs: [**2125-1-12**] 03:40PM BLOOD WBC-6.0 RBC-3.89* Hgb-11.3* Hct-35.8* MCV-92 MCH-29.0 MCHC-31.5 RDW-13.7 Plt Ct-199 [**2125-1-12**] 03:40PM BLOOD Neuts-63.0 Lymphs-24.7 Monos-9.3 Eos-1.6 Baso-1.5 [**2125-1-12**] 03:40PM BLOOD Glucose-263* UreaN-23* Creat-0.6 Na-142 K-4.5 Cl-101 HCO3-34* AnGap-12 [**2125-1-15**] 03:57AM BLOOD ALT-14 AST-39 LD(LDH)-517* AlkPhos-62 TotBili-0.2 [**2125-1-13**] 08:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7 [**2125-1-13**] 06:37PM BLOOD Type-ART Temp-38.3 pO2-92 pCO2-69* pH-7.33* calTCO2-38* Base XS-6 Intubat-NOT INTUBA Comment-SIMPLE FAC [**2125-1-12**] 08:27PM BLOOD Lactate-1.7 [**2125-1-15**] 06:44AM BLOOD freeCa-1.13 Pertinent Labs: [**2125-1-26**] 06:05AM BLOOD WBC-6.5 RBC-2.95* Hgb-8.4* Hct-28.2* MCV-96 MCH-28.4 MCHC-29.8* RDW-14.7 Plt Ct-467* [**2125-1-29**] 06:17AM BLOOD Glucose-162* UreaN-14 Creat-0.4 Na-143 K-5.0 Cl-100 HCO3-42* AnGap-6* [**2125-1-15**] 03:57AM BLOOD proBNP-357* [**2125-1-22**] 07:12AM BLOOD Triglyc-90 [**2125-1-15**] 11:47AM BLOOD Ammonia-38 [**2125-1-15**] 12:05PM BLOOD Lactate-0.7 CXR [**2124-1-13**] A frontal view of the chest was obtained. The patient is rotated. Slightly increased retrocardiac opacity is likely atelectasis although infection cannot be excluded in the appropriate clinical setting. There is linear atelectasis in the left mid lung. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes and hilar contours are stable allowing for patient position. No upper abdominal or osseous abnormality is identified. IMPRESSION: Retrocardiac opacity is likely atelectasis although infection cannot be excluded in the appropriate clinical setting. If further imaging evaluation is needed, a lateral view could be obtained. CHEST (PORTABLE AP) Study Date of [**2125-1-26**] 9:36 AM IMPRESSION: AP chest compared to [**1-20**]: Left upper lobe has collapsed again rendering the entire left lung airless. Right lung is grossly clear. Heart size is indeterminate. Right PIC line ends in the upper SVC. Stomach is moderately-to-severely distended. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2125-1-15**] 5:24 PM IMPRESSION: 1. No evidence of pulmonary embolism, substantial evidence of pulmonary hypertension and reflux of the contrast material into IVC with dilatation of IVC and hepatic veins, consistent with known tricuspid regurgitation. 2. Multifocal consolidations involving both lungs, mostly pronounced in the right upper and left lower lobe, and might be consistent with multifocal infection/aspiration. 3. Narrowing of the airways, most likely due to tracheobronchomalacia. Some amount of secretions is present in both lower lobes bronchi. 4. The extended ET tube cuff and should be readjusted. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2125-1-24**] 10:04 AM FINDINGS: Swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. No gross aspiration or penetration was seen. Free spill was observed with liquids. IMPRESSION: No gross aspiration. For full details, please see a detailed speech and swallow note in OMR. TTE: IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis and moderate pulmonary artery systolic hypertension. Normal left ventricular cavity size with preserved global and regional systolic function. This constellation of findings suggests a primary pulmonary process (e,g., pulmonary embolism, bronchospasm, sleep apnea, etc.). Compared with the prior study (images reviewed) of [**2119-10-30**], the findings are new, and suggestive of a primary pulmonary process. Micro: Blood cx- neg Urine cx- neg Brief Hospital Course: BRIEF HOSPITAL COURSE: 71 yo F with h/o developmental delay, h/o aspiration pneumonia, and other medical issues presents with senior care center because of cough and O2 Sat 88%. . ACTIVE ISSUES: # Aspiration Pneumonia: Based on limited history, most likely an aspiration event, with differential including aspiration pneumonitis vs. pneumonia. She was afebrile without leukoctyosis on admission. CXR demonstrated left lower lobe pna. Noted to have significant secretions and requiring 3-4L NC. Levofloxacin was started for empiric coverage of aspiration pneumonia. On HD2 she spiked a fever and flagyl was added for better anaerobic coverage. On HD3, she desaturated to the low 80s on 5L NC after receiving chest physical therapy. She received a nebulyzer treatment. A repeat chest xray demonstrated worsening of left lower lobe infiltrate and new RLL opacity. Concern for persistent aspiration events despite NPO status, mucus plugging versus/and volume overload in setting of volume rescussitation the day prior. She was given 20mg IV lasix. An ABG demonstrated hypoxic respiratory failure (7.36/66/52) on 5L NC. She was transferred to the MICU for further management. In the MICU, the patient was found to have multilobar pneumonia with bilateral pleural effusions. She was treated with broad-spectrum abx, cefepime and vancomycin, started [**1-15**] and planned for 8 day course. She completed her course of antibiotics and remained afebrile. She underwent a speech and swallow evaluation which showed her to have a increased risk of aspiration during eating. These results were discussed with her family and the decision was made to allow her to continue to eat. Her family has decided to go ahead with PEG tube placement in the future if she is having difficulty eating. This decision was made by the family even with an extensive discussion where they were informed that it most likely not affect her mortality outcome. . # Tachycardia: Sinus tachycardia. She was given IV metoprolol 5mg x 2 on HD2 with improvement after triggering for tachycardia. She was volume rescussitated with 500cc bolus NS and given 1L NS as maintenance on HD with concern for hypovolemia. Heart rates persistently in 110s on HD3. Her HR was intermittently elevated during her stay in the MICU, likely due to over-diuresis and in the setting of infection. Once her infection resolved and she was adequately volume resuscitated her tachycardia resolved. . # Left Upper Lobe Lung Collapse- On a portable cxr it was noted that her LUL had collapsed most likely due to prior secretion aspiration event. She was given chest PT and deep suction which improved her lung areation on PE. Breath sounds returned B/L. Pulmonary evaluated her and determined no other intervention was warranted. She was sating in the mid 90s on RA. . #Elevated [**Name (NI) 9988**] Pt's bicarb was elevated to a max of 42 during this admission. Most likely related to decreased free water intake consider pt was not able to drink with her [**Last Name (un) 9989**] cup like she uses at home while in the hosptial. This corrected with IV free water replacement. A nursing aide was asigned to helping her drink more frequently during the day. . # T2DM: continued on a insulin sliding scale. Metformin was held. . # Schizophrenia/anxiety: She was continued on home risperidone and valproic acid. Sertraline was continued as well. . # HLD: She was continued on simvastatin. . # Code status: Confirmed as Full code by nursing facility. She has a HCP who is out of state. In the hospital course, Health Care Proxy changed her to code status to DNR/ok to intubate. . #Transitional: Pt should be fed using strict aspiration precautions including soft dysphagia diet, seated at 90 degrees, with 1:1 supervision with eating. She has a follow up appointment with her PCP. Medications on Admission: - MVI daily - ASA 81 mg daily - vitamin D 3 1000 units daily - valproic acid 750 mg qAM - risperidone 1 mg qam - trusopt 1 drop TID OS - artificial tears 2 drops TIS OU - colace 100 mg [**Hospital1 **] - metformin 500 mg at 4PM - senna qHS daily - valproic acid 1000 mg qHS - risperidone 3 mg qPM - zocor 5 mg qHS - zoloft 75 mg qPM - Tylenol 650 mg q4h prn - ativan 1 mg prn q6h prn - zoloft 75 mg at night Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: Two (2) Drop Ophthalmic TID (3 times a day). 2. multivitamin Tablet Sig: One (1) Tablet PO once a day. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: Fifteen (15) ml PO QAM (once a day (in the morning)): Total dose 750mg daily. 6. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: Twenty (20) ml PO QPM (once a day (in the evening)). 7. risperidone 1 mg Tablet Sig: One (1) Tablet PO qam. 8. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. metformin 500 mg Tablet Sig: One (1) Tablet PO 4 pm. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for constipation. 12. risperidone 3 mg Tablet Sig: One (1) Tablet PO q pm. 13. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. sertraline 25 mg Tablet Sig: Three (3) Tablet PO q pm. 15. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 16. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. 17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for Itching. Disp:*1 bottle* Refills:*3* 18. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 3 days: please apply to rash on chest. Disp:*1 bottel* Refills:*0* 19. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig: Twenty (20) mL PO at bedtime: Total 1000mg at bedtime. 20. metformin 1,000 mg Tablet Sig: One (1) Tablet PO Every morning. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Aspiration Pneumonia Secondary Diagnosis: Developmental Delay Diabetes Type II Hyperlipidemia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with pneumonia caused by your secretions from your mouth going into your airway. It is very important that you continue to be fed with supervision from this point forward. The following changes have been made to your medications: START: Sarna Lotion apply to skin for itching as needed Mupirocin 2% cream apply to chest rash twice per day for 3 more days Please see below for follow up appointments that have been made for you. Followup Instructions: Department: BIDHC [**Location (un) **] When: FRIDAY [**2125-2-2**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking:

[ "263.9", "311", "250.00", "728.85", "V49.86", "787.29", "V15.52", "934.1", "427.89", "507.0", "V12.72", "276.0", "486", "315.9", "276.9", "295.90", "518.81", "272.4", "511.9", "518.0", "E912", "285.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "96.04", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

13955, 13961

7911, 8068

276, 333

14119, 14119

4178, 4178

14869, 15158

12168, 13932

13982, 13982

11735, 12145

14294, 14846

3270, 3700

1162, 1475

230, 238

8083, 11709

361, 1143

14044, 14098

4194, 4846

14001, 14023

14134, 14270

4862, 7865

1497, 3054

3070, 3230

3725, 4159

42,455

173,960

12666

Discharge summary

report

Admission Date: [**2108-3-25**] Discharge Date: [**2108-4-4**] Date of Birth: [**2041-10-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2108-3-30**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with saphenous vein grafts to first obtuse marginal, second obtuse marginal and ramus intermedious. [**2108-3-26**] Cardiac Catheterization History of Present Illness: Mr. [**Known lastname 3924**] is a 66 year old male with no sigificant PMH who presented with intermittent chest pain. He described the pain as substernal, and radiated to right shoulder and neck. Each episode lasted for 15 min to 2 hrs. Had six episodes in the last 24 hrs prior to admission. Chest pain was associated with shortness of breath and occured with mild exertion. At the outside hospital, the initial ekg showed normal sinus rhythm. Then during episode of chest pain, ekg notable for ST elevations in II, III, aVF. Cardiac enzymes were negative. He was started on Nitro and Heparin drip, given Aspirin and Plavix, and transferred to the [**Hospital1 18**] for further evaluation and treatment. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Low-grade, Low-stage Prostate Cancer - no treatement. Hypertension Hyperlipidemia History of Recurrent Syncope Social History: Smoked less than 1 ppd for 5 years, quit 40 yrs back. ETOH occasional, no illicits. Works for financial services. Family History: Father had MI in 60s. Physical Exam: VS: 97 120/70 72 98/2l GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2108-3-25**] BLOOD WBC-5.2 RBC-4.91 Hgb-15.2 Hct-44.0 MCV-90 MCH-31.0 MCHC-34.6 RDW-13.2 Plt Ct-279 [**2108-3-25**] BLOOD PT-14.4* PTT-150* INR(PT)-1.2* [**2108-3-25**] BLOOD Glucose-122* UreaN-21* Creat-1.3* Na-146* K-3.9 Cl-108 HCO3-23 AnGap-19 [**2108-3-25**] BLOOD cTropnT-<0.01 [**2108-3-26**] BLOOD CK-MB-2 cTropnT-0.01 [**2108-3-25**] BLOOD Albumin-4.3 Calcium-9.9 Phos-3.1 Mg-2.7* [**2108-3-26**] BLOOD %HbA1c-5.8 [**2108-3-30**] BLOOD Triglyc-86 HDL-44 CHOL/HD-3.5 LDLcalc-94 [**2108-3-27**] Cardiac Cath: 1. Coronary angiography of this co-dominant system revealed 2 vessel coronary disease and LMCA disease. The LMCA had a 60-70% stenosis distally that was eccentric. The LAD had a 40-50% ostial stenosis which was also eccentric and hazy. The LCX had an 80% stenosis at its origin and a 90% OM1 stenosis. The RCA had a proximal 40% stenosis. 2. Limited resting hemodynamics revealed mildly elevated systemic arterial pressure with an SBP of 147 mm Hg. The LVEDP was elevated at 23 mm Hg. 3. Left ventriculography revealed normal left ventricular systolic function with an ejection fraction of 55-60% without focal wall motion abnormality or mitral regurgitation. [**2108-3-27**] Echocardiogram: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. 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. [**2108-3-30**] Intraop TEE: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. POST-BYPASS: The patient is in sinus rhythm and on an infusion of phenylephrine. Biventricular function is preserved. The aorta is intact. The Swan Ganz catheter is in the proximal right PA. The examination is otherwise unchanged. [**2108-4-4**] Hct-29.5* [**2108-4-2**] WBC-9.9 RBC-3.16* Hgb-9.5* Hct-27.6* MCV-87 MCH-30.2 MCHC-34.6 RDW-14.0 Plt Ct-190 [**2108-4-1**] WBC-16.4* RBC-2.93* Hgb-8.7* Hct-25.4* MCV-87 MCH-29.8 MCHC-34.5 RDW-13.6 Plt Ct-221 [**2108-4-4**] UreaN-25* Creat-1.6* K-4.0 [**2108-4-3**] Creat-1.7* [**2108-4-2**] Glucose-106* UreaN-14 Creat-1.4* Na-140 K-4.6 Cl-107 HCO3-25 [**2108-4-1**] Glucose-141* UreaN-16 Creat-1.4* Na-136 K-4.2 Cl-106 HCO3-24 [**2108-3-31**] Glucose-130* UreaN-16 Creat-1.2 Na-135 K-4.2 Cl-107 HCO3-22 [**2108-4-4**] Mg-2.4 Brief Hospital Course: Mr. [**Known lastname 3924**] was admitted under cardiology with unstable angina. Given concern for acute coronary syndrome versus vasospasm, he was started on Integrilin and Diltiazem, in addition to Heparin and Nitro. He ruled out for myocardial infarction. He remained pain free on intravenous therapy. The following day, he underwent cardiac catheterization which revealed severe two vessel coronary artery disease including a 70% left main lesion - see result section for additional details. Cardiac surgery was consulted and further preoperative evaluation was performed. Given recent Plavix dose, surgery was delayed for several days. Preoperative echocardiogram showed normal ejection fraction with only trivial mitral regurgitation - see result section for additional detail. His preoperative course was otherwise unremarkable and he was cleared for surgery. On [**3-30**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass grafting surgery. For surgical details, please see dictated operative note. Given inpatient stay was greater than 24 hours prior to surgery, Vancomycin was given for perioperative antibiotic coverage. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the telemetry floor on postoperative day two. He completed a course of Ibuprofen for postoperative pericarditis. He tolerated beta blockade, and remained in a normal sinus rhythm. Beta blockade was advanced as tolerated. One unit of packed red blood cells was transfused for a hematocrit near 24%. Over several days, he continued to make clinical improvements with diuresis and was cleared for discharge to home on postoperative day five. At discharge, BP 106/66 with HR of 84 and room air saturation of 95%. All surgical wounds were clean, dry and intact. Medications on Admission: None Discharge Medications: 1. Atorvastatin 80 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary Artery Disease, s/p CABG Postop Pericarditis - resolved Hypertension Dyslipidemia Prostate Cancer Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: - Dr [**Last Name (STitle) 914**] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment - Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] (PCP) in [**12-16**] weeks ([**Telephone/Fax (1) 39136**]) please call for appointment - Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2108-4-4**]

[ "790.01", "423.9", "414.01", "272.4", "411.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.63", "36.13", "36.15", "99.04", "88.53", "37.22", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

8673, 8732

5898, 7823

330, 602

8882, 8889

2624, 5875

9400, 9809

1765, 1789

7878, 8650

8753, 8861

7849, 7855

8913, 9377

1804, 2605

280, 292

630, 1482

1504, 1617

1633, 1749

6,728

108,296

6599

Discharge summary

report

Admission Date: [**2148-2-23**] Discharge Date: [**2148-2-27**] Date of Birth: [**2079-1-15**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name8 (NamePattern2) 1103**] Chief Complaint: Bilateral knee pain Major Surgical or Invasive Procedure: Bilateral total knee arthroplasty History of Present Illness: Mr. [**Known lastname 12303**] has had end stage degenerative joint disease of both knees. He presents for definitive treatment. Past Medical History: OA Family History: NC Physical Exam: Gen-Alert/oriented, NAD VS- 100.5, 140/70, 80, 20, 96%RA CV-RRR Lungs-CTA bilat Abd-soft NT/ND Ext-Bilat knees:incision clean/dry/intact, without evidence of infection, +[**Last Name (un) 938**]/FHL/AT, +DPP, +sensation. Bilaterally Pertinent Results: [**2148-2-23**] 06:03PM GLUCOSE-125* UREA N-19 CREAT-0.9 SODIUM-142 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-24 ANION GAP-16 [**2148-2-23**] 06:03PM WBC-14.5*# RBC-3.45* HGB-11.2* HCT-33.4* MCV-97 MCH-32.5* MCHC-33.6 RDW-13.7 Brief Hospital Course: Patient was admitted on [**2148-2-23**] for elective total knee arthroplasty. Consent and medical clearance was obtained prior to surgery. Surgery went without complications, please see op-note. Patient had an epidural placed prior to surgery for pain control. Post-op patient was transferred to the unit for observation, patient was hypotensive post-op to 120-83/78-46. HCt had dropped from 39-33. Patient was given 2units and taken to the unit for observation. Patient was stabalized and transferred to the orthopedic floor on [**2148-2-24**] without events. Epidurad was d/c'ed [**2-24**] and lovenox was started for anti-coagulation. Patient continued to progress. Pain remained controlled with oral pain medication. Patient did have low grade temp on [**2-25**] UA/cxr/wound check were all negative. Patient also had hct drop to 23 on [**2148-2-26**] but was stable. Patient was transfused 2 units PRBC. Patient remained stable asymptomatic. Patient continued to progress. Patient was discharged in stable condition. 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. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 2 weeks. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Center Discharge Diagnosis: Bilateral knee osteoarthritis Discharge Condition: stable Discharge Instructions: Please cont with weight bearing as tolerated bilateral legs. Range of motion as tolerated. Oral pain medication as needed. Lovenox for anti-coagulation x2weeks. Cont with physical therapy. Please call/return if any fevers, increased discharge from incision, or trouble breathing. Physical Therapy: Activity: Ambulate Knee immobilizer: while in bed PROM 0-60 degrees every two hours alternating between legs / at night knee immobilizers / WBAT Treatments Frequency: -[**Month (only) 116**] leave incision open to air. -Please do not soak or scrub incision. Please pat incision dry after getting wet. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1113**] Date/Time:[**2148-3-1**] 11:10 Completed by:[**2148-2-27**]

[ "E878.1", "458.29", "285.1", "715.36", "E849.5" ]

icd9cm

[ [ [] ] ]

[ "81.54", "99.04" ]

icd9pcs

[ [ [] ] ]

2767, 2823

1107, 2130

349, 385

2897, 2906

857, 1084

3556, 3744

585, 589

2153, 2744

2844, 2876

2930, 3210

604, 838

3228, 3375

3397, 3533

290, 311

413, 543

565, 569

44,643

199,779

34690

Discharge summary

report

Admission Date: [**2198-8-25**] Discharge Date: [**2198-9-3**] Date of Birth: [**2128-2-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: choledocholiathiasis, hypotension, SIRS Major Surgical or Invasive Procedure: ERCP with sphincterotomy, NGt placement ERCP [**8-25**], spincterotomy, stone retrieval. *s/p ERCP repeated [**9-3**] for CBD stent placement* History of Present Illness: HPI: 70 yo F with HTN and hypercholesterolemia who presents with vomiting and diarrhea [**2-10**] acute choledocholithiasis c/b gallstone pancreatitis and ileus. . Prior to admission, patient reports 2-3 days of vomiting and diarrhea and poor po intake. She denies any associated fevers, chest pain, shortness of breath, dizziness, lightheadedness or dysuria. She notes a similar episode several months ago consisting of 1 week of vomiting and diarrhea that resolved w/o intervention, and had attributed the symptoms to the flu. . The patient initially presented to an [**Hospital3 10310**] Hospital. She was noted to have triage bp 59/36, improved to 118/44 with 2 L NS. She was noted to have a WBC 24,000 with BUN/Cr 44/4.2 (baseline unknown). CT abdomen/pelvis reportedly revealed a dilated common bile duct, pancreatits and question of an ileus. She received Piperacillin/Tazobactam 3.375g. She was transferred to [**Hospital1 18**] for further care including urgent ERCP. . On presentation to [**Hospital1 18**] ED, T 98.6 HR 75 BP 108/55 18 99% 2L. While in the ED, the patient did spike to 101.3 and had hypotension to 66/38. She received a total of 5 L NS and 1 dose of pip/tazo 4.5gm with improvement in bp to 100/43. She underwent RUQ U/S revealing a non-obstructive common bile duct stone without dilatation, gallbladder thickening or pericholecystic fluid. Intermittent obstruction could not be excluded. Given her history, she was taken for ERCP where she reportedly had several large stones extracted with good biliary drainage after extraction. No pus was noted. Of note, she was also found on routine blood work to have a Cr of 3.9. . ROS: Otherwise negative in detail. She does note an estimated 8lb weight loss over an estimated 5 months. She notes a cough productive of bland sputum starting one week prior to presentation. She denies any new lower extremity edema Past Medical History: HTN Hypercholesterolemia Social History: Lives alone. Denies tobacco use. Notes rare EtOH use. Family History: No family history of GI malignancy or gallbladder disease. Physical Exam: AF, VSS Gen: Well-appearing. NAD. HEENT: PERRL. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Obese, mildly distended. Normoactive bowel sounds. No tenderness, rebound or guarding. Ext: No edema. Skin: no jaundice Neuro: A&O x3. . Pertinent Results: BUN/creat 49/3.9-->24/1.0-->11/0.7 Mag 1.9 Phos 3.0 WBC 10.7-->16->14 with 76.9%N. Lipase on admission: 3279->176 LFTs normalized ALT 184->27 AST 101->23 . UA [**8-30**] NEGATIVE Urine cx [**8-30**]: YEAST 10K to 100K Blood cx [**8-25**], [**8-26**]: NTD Urine Cx [**8-25**] neg Stool cx and c-diff [**8-25**]: negative . . Imaging/results: . RUQ US: [**8-31**]: 1. Limited examination. Echogenic liver consistent with fatty infiltration, although other forms of liver disease including more significant hepatic fibrosis or cirrhosis, could result in a similar appearance. 2. Decreased caliber of the common bile duct since [**2198-8-25**], now non- distended at 4 mm, but with small shadowing stones seen within the distal duct. 3. Cholelithiasis without evidence of cholecystitis . CT noncontrast [**8-30**]: IMPRESSION: 1. Bilateral pleural effusions, most prominent on the left with adjacent basilar atelectasis. No suspicious consolidation worrisome for pneumonia. 2. Scattered not enlarged mediastinal lymph nodes are probably reactive. 3. Slightly prominent esophagus, could be due to inadequate distension or esophagitis, but difficult to assess without oral contrast. Correlate with clinical symptoms. If warranted, barium swallow could further characterize this. . KUB [**8-28**]: resolving ileus . KUB:[**8-26**] Findings are most consistent with an adynamic ileus with some increased distention of both small and large bowel with air. . . CXR; [**8-26**]: An NGT extends below the diaphragm, however, courses quite laterally and inferiorly in the abdomen. This may indicate an abdominal wall hernia. Correlation with administration of air and auscultation is recommended. Some dilated loops of large and small bowel were noted. No free air seen. Left basilar atelectasis and/or fluid stable in appearance. [**2198-8-25**]: ERCP Impression: Impacted stone in the major papilla Pre-cut sphincterotomy Stones at the common bile duct Mild Biliary dilation Stone extraction with balloon catheter [**9-3**] ERCP: Impression: Evidence of a previous sphincterotomy was noted in the major papilla. A single diverticulum with large opening was found on the rim of the major papilla. There was a filling defect that appeared like sludge in the lower third of the common bile duct. The sludge was extracted successfully using a 12 mm balloon. A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully Recommendations: Please call if develops jaundice, black stools, fever, or abdominal pain juices today when awake, alert, and at baseline follow for response/complications Consider cholecystectomy Repeat ERCP in 3 months for stent removal. --------- Discharge: [**2198-9-3**] 05:30AM BLOOD WBC-11.8* RBC-3.44* Hgb-10.5* Hct-30.9* MCV-90 MCH-30.5 MCHC-33.9 RDW-12.6 Plt Ct-296 [**2198-9-3**] 05:30AM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2* [**2198-9-3**] 05:30AM BLOOD Glucose-128* UreaN-10 Creat-0.6 Na-133 K-4.0 Cl-101 HCO3-24 AnGap-12 [**2198-9-3**] 05:30AM BLOOD ALT-14 AST-21 AlkPhos-67 [**2198-8-27**] 05:30AM BLOOD Lipase-136* [**2198-9-3**] 05:30AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.2 Mg-1.9 Brief Hospital Course: 70 year old female with HTN, dyslipidemia admitted [**8-25**] with abdominal pain, nausea/vomiting, diarrhea. Labs and imaging demonstrating cholilithiasis, choledocholithiasis complicated by gallstone pancreatitis (lipase >3000)and cholangitis requiring ICU stay, s/p 5L IVF/zosyn, s/p emergent ERCP [**8-25**] with impacted stones s/p sphincterotomy, stone retrieval. Transfered to gen med [**8-26**]. Pain improved, labs improved. Also had ARF, which improved back to baseline with IVF. [**Hospital 8351**] hospital course complicated by ileus s/p NGT placement [**8-26**], which eventually resolved, with pt tolerating PO, Abx switchted to cipro/flagyl [**8-29**] and she completed 7day course [**8-31**]. Was doing very well and ready for discharge when she started having low grade temps and leukocytosis [**8-31**]. Work up with UA, CXR/CT chest was negative. RUQ US showed presence of CBD stone. Repeat ERCP performed [**9-3**] with stone extraction and stent placement. She did very well post procedure and was discharged home. She will be scheduled to return for stent removal in 3 months. She was advised to follow up for evaluation for cholecystectomy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**]. Medications on Admission: - Lisinopril/HCTZ 10/12.5mg Daily - Atenolol 50mg Daily - Simvastatin 20mg Daily in the evening Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: choledocholiathiasis Discharge Condition: stable Discharge Instructions: Please follow your temperatures. If you have new cough, shortness of breath, recurrent of abdominal pain, nausea, please call you doctor or return to the ED. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2198-9-12**] 11:30 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2198-9-12**] 2:20 please follow up with your primary care doctor, Dr. [**Last Name (STitle) **], in 1 week after discharge, [**Telephone/Fax (1) 5685**]

[ "560.1", "272.0", "584.9", "038.9", "576.1", "995.92", "574.91", "577.0", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7688, 7694

6049, 7301

352, 497

7758, 7766

2891, 2981

7972, 8405

2546, 2606

7447, 7665

7715, 7737

7327, 7424

7790, 7949

2621, 2872

273, 314

525, 2411

2995, 6026

2433, 2459

2475, 2530

19,272

129,280

51217

Discharge summary

report

Admission Date: [**2134-1-31**] Discharge Date: [**2134-2-17**] Date of Birth: [**2080-11-11**] Sex: F Service: ORTHOPEDICS HISTORY OF PRESENT ILLNESS: This is a 53-year-old female who was involved in a high-speed motor vehicle accident on [**2134-1-31**], which resulted in multiple injuries involving closed fracture of the distal midshaft tibia and fibula on the left, a right calf compartment syndrome, and right ankle bimalleolar fracture. PAST MEDICAL HISTORY: Breast cancer. Depression. Fibromyalgia. Hyperthyroidism. Muscle spasms. Lumpectomy of the right breast. ALLERGIES: PAXIL CAUSING ANAPHYLAXIS. DEMEROL, MOTRIN, AND TETRA CAUSING SWELLING ON THE NECK. THE PATIENT IS ALSO ALLERGIC TO TAPE. MEDICATIONS ON ADMISSION: Klonopin, .................., Synthroid, Buspar. PHYSICAL EXAMINATION: General: On presentation the patient was alert and oriented times three. She was in no distress. GCS score of 15. Vital signs: Temperature 97.2??????, heart rate 109, blood pressure 126/46, respirations 20, oxygen saturation 99% on room air. HEENT: The patient had a cervical collar. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. Abdomen: Soft, nontender, nondistended. Obese. Rectal: Guaiac positive. Rectal sphincter had normal tone. Extremities: There was an abrasion over the right shin. There was valgus deformity over the right leg. Dorsalis pedis pulse on the right side appreciated by Doppler only. There was an abrasion of the anterior left knee and left calf, the right calf was swollen with ecchymosis. Both feet and all toes were warm. There was good capillary refill. Neurological: Normal, including motor exam and sensation to light touch. IMAGING: X-ray of right tibia showed tibial fracture with valgus angulation and right bimalleolar ankle fracture. Left lower extremity with midshaft tibia/fibular fracture and left proximal fifth metatarsal fracture. HOSPITAL COURSE: Fracture tibial plateau was reduced in the Emergency Department. Later that day, the patient was taken to the Operating Room. The patient underwent multiple external fixation of the right lower extremity and ankle with closed reduction of both knee and ankle fractures. Right calf with four compartment fasciotomies and VAC placement was also performed. The surgery was done after an in depth discussion with the patient regarding the seriousness of her injuries. The patient had full understanding of the procedure and agreed to undergo surgery. On postoperative day #1, the patient was able to move her arms and toes. The patient was started on intravenous Levofloxacin and Kefzol postoperatively, as she was running a low-grade temperature. Her hematocrit was low at 21, and the patient was transfused 2 U of packed red blood cells. She was able to communicate by writing notes. Her distal lower extremity pulses were detected by Doppler. Antibiotics were given, along with subcue Heparin. On [**2134-2-3**], the patient was taken back to the Operating Room for closure of the wound and two fasciotomies of the right leg. Prior to surgery, the calf was supple. The skin was minimally swollen and was easily approximated. The surgery was imperative to prevent the high risk of infection of the fractured tibial plateau. The patient tolerated the procedure well and was transferred to the Medical Surgical Floor. The patient had a central venous line placed in the left subclavian on [**2134-2-1**]. The patient had a CT scan of the lumbosacral spine that showed no spondylolysis or any evidence of facet injury. She had some degenerative changes at L4, 5, and L5-S1 facet joints. Logroll precautions were discontinued. During this admission, peripheral pulses were carefully monitored. For anticoagulation, the patient was started on Lovenox. After the second surgery, the patient was continued on intravenous Ancef for prophylaxis of infection. On postoperative day #2 from the second surgery, the patient was able to ambulate out of bed to chair with assistance, nonweightbearing of the right lower extremity. On [**2134-2-8**], the patient was taken to the Operating Room again where fixators were removed. The patient underwent open reduction and internal fixation of the right tibial plateau and right ankle. There were no complications during the surgery. For control of pain, Dilaudid PCA was successfully used. The patient was mobilized with Physical Therapy, nonweightbearing of the right lower extremity. PCA was discontinued on postoperative day #3, [**2134-2-11**], and pain was controlled with oral Dilaudid and OxyContin with good effect. The patient was reevaluated and discharged home on [**2134-2-17**], after home safety recommendations were discussed with the patient. The patient will need to continue to be nonweightbearing on the right lower extremity, weightbearing as tolerated on the left. She will need to continue Lovenox 30 mg subcue q.24 hours for the next 14 days. She will follow-up with Dr. [**First Name (STitle) 11674**] on [**2134-2-24**], one week after discharge. DISCHARGE DIAGNOSIS: 1. Status post open reduction and internal fixation of right tibial plateau fracture, open reduction and internal fixation of right ankle fracture on [**2134-2-8**]. 2. Please see preoperative diagnosis. 3. Bivalved cast of the right lower extremity, nonweightbearing. DISCHARGE MEDICATIONS: Docusate Sodium 100 mg p.o. b.i.d., Bisacodyl 10 mg p.r. at h.s. p.r.n., Lovenox 30 mg subcue q.24 hours, Tylenol 650 mg p.o. q.4-6 hour p.r.n., Oxycodone 6 mg p.o. q.4-6 hours p.r.n., Iron .................. Complex 150 mg b.i.d. p.o. for 30 days, Clonazepam 1 mg p.o. b.i.d., Ranitidine 150 mg p.o. b.i.d., Sertraline HCL 25 mg p.o. q.d., Levothyroxine Sodium 112 mcg p.o. q.d., Buspar 10 mg p.o. b.i.d., Milk of Magnesia 30 ml p.o. q.6 hours p.r.n. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 44181**] Dictated By:[**Last Name (NamePattern1) 4307**] MEDQUIST36 D: [**2134-4-23**] 15:35 T: [**2134-4-26**] 10:36 JOB#: [**Job Number 106267**]

[ "V10.3", "E823.0", "824.4", "822.0", "311", "729.1", "823.22", "285.1", "958.8" ]

icd9cm

[ [ [] ] ]

[ "78.17", "83.65", "83.14", "79.36", "88.48", "93.57" ]

icd9pcs

[ [ [] ] ]

5440, 6170

5143, 5416

765, 815

1984, 5122

838, 1966

174, 468

491, 738

5,631

170,408

52896

Discharge summary

report

Admission Date: [**2157-12-31**] Discharge Date: [**2158-1-9**] Date of Birth: [**2112-3-4**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 6114**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: EGD Bronchoscopy Intubation Placement/removal of central line History of Present Illness: Pt is a 45 yo female w/ h/o hodgkins disease (s/p xrt 17 yrs ago c/b development of esophageal stricture s/p multiple esophageal dilatations), recurrent aspiration PNA's, COPD who presents with worsening SOB. Pt was recently hospitalized in early [**Month (only) 1096**] with similar complaints. At that time she had dilatation of her middle esophagus however still had tight LES. After the hospitalization the pt was able to tolerate PO but still had trouble swallowing. @ days prior to this admission she had several episodes of emesis and felt as if she had aspirated. She used her inhaler with little relief. Progressively her breathing worsened and decided to come to the hospital. She states she completed her antibiotic course from last admission. She denies any recent fevers, chills, chest pain, palpitations, wt loss, myalgias, arthralgia, LE edema. She got the flu shot this year and pneumovax last year. She has a family history of early COPD development. In the ED she was started on ceftaz, azithro, flagyl. Currently she states that her breathing is improved, however still worse then her baseline. She does have a headache but otherwise feels unchanged from admission. Past Medical History: PMHX: # copd (stage 3 emphysema)- Her pulmonologist is Dr. [**Last Name (STitle) **]. Her last PFTS [**8-3**]- fvc-75%, fev1- 31%, mmf-9%, and fev1/fvc-41%. # anxiety # thrombocytosis (700s-900s) # asplenic- pneumovax [**5-2**] # erosive gastritis- last egd [**2156**], on protonix # Hodgkins- s/p xrt, s/p elap for staging # anticardiolipin ab- s/p cva- on coumadin- goal [**2-2**], IgM+ [**7-3**]. # pityriasis rosea # anemia: h/o iron deficiency, recently taken off of iron supplements, last iron level 389 ([**6-3**])(, tibc 534, ferritin 22. MCV still 70. Recent SPEP negative. TSH 1.4 # hypothyroidism PSHX: s/p chole s/p splenectomy s/p hernia repair Allergies: PCN- hives Social History: SHX: +tobacco history- approx 18 pack years, quit 5 years ago.Has two children<12 years old, divorced. Unemployed [**2-1**] lung disease. Family History: FHX: father- MI mother and grandmother with emphysema at a young age but both smoked Physical Exam: PE T 100.1 BP 130/78 HR 126 RR 28 O2sats 97% 3LNC Wt 164 lbs Gen: Mildly dyspneic, able to complete sentences HEENT: clear OP, dry mm Neck: supple, no LAD Lungs: Barrel chested, decrease BS at right base w/ crackles bilaterally Heart: Tachy, distant heart sounds, no m/r/g Abd: Soft, NT, ND + BS Ext: no edema, 2+ DP bilaterally Neuro: A&O times 3 Pertinent Results: CTA Chest [**2157-12-31**] 1. No pulmonary embolus detected. 2. Mixed changes in the numerous bilateral nodular opacities. The appearance favors an infectious etiolgy such as [**Doctor First Name **], TB or atypical pneumonia. Continued follow/up is recommended to assess for resolution after treatment. [**2157-12-31**] 05:20PM BLOOD WBC-38.4*# RBC-3.75* Hgb-7.4* Hct-27.0* MCV-72* MCH-19.8* MCHC-27.5* RDW-18.0* Plt Ct-958* [**2158-1-5**] 03:41AM BLOOD WBC-24.6*# RBC-3.56* Hgb-8.3* Hct-26.1* MCV-73* MCH-23.2* MCHC-31.6 RDW-20.2* Plt Ct-576* [**2158-1-7**] 06:40AM BLOOD WBC-15.9* RBC-4.05* Hgb-9.2* Hct-30.5* MCV-75* MCH-22.7* MCHC-30.1* RDW-21.9* Plt Ct-603* [**2158-1-9**] 06:10AM BLOOD WBC-12.8* RBC-4.20 Hgb-9.8* Hct-32.2* MCV-77* MCH-23.3* MCHC-30.4* RDW-22.3* Plt Ct-573* [**2157-12-31**] 05:20PM BLOOD Glucose-105 UreaN-9 Creat-0.7 Na-139 K-3.9 Cl-103 HCO3-27 AnGap-13 [**2158-1-5**] 03:41AM BLOOD Glucose-123* UreaN-9 Creat-0.4 Na-141 K-3.4 Cl-100 HCO3-33* AnGap-11 [**2158-1-9**] 06:10AM BLOOD Glucose-92 UreaN-11 Creat-0.5 Na-140 K-3.8 Cl-102 HCO3-32* AnGap-10 [**2158-1-7**] 06:40AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3 [**2158-1-3**] 05:02PM BLOOD Type-ART pO2-87 pCO2-86* pH-7.21* calHCO3-36* Base XS-3 [**2158-1-4**] 12:34PM BLOOD Type-ART Temp-36.7 pO2-97 pCO2-45 pH-7.42 calHCO3-30 Base XS-3 Intubat-NOT INTUBA [**2158-1-6**] 06:11AM BLOOD Type-ART Temp-36.3 pO2-71* pCO2-46* pH-7.48* calHCO3-35* Base XS-9 Intubat-NOT INTUBA Brief Hospital Course: 45 yo female w/ h/o hodkins disease s/p xrt c/b esophageal stricture, multiple aspiration PNA's, COPD who presents with SOB. 1.)Shortness of breath -- Mrs. [**Known lastname **] has recurrent pneumonias resulting from her esophogeal stricture, which causes food to stick while swallowing, forcing her to induce emesis, resulting in aspiration. This sequence of events apparently preceded this admission. It was felt there may have been both an aspiration pneumonia as well as an exacerbation of her COPD. After admission, she was started on ceftzidime, azithromycing, and metronidazole. Pulmonology was consulted for a bronch/BAL to help in determining the ultimate etiology and for micro data. During the bronchoscopy, she developed severe bronchospasm, was intubated, and transferred to the MICU, where she rapidly improved with steroids and scheduled nebs. She was easily extubated the following day and called out the floor. Ultimately, her BAL returned with no microbiological growth, and her antibiotics were stopped, as she was afebrile, was responding best to COPD tx, and was felt not to be infected. She was started on a steroid taper and changed back over to her home inhaler regimen. On this course, she did well with improved O2 saturation, baseline SOB, and no fevers or cough. She was evaluated for home O2, but as she did not desaturate with ambulation, she was felt not to be eligible. 2.)Esophogeal stricture -- She was last dilated on [**2157-12-13**], although the distal portion of the esophagus was not visualized. She was seen by GI inhouse, who performed an EGD that showed strictures and they performed dilation. She was placed on a soft mechanical diet to prevent her from inducing emesis, with the plan for her to follow-up as an outpatient for a re-dilation. 3.)Anti-cardiolipin Ab -- Pt has a h/o CVA. She came in on warfarin, with an INR of 3.3 Warfarin was held and she was put on heparin for invasive procedures. For her outpatient EGD, the warfarin was held on discharge, and she was sent out on Lovenox, with a plan for her to restart warfarin with frequent INR checks, trasitioning back to warfarin after the EGD. Medications on Admission: Buspirone 30mg [**Hospital1 **], tiotropium, levoxyl 125mcg qday, protonix 40mg [**Hospital1 **], albuterol, coumadin 1mg qday, FeSO4 Discharge Medications: 1. Nebulizer with Adult Mask Device Sig: One (1) device Miscell. once. Disp:*1 device* Refills:*0* 2. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: One (1) dose Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*60 doses* Refills:*2* 3. Buspirone HCl 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Enoxaparin Sodium 100 mg/mL Syringe Sig: One (1) ml Subcutaneous Q24H (every 24 hours). Disp:*20 syringes* Refills:*0* 10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. Disp:*2 inhalers* Refills:*2* 11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation TID (3 times a day). Disp:*2 inhalers* Refills:*2* 12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 13. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day for 12 days: Take 4 tablets for 3 days then 3 for 3 days then 2 for 3 days then 1 for 3 days, then stop. Disp:*30 Tablet(s)* Refills:*0* 14. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 15. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO once a day: On hold until after EGD. Discharge Disposition: Home Discharge Diagnosis: Aspiration pneumonia COPD exacerbation Secondary: copd (stage 3 emphysema) anxiety thrombocytosis (700s-900s) asplenic- pneumovax [**5-2**] erosive gastritis- last egd [**2156**], on protonix Hodgkins- s/p xrt, s/p exlap for staging XRT-related esophogeal strictures anticardiolipin ab- s/p cva- on coumadin- goal [**2-2**], IgM+ [**7-3**]. pityriasis rosea anemia Discharge Condition: Fair, with improved sx, no fever off antibiotics, good oxygen saturation Discharge Instructions: Please call your primary doctor or return to the ED for shortness of breath, fevers/chills, chest pressure/pain, or other concerning symptoms. Take medications as prescribed. You will be taking Lovenox (enoxaparin), an anticoagulant, in place of your warfarin until you get your EGD. Stop the injections the day before your EGD. On the evening of the EGD, please restart your warfarin. On the following day ([**1-18**]) take both your warfarin and the Lovenox injection. You will take both of these medications for two days ([**1-18**] and [**1-19**]), then have your blood levels checked. Your PCP will tell you when you can stop the Lovenox injections. Until you get your EGD, please adhere to a full liquids and soft solids diet. You can take things such as boost shakes. Please follow-up as below. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5629**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-1-11**] 10:30 Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2158-1-17**] 8:00 Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Where: GI ROOMS Date/Time:[**2158-1-17**] 8:00 You have an appointment with Dr. [**Last Name (STitle) **] on [**1-25**] at 1:20 pm. Please call [**Telephone/Fax (1) 55570**] to confirm.

[ "V15.3", "696.3", "286.7", "530.3", "507.0", "300.00", "289.9", "795.79", "E934.2", "491.21", "280.9", "518.84", "201.90" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "99.04", "96.71", "38.91", "42.92", "99.07" ]

icd9pcs

[ [ [] ] ]

8584, 8590

4387, 6550

291, 354

8998, 9072

2919, 4364

9931, 10616

2449, 2535

6734, 8561

8611, 8977

6576, 6711

9096, 9908

2550, 2900

232, 253

382, 1568

1590, 2277

2293, 2433

76,097

126,100

5187

Discharge summary

report

Admission Date: [**2109-10-25**] Discharge Date: [**2109-11-5**] Date of Birth: [**2057-1-18**] Sex: F Service: NEUROLOGY Allergies: Oxycontin / Percocet Attending:[**First Name3 (LF) 618**] Chief Complaint: Aphasia with Right Hemiparesis Major Surgical or Invasive Procedure: - Administration of IV tPa - Stenting of left ICA History of Present Illness: PER STROKE FELLOW: This is a 57 yo RH woman with history of HTN and hyperlipidemia per her sister not on any medications who presents after complaining of right arm "pain" according to her sister starting at 8pm tonight and then became very sleepy. She then fell asleep on the couch. Her family was leaving at 830pm and attempted to wake her up and noted that she was mute and not responding. Per her sister she was "focusing to the left" by this she means looking towards the left. The family also noted that she was not moving her right side. She was brought to ER for further eval. ROS: Per her family she has not seemed herself for the last couple of weeks. She has complained of weakness of the right upper extremity it has been difficult for her to put on her bra and hold her granddaughter. She had not reported any loss of vision or other symptoms per the family. Past Medical History: PMH: fibromyalgia, asthma, HTN, GERD, OA, depression, dyslipidemia, chronic back pain PSH: carpal tunnel release, c-section, [**Hospital Ward Name **] cyst removal Social History: HABITS: - smoker 2ppd since age 14 has been "cutting back" recently to about 1ppd. - Family denies alcohol. Family History: not obtained Physical Exam: On ADMISSION: vitals BP 135/76,HR 76, RR 18, 99%RA FSBS 140, MS: She is somnolent but easily arousable, she is mute, does not follow commands, she does appear to attend to right side. CN: eyes cross midline, no blink to threat on the right, rigght NLF flat, Motor: No movement against gravity in the right upper or lower ext. right toe is upgoing. Sensory: does not grimace on the right. coord: unable to perform due to aphasia. gait: deferred. 1a LOC =1 1b Orientation =2 1c Commands= 2 2 Gaze =0 3 Visual Fields =1 4 Facial Paresis = 1 5a Motor Function R UE = 3 5b Motor Function L UE= 0 6a Motor Function R LE= 3 6b Motor Function L LE= 0 7 Limb Ataxia = 0 8 Sensory perception = 0 9 Language = 3 10 Dysarthria = 2 11 Extinction/Inattention = 0 NIHSS 18 Pertinent Results: Admission Labs: . WBC-8.0 RBC-4.24 HGB-11.6* HCT-34.0* MCV-80* MCH-27.3 MCHC-34.0 RDW-13.3 GLUCOSE-89 UREA N-11 CREAT-0.5 SODIUM-141 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 PT-12.9 PTT-26.6 INR(PT)-1.1 . URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.046* . Modifiable Risk Factors for Stroke HBA1c: pending Chol, TG, HDL, LDL . IMAGING: . CTA/P Head, Neck ([**2109-10-25**]): IMPRESSION: 1. Findings suggestive of an acute left ACA infarct with no hemorrhage. 2. High-grade, greater than 80%, stenosis of the left internal carotid artery. 3. CT perfusion demonstrating decreased blood volume and increased transit time indicative of infarct in the left anterior cerebral artery distribution. 4. Occlusion of the left anterior cerebral artery in its A2 segment at the level of the genu of corpus callosum. . CT Head ([**2109-10-26**]): IMPRESSION: Foci of increased density along the left frontal cortex could be secondary to contrast within the ischemic cerebral cortex or due to petechial hemorrhages. No other abnormalities are seen. . CT Head ([**2109-10-26**]): IMPRESSION: Hypodensity involving the left frontal lobe in a distribution compatible with further evolution of known left ACA territorial infarction. No evidence of associated superimposed hemorrhage, shift, or herniation. NOTE ADDED IN ATTENDING REVIEW: The hyperattenuating foci at the periphery of this process, demonstrated on the study of some 14 hours earlier are no longer evident; this likely represented "pooling" of residual contrast material (from interval catheter angiogram) at the margin of the ischemic/infarcted zone of cortex. There is no evidence of hemorrhagic conversion at this time. . MRI/A Brain ([**2109-10-27**]): PRELIM READ: Evolving left anterior cerebral artery infarct with multifocal left middle cerebral artery infarcts involving both the cortex and deep brain nuclei as well as several punctate embolic infarcts within the left posterior cerebral artery distribution. . Transthoracic Echocardiogram: [**10-29**] The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). A patent foramen ovale or small secundum-type atrial septal defect is present. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF 70%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Positive bubble study indicating presence of patent foramen ovale or small secundum atrial septal defect. CTA head [**10-31**] IMPRESSION: 1. Visualized stent in the left internal carotid artery appears to be patent, with normal blood flow in the carotid artery . The reminder of the intracranial circulation is unremarkable. 2. Sequelae for prior left anterior and middle cerebral artery distribution infarct, overall unchanged. Asymmetry of pattern of vascular enhancement in cerebral convexities, possibly related to increased collateral flow to the left cerebral hemisphere. CXR [**11-1**]: FINDINGS: The new Dobbhoff catheter is satisfactory with its tip in the distal stomach. Lungs are fully expanded and clear with no mass, consolidation, or pneumothorax. Cardiomediastinal silhouette is normal. A gastric band is noted. IMPRESSION: Satisfactory placement of new Dobbhoff catheter. Brief Hospital Course: Ms. [**Known lastname 732**] is a 57 year-old right-handed smoker with a past medical history including hypertesnsion and hyperlipidemia who presented to the [**Hospital1 18**] with a global aphasia and right hemiparesis. She was admitted to the stroke service from [**2109-10-25**] to [**2109-11-5**]. . NEURO . The patient's symptoms were quite concerning for stroke. Accordingly, CT of the head with angiography and perfusion components was performed. The study demonstrated an acute left ACA infarct with decreased blood volume and increased transit time in the left anterior cerebral artery distribution in the setting of a high grade (>80%) stenosis of the left internal carotid artery. As clnical evaluation revealed a NIHSS of 18, and there were no contraindications, IV tPa was administered. The patient was subsequently taken to the operating room for emergent stenting of the left internal carotid artery. Follow-up CT scans demonstrated stability of the left ACA infarction without superimposed hemorrhage, shift, and herniation. In addition to the evolving left anterior cerebral artery infarct, an MRI/A demonstrated multifocal left middle cerebral artery infarcts involving both the cortex and deep brain nuclei as well as several punctate embolic infarcts within the left posterior cerebral artery distribution. To evaluate for a cardioembolic source, a transthoracic echocardiogram was done. The study showed no source of an embolism but a patent foramen ovale (see Pertinent Results). Although it was felt that her embolic event was most likely the result of embolization from carotid stenosis, give PFO, she underwent a hypercoagulable evaluation that was negative (see pertinent results). She was treated with ASA 81 mg, and Plavix 75 mg. She should remain on these medications until follow up with neurology or at least six months. She was started on atorvastatin 40mg, her LDL was 101, her goal is deemed to be < 70. . After above treatment, she improved only mildly clinically. She became more alert and awake, however remained severely aphasic (global), unable to follow commands reproducibly. She had a dense right hemiparesis. . ID. Course was complicated by aspiration PNA on noted on [**10-29**] based low grade fever, witnessed aspiration, tachypnea and and intermittent hypoxemia and leukocytosis to 14K. The remainder of infectious evaluation, including UA/UCx, BCx were negative. There was no diarrhea. She was treated with seven day of Levofloxacin/Flagyl and her respiratory status improved. At time of discharge, she remained afebrile with RR 12-18 and normoxemic, however her WBC remained persistently elevated over the last two HD 14.7 -> 15.9 at time of discharge. No source of infection was noted, however this may require re-evaluation should she become febrile or show other signs of SIRS. . CV. Patient was temporarily hypertensive acutely post CVA and stening in range of 190-200s systolic. She was started on Lisinopril and Norvasc. Blood pressure goal is deemed to be 130/80 or less mmHg. . GI. Patient had dysphagia and aspiration s/p stroke. Nutrition was provided via an NGT/dobhoff tube. Given her history of obestity s/p Gastric banding and hernia repair w/ mesh, she was evaluated by surgery. Gastric band was decompressed to allow dobhoff placement and adequate nuntrition. She will require further surgery follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] for her gastric band. Patient undrewent multiple swallow evaluations, the latest showing a safe ability for intake of regular solids and nectar thick liquids. She will require a repeat evaluation and monitoring of calorie counts prior to change to thin liquids and discontinuation of the dobhoff feeding tube. . PULM. History of Asthma. Not an active issue during hospitalization. Patient was treated with albuterol nebulizers as needed. . CHRONIC PAIN. Not an active issue during hospitalization. Amytriptilline was held during post acute stroke phase to monitor mental status. This may be restarted if patient's mental status continues to remain alert and awake. Medications on Admission: ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - [**12-28**] Tablet(s) by mouth every 6 hours as needed for pain AMITRIPTYLINE - 10 mg Tablet - [**12-28**] Tablet(s) by mouth at bedtime ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth once a day CELECOXIB [CELEBREX] - (Prescribed by Other Provider) - 200 mg Capsule - one Capsule(s) by mouth once a day CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain Medications - OTC ACETAMINOPHEN [TYLENOL ARTHRITIS PAIN] - (Prescribed by Other Provider; OTC) - 650 mg Tablet Sustained Release - 2 Tablet(s) by mouth every four (4) hours as needed FERROUS SULFATE [IRON (FERROUS SULFATE)] - (Prescribed by Other Provider) - 325 mg (65 mg) Tablet - one Tablet(s) by mouth once a day PEDIATRIC MULTIVITS-IRON-MIN [FLINTSTONES COMPLETE] - (Prescribed by Other Provider) - Tablet, Chewable - one Tablet(s) by mouth once a day . NKDA Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP > 180. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 13. Morphine Sulfate 1 mg IV Q2H:PRN pain 14. 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. 15. 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. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Left MCA and ACA strokes Secondary: HTN, HL Discharge Condition: Stable. T 98.9F, BP 108-127/50-60s, HR 60s, RR 16, 99% RA. Neurological exam: Aphasic, global; awake, alert, does not follow commands. Eyes cross midline, pupils 4-> 2 mm bilaterally, R facial droop and dense R sided hemiplegia. Grimaces to noxious on R side. Right toe extensor. Discharge Instructions: You were admitted to [**Hospital1 18**] with difficulty with speech and right sided weakness. You had a severe stroke. You were treated with tPA (a clot lysing material) to improve you symptoms as well as a stent to your left carotid artery. You were also treated for high blood pressure, high cholesterol and malnutrition. You were started on multiple medications, please ensure to continue to take these. You were arranged follow up with a neurologist. You should also follow up with your primary care doctor, and your surgeon. Followup Instructions: NEUROLOGY: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2109-12-31**] 1:30 PRIMARY CARE: Please call the office of Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] at [**Telephone/Fax (1) 1792**] within one month of discharge from rehabilitation. SURGERY: Please follow up with Dr. [**Last Name (STitle) **] who is taking care of your gastric band, please call ([**Telephone/Fax (1) 21213**] to follow up within 3 weeks of discharge from the hospital. NEUROSURGERY: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2109-12-5**] at 10.30am in the [**Hospital **] Medical Building. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2109-11-10**]

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icd9cm

[ [ [] ] ]

[ "88.41", "99.10", "38.93", "00.63", "00.45", "00.40", "96.04", "96.6", "96.71", "00.61" ]

icd9pcs

[ [ [] ] ]

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67,589

163,992

38838

Discharge summary

report

Admission Date: [**2150-3-23**] Discharge Date: [**2150-3-26**] Service: ORTHOPAEDICS Allergies: Celecoxib / Olmesartan / Beta-Blockers (Beta-Adrenergic Blocking Agts) / Digoxin / Oxymetazoline Attending:[**First Name3 (LF) 8587**] Chief Complaint: hardware failure(screw protusion)right distal femur Major Surgical or Invasive Procedure: removal of hardware right femur History of Present Illness: This is a pleasant 88-year-old female who sustained a fall and had a supracondylar femur fracture that was fixed with a lateral plate six months ago. She had been doing well until she had noticed increasing prominence around her lateral plate. She was referred to the [**Hospital1 **] for evaluation of hardware loosening. Past Medical History: Hypertension occasional arrhythmia Social History: She does not use tobacco and occasionally drinks alcohol and lives independently. Family History: NC Physical Exam: Physical examination on discharge: VS: 97.5 75 134/71 18 96/RA General: Elderly female, lying in bed. Awake and interactive. HEENT: Normal cephalic atraumatic, pupils equal round reactive to light accommodation, extra ocular motions intact bilaterally. Oral mucosa moist. NECK: No lymphadenopathy, no jugular venous distention, no bruit. Cardiac: Regular rate and rhythm, no murmurs, no gallops, no rubs. RESP: Clear, no wheezes, no crackles, no rhonchi. Abdomen: + Bowel sounds, soft, non-distended, non-tender, no masses, no guarding or rebound tenderness. Spine & Extremities: No mid-line tenderness. No focal neurological deficits. -Left lower extremity: Skin intact. No deformity. Compartments soft and compressible. 2+ dorsal pedialis. Motor and sensory grossly intact. -Right lower extremity: Skin intact. No deformity. Compartments soft and compressible. 2+ dorsal pedialis. Motor and sensory grossly intact. SKIN : No rash, no ulceration, no erythema in decubiti. Neurological: Alert and oriented to person, place and date. Cranial nerves [**2-6**] intact Pertinent Results: [**2150-3-25**] 04:53AM BLOOD WBC-5.8 RBC-2.98* Hgb-9.5* Hct-29.2* MCV-98 MCH-31.8 MCHC-32.4 RDW-13.1 Plt Ct-233 [**2150-3-25**] 04:53AM BLOOD Glucose-97 UreaN-20 Creat-0.7 Na-133 K-3.9 Cl-99 HCO3-26 AnGap-12 [**2150-3-25**] 04:53AM BLOOD Plt Ct-233 [**2150-3-25**] 04:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2150-3-24**] 08:21PM BLOOD Type-ART pO2-101 pCO2-44 pH-7.43 calTCO2-30 Base XS-3 Comment-RECEIVED O TTE [**2150-03-25**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Probable diastolic dysfunction. Mild aortic regurgitation. Moderate pulmonary artery systolic hypertension. Brief Hospital Course: Ms [**Known lastname 86207**] was admitted to the Orthopedic service on [**2150-3-23**] for removal of hardware in right femur due to a prominent screw from the locking plate that has backed out from possible nonunion of her supracondylar femur fracture left. She underwent surgery without complication on [**2150-3-24**]. She was extubated without difficulty and transferred to the recovery room in stable condition and later transferred to the floor. On the floor she did initially fine but suddenly felt "unwell" while sitting upright eating dinner. She may have felt some dizziness, but denied chest pain, shortness of breath, abdominal pain, nausea, and palpitations. She was slumped forward in her chair, but did not fall out. She was transferred to the bed and a code blue was called. There was some concern that she was initially apneic, but she was breathing regularly by the time the code team arrived. ABG showed 7.43/44/101/30 with a lactate of 1.8. Telemetry revealed a narrow complex rhythm that was regular, and she maintained a pulse throughout the Code. FS was 161 and BP was 109/67. She received approximately 500 cc of NS and was transferred to the MICU. She did loose her urine, but denied loss of bowel continence, post-ictal confusion, chest pain, and palpitations when she woke up. No tremors or jerks were noted by the Code team. Of note, patient did once syncopize 5 years ago while walking. It has not happened since then. Her metabolic workup was unremarkable. No events on tele overnight in the ICU. Enzymes were flat, ABG and EKG normal. Finger stick was normal. Although patient had some bladder incontinence, seizure seems less likely as patient was not post-icital and normal CT head. No murmurs on exam. CXR unremarkable. Given prodrome and the fact that patient has had syncope before, and that this event occurred while eating, patient may have had vasovagal event. A TTE was performed which demonstrated normal global systolic function. She was transferred from the ICU to the floor on [**2150-3-25**] in stable condition. Her right knee has been tapped on [**2150-3-25**] to rule out a persisting infection prior to a potential knee revision. Results are currently pending. She had adequate pain management and worked with physical therapy while in the hospital. The remainder of her hospital course was uneventful and Ms. [**Known lastname 86207**] is being discharged on [**2150-3-26**]. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Tablet(s) 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 4 weeks. 7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] Discharge Diagnosis: 1. hardware failure, right femur. 2. Old supracondylar femoral fracture with persistent fracture line with some osseous bridging. 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: Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. Activity: -Continue to be touch down weight bearing on your right leg. -Elevate right leg to reduce swelling and pain. -Keep brace on at all times. Keep brace dry. 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. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of 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. Physical Therapy: right lower extremity touch down weight bearing in hinged knee brace with gentle range of motion to right knee. Treatments Frequency: 1. Discontinue sutures 14 days from date of surgery. 2. Elevate right leg. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Completed by:[**2150-3-26**]

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icd9cm

[ [ [] ] ]

[ "81.91", "78.65" ]

icd9pcs

[ [ [] ] ]

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118,666

39088

Discharge summary

report

Admission Date: [**2153-4-13**] Discharge Date: [**2153-5-10**] Date of Birth: [**2073-1-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1115**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: I&D of abdominal wall abscess with placement of drainage ostomy History of Present Illness: Ms. [**Known lastname 56684**] is a 80 yo F NH resident with PMHx of DM2, HTN, dementia, POD admitted for a lower abdominal abscess from perforated diverticulosis. Patient was transferred from OSH for abdominal pain/distention, found to have CT with a possible bladder rupture which turned out to be an abscess. I&D was performed on [**4-13**] with drain placed. Currently, the patient has feculant material coming from the drain from a presumed fistula. Per the surgical team, the patient is not an operative candidate. Past Medical History: dementia HTN diverticulosis GI bleed DM cholescystectomy hysterctomy tonsillectomy Social History: Unable to obtain due to mental status Family History: Unable to obtain due to mental status Physical Exam: NIGHT FLOAT PHYSICAL EXAM Gen: NAD. Oriented x1(name). HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no exudates or ulceration, dry MM Neck: Supple, JVP not elevated. CV: RRR, normal S1, S2. No m/r/g. Chest: Resp were unlabored, no accessory muscle use. Faint crackles at b/l bases, no rales, wheezes or rhonchi. Abd: Obese, mildly distended but soft and NT. No HSM or tenderness. Ostomy noted in suprapubic region with pink-brown liquid Ext: 2+ edema to bilateral thighs/lower back, 1+ dependent edema b/l upper extremities Skin: No stasis dermatitis, ulcers, scars. Neuro: Alert and oriented x 1, CNs II-XII grossly intact, unable to participate in remainder of exam . ACCEPTING TEAM PHYSICAL EXAM 97.6 96.7 134/74 (109-139) 92 (86-100) 24 95%RA Ill appearing woman in no distress, with NGT in place. She opens eyes to voice and can follow simple commands like smile or hand wave, but can't squeeze hand. She cannot verbalize spontaneously or on command. She does track across the room and is alert. L CVL in place, no surrounding erythema or signs of infxn No JVD CTAB anteriorly but poor lung exam, no labored breathing S1 S2 are regular for a bit then spontaneously break into irregular tachycardia, no murmurs are heard. PMI not displaced Obese, ND, BS+ with draining bag in place below umbilicus, with tan brown liquid in bag. She is able to nod yes that she is having pain when abdomen is deeply palpated. Abd not rigid. BUE with scattered ecchymosis, but LUE is somewhat larger than RUE and on medial aspect RUE is erythematous macule BLE with pitting edema to just below mid shin. DP's not palpable. . ON discharge: NAD, VSS. Pt is aaox0, however responsive and interactive. Her anasarca has resolved, she remains tachycardic. Ostomy bag in place draining fistula, lungs are clear. She has several excoriations on her L arm. Pertinent Results: ADMISSION LABS: [**2153-4-13**] 01:03AM BLOOD WBC-18.2* RBC-2.78* Hgb-7.4* Hct-23.8* MCV-86 MCH-26.7* MCHC-31.2 RDW-16.2* Plt Ct-278 [**2153-4-13**] 03:06AM BLOOD WBC-25.3* RBC-3.01* Hgb-8.3* Hct-26.0* MCV-86 MCH-27.5 MCHC-31.8 RDW-16.1* Plt Ct-285 [**2153-4-13**] 02:00PM BLOOD WBC-29.5* RBC-3.34* Hgb-9.0* Hct-28.5* MCV-85 MCH-26.9* MCHC-31.6 RDW-15.8* Plt Ct-348 [**2153-4-14**] 02:22AM BLOOD WBC-24.0* RBC-2.80* Hgb-7.4* Hct-24.0* MCV-86 MCH-26.5* MCHC-31.0 RDW-15.8* Plt Ct-283 [**2153-4-16**] 04:01AM BLOOD WBC-17.5* RBC-3.38*# Hgb-9.1*# Hct-28.2* MCV-83 MCH-27.0 MCHC-32.4 RDW-15.9* Plt Ct-205 [**2153-4-17**] 03:25AM BLOOD WBC-17.2* RBC-3.01* Hgb-8.0* Hct-25.4* MCV-84 MCH-26.7* MCHC-31.6 RDW-16.4* Plt Ct-207 [**2153-4-13**] 01:03AM BLOOD Neuts-90.0* Lymphs-7.8* Monos-2.0 Eos-0.1 Baso-0.1 [**2153-4-17**] 11:31PM BLOOD Neuts-89.7* Lymphs-8.5* Monos-1.4* Eos-0.3 Baso-0.1 [**2153-4-13**] 01:03AM BLOOD PT-16.8* PTT-32.7 INR(PT)-1.5* [**2153-4-13**] 01:03AM BLOOD Glucose-67* UreaN-28* Creat-0.8 Na-141 K-3.7 Cl-116* HCO3-20* AnGap-9 [**2153-4-13**] 03:06AM BLOOD Glucose-84 UreaN-25* Creat-0.7 Na-140 K-3.4 Cl-117* HCO3-18* AnGap-8 [**2153-4-13**] 02:00PM BLOOD Glucose-121* UreaN-21* Creat-0.8 Na-140 K-4.2 Cl-116* HCO3-18* AnGap-10 [**2153-4-14**] 02:22AM BLOOD Glucose-243* UreaN-21* Creat-0.8 Na-138 K-3.9 Cl-115* HCO3-20* AnGap-7* [**2153-4-15**] 04:10AM BLOOD Glucose-184* UreaN-25* Creat-0.7 Na-137 K-4.1 Cl-112* HCO3-23 AnGap-6* [**2153-4-13**] 01:03AM BLOOD ALT-4 AST-6 CK(CPK)-7* AlkPhos-87 TotBili-0.6 [**2153-4-17**] 11:31PM BLOOD ALT-14 AST-29 LD(LDH)-183 AlkPhos-738* TotBili-0.3 [**2153-4-24**] 06:14AM BLOOD Lipase-113* GGT-199* [**2153-4-13**] 01:03AM BLOOD CK-MB-NotDone [**2153-4-13**] 01:03AM BLOOD cTropnT-<0.01 [**2153-4-15**] 11:01PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-4-16**] 06:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-4-16**] 04:11PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-4-17**] 11:31PM BLOOD ALT-14 AST-29 LD(LDH)-183 AlkPhos-738* TotBili-0.3 [**2153-4-24**] 06:14AM BLOOD ALT-11 AST-21 AlkPhos-368* TotBili-0.2 [**2153-4-13**] 01:03AM BLOOD Albumin-<1.0* [**2153-4-13**] 03:06AM BLOOD Albumin-1.1* Calcium-6.8* Phos-2.6* Mg-1.1* [**2153-4-13**] 03:06AM BLOOD Triglyc-73 [**2153-4-15**] 11:01PM BLOOD TSH-3.8 [**2153-4-13**] 01:06AM BLOOD Lactate-1.1 [**2153-4-13**] 02:11PM BLOOD Lactate-1.5 [**2153-4-14**] 03:05AM BLOOD Glucose-241* Lactate-1.7 [**2153-4-14**] 04:04PM BLOOD Lactate-2.0 . [**4-12**] EKG Regular supraventricular rhythmn with baseline artifact precluding definitive rhythm analysis, possibly sinus rhythm with diminutive P waves. Low QRS voltage diffusely. Diffuse non-diagnostic repolarization abnormalities. No previous tracing available for comparison. . Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] . Intervals Axes Rate PR QRS QT/QTc P QRS T 110 160 84 300/387 -49 23 26 . [**4-13**] EKG Sinus tachycardia. Short P-R interval. Low voltage. Leftward axis. ST-T wave abnormalities. Since the previous tracing of [**2153-4-12**] probably no significant change. Clinical correlation is suggested. . Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. . Intervals Axes Rate PR QRS QT/QTc P QRS T 104 100 82 316/393 37 -4 119 . [**4-13**] CXR . SINGLE SUPINE VIEW OF THE CHEST AT 12:00 A.M.: Lung volumes are low, resulting in vascular crowding. Opacity at the left lung base is probably atelectasis or a very small pneumonia. There is no pneumothorax. The heart size is normal. Accounting for patient rotation, there is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. There is no increase in interstitial markings. There is extensive subcutaneous air in the left abdominal wall, tracking along the left chest wall. . IMPRESSIONS: 1. Left lung base opacity may indicate atelectasis or layering pleural effusion. 2. Extensive subcutaneous air overlying the left abdominal wall, tracking to the left chest wall. OSH abdominopelvic CT (reviewed on a separate workstation and not available on [**Hospital1 18**] PACS) demonstrates this to extend from a large abscess in the anterior pelvis. . [**4-15**] EKG Probable atrial fibrillation but baseline artifact makes assessment difficult. Low precordial lead QRS voltage. Modest low amplitude T wave changes. Findings are non-specific. Since the previous tracing of [**2153-4-13**] the rhythm now appears to be atrial fibrillation but baseline artifact makes comparison difficult. . Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. . Intervals Axes Rate PR QRS QT/QTc P QRS T 92 0 102 380/436 0 1 100 . [**4-17**] CXR . IMPRESSION: ET tube in standard placement, nasogastric tube ends in the stomach, left subclavian line in the mid SVC. Small-to-moderate bilateral pleural effusions, and substantial left lower lobe atelectasis unchanged. Heart size normal. No pneumothorax. . [**4-24**] CXR . IMPRESSION: AP chest compared to [**4-19**]: . Moderate left pleural effusion has increased, small to moderate right pleural effusion is new. Left lower lobe previously collapsed is still consolidated and there is new right infrahilar consolidation which could be atelectasis or developing pneumonia. Heart size is obscured but mediastinal vasculature is mildly engorged indicative of volume overload or cardiac decompensation. Nasogastric tube passes into the stomach and out of view. . [**4-24**] RUE U/S IMPRESSION: No evidence of deep vein thrombosis in the right arm. . [**4-27**] CT Pelvis IMPRESSION: 1. Resolution of fluid collections post surgical drainage of large anterior abdominal wall abscess. 2. Small amount o free fluid in the pelvis. 3. Dramatic reduction in the subcutaneous/fascial gas in comparison to the prior study. 4. Persistent large abdominal wall hernia with nonobstructed loops of bowel 5. Increased large pleural effusions with bilateral lower lobe collapse. The study and the report were reviewed by the staff radiologist. . LABS ON DISCHARGE: . Na 139 K 4.3 Cl 108 BUN 23 Creat 0.5 Gluc 155 WBC 7.5 Hct 27.3 Platelets 389 Brief Hospital Course: 80 yoF with DM, HTN, dementia, diverticulosis/GIB who was admitted to SICU after found to have perforated diverticulosis/abdominal abscess/fistula which is now s/p drainage/I&D and 3 wk course of vanc/zosyn, whose post-op course complicated by re-intubation for CHF vs aspiration PNA, extubated after diuresis; also with tachy-brady (atrial tach, asymptomatic bradycardia) syndrome and malnutrition. During this hospitalization, her goals of care were changed to be DNR/DNI and goals were shifted towards comfort care after discuassion with hospice and family. She will f/u with hospice at her nursing facility on discharge. . 1. Respiratory failure: Unclear if truly CHF vs aspiration pneumonia, but pt with bilateral pleural effusions and vascular engorgement reflective of gross volume overload. She was intubated on admission and intubated a second time through admission, however was extubated after diuresis. She was called out of the ICU and diuresed further, and had no further respiratory issues through admission, was satting well on RA and not tachypneic by discharge. She was kept on aspiration precautions, had S/S evaluation showing that she can tolerate soft solids and should have nutritional supplement with meals and 1:1 supervision during eating. . 2. Abscess: Pt was admitted to SICU septic from abdominal abscess. Taken to OR and is s/p I&D with feculent material draining into ostomy bag several days after procedure. Assumed fistula between GI tract, abscess, and skin; however pt not a surgical candidate given poor nutritional state. She was therefore treated with 3 wks of vanc/zosyn with no further signs of infection. She was discharged with an ostomy bag draining the fistula. . 3. Tachy/bradycardia: Pt noted to have runs of narrow complex SVT through SICU and started on Metoprolol; then noted to have bradycardia and beta blockade held. EP was consulted and did not feel any intervention warranted. Off beta blockade, had fewer episodes of bradycardia and noted to have 4.5 second pauses, so transferred to CCU for further monitoring. After transfer to the CCU, a family meeting was held to discuss the possibility of pacemaker placement, however not consistent with goals of care which are to avoid further interventions and procedures. Pt was discharged off of her bblocker given risk of bradycardia, and HRs in the low 100s were tolerated. . 4. Mental status: Has baseline dementia with superimposed delirium, although unclear whether this may also be her new baseline mental status. She was occasionally oriented to person only, alert and conversational but oftentimes lethargic, but would respond to voice and carry conversational. She was often inattentive though. She could do days of the week forward with frequent prompting and months of the year forward to about [**Month (only) 216**], again with frequent prompting. She had improved greatly through her course though with ability to state days of the week backwards in the week prior to discharge and at baseline MS per family . 5. Nutrition: Pt with low albumin precluding fistula repair. In discussion with surgery, she was a poor candidate for PEG placement her hx of pulling tubes. Dobhoff was placed but then pulled by pt. Discussion of goals of care was held with family and palliative care, who opted for no further interventions to help improve pts nutrition other than supervision while eating and nutritional supplements. . 6. HTN/Pump: She was continued on Metoprolol (as above, continued on it after pacer placement), Lasix, Valsartan, Simva, baby ASA. She had an echo while admitted that showed EF 60% but with some evidence of diastolic failure through elevated pulmonary pressure. She was grossly anasarcatous but unlikely due to CHF, more likely due to poor albumin and overly aggressive volume resuscitation. Her bblocker was held due to her bradycardia, and simvastatin and asa were dc'd on discharge given newly defined goals of care. She was discharged on a smaller dose of lasix than what she was taking on admission due to her poor PO intake. . 7. DM: Continued on regular insulin sliding scale with good control. . 8. Anemia: Hct's stable through admission. Has h/o GIB, was continued on PPI. Ostomy contents were guaic and were positive, so likely having chronic slow ooze from GI tract. Hct 27 and stable on discharge. . 8. Goals of care: extensive goals of care discussion was held by medical team, palliative care and pts family whose goals are towards comfort. Therefore, pacemaker and peg tube placement were not done and medications were minimized on discharge. She was permitted to maintain HR in the 100s given decision not to place pacemaker. Hospice has been notified at her rehab facility and the family will follow up with them on discharge. Family also expressed interest in not rehospitalizing, however this will need to be further addressed by hospice on discharge. Pts code status was changed to DNR/DNI during the hospitalization. . COMM: [**First Name8 (NamePattern2) **] [**Known lastname 56684**] (in [**Country **]) [**Telephone/Fax (1) 86637**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) 86638**] (work), [**Telephone/Fax (1) 86639**]. [**Name (NI) **] [**Name (NI) 56684**] (son) **[**Telephone/Fax (1) 86640**]** or [**Telephone/Fax (1) 86641**] Medications on Admission: Meds: Toprol XL 25', Diovan 80', Aricept5', Duoneb, Zocor 20mg qdaily, Prilosec, Insulin sliding scale, iron 325mg twice daily Discharge Medications: 1. Miconazole Powder [**Telephone/Fax (1) **]: One (1) application Miscellaneous once a day: apply to affected areas daily. 2. Ipratropium Bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Oxycodone 5 mg/5 mL Solution [**Telephone/Fax (1) **]: One (1) PO Q4H (every 4 hours) as needed for pain: hold if RR<12, oversedated. Disp:*100 mL* Refills:*0* 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Valsartan 80 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Last Name (STitle) **]: One (1) Nasal once a day. 8. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day as needed for pain. 9. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 10. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) unit Injection four times a day: please take according to your sliding scale prior to hospitalization. 11. Albuterol Sulfate Inhalation Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: Ruptured abdominal abscess with likely communicating fistula. Tachy-brady syndrome, s/p pacemaker placement Malnutrition Volume overload/Anasarca Altered mental status Discharge Condition: Mental Status: Confused - always Level of Consciousness: Lethargic but arousable Activity Status: Bedbound Discharge Instructions: You were admitted to [**Hospital1 18**] for septic shock in the setting of a ruptured abdominal abscess. You were in the ICU where they resuscitated you. You received antibiotics for your abscess. You also had a problem with you heart rhythm and your medications were changed to help control your heart rhythm. You had a tube placed in your nose to your stomach so that you can improve your nutrition, however you eventually removed this tube on your own. Given that our goal was to make you comfortable, we decided not to place a permanent feeding tube. You were discharged to your nursing facility and will follow-up with hospice at your facility. . The followed changes were made to your medication regimen: 1) Your blood pressure medications were changed. Please stop taking metoprolol, lisinopril and nifedipine. You should start taking valsartan 240 mg daily. 2) Your lasix dose has been decreased from 40 to 20 mg. This may need to be adjusted after you leave the hospital. 3) You were given a prescription for oxycodone for pain 4) Please take your insulin per your pre-hospitalization schedule 5) Your donepezil was discontinued . Please call your doctor if you feel that your pain is not well controlled or you are not comfortable. Please follow up with your doctor and the hospice service at your nursing facility Followup Instructions: Please follow up with hospice and your doctor at your nursing facility. Hospice has notified that you will be coming and will be discussing goals of care with your family when you arrive.

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28508

Discharge summary

report

Admission Date: [**2178-11-12**] Discharge Date: [**2178-12-3**] Date of Birth: [**2106-1-8**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 30**] Chief Complaint: back pain Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: 72 yo Portugese speaking F with hx of HTN, ? CHF, hyperchol presents with acute onset of upper back pain starting approx 12 hours prior to transfer. Pt states that she has never had pain like this before and did have associated nausea and vomiting. No CP or SOB. No Lightheadedness or dizziness. Pt does report that she was admitted to an outside hospital for "heart problems". By report from the OSH pt has a hx of a chronic thoracic aortic aneurysm. Pt presented to OSH ED with pain and vomiting. Found to have BP 240/120. Pt received Labetolol and Nipride and BP improved to 140's, HR 60's. CTA suggestive of acute on chronic thoracic aortic disection. Pt transfered for further management and surgical consult. Past Medical History: HTN CHF: necessitating hosp in [**Month (only) 958**] Hypercholesterol Hx thoracic aortic aneurysm Social History: denies smoking, drinking of IV drug use. Born in [**Last Name (un) **], lived in [**Country 6171**] adn [**Country 480**] approx 30yr ago. Retired; used to work in factories. No hx of blood transfusions. 3 children from 3 men, now currently married Family History: DM CVA hx of aneurysms in sister and [**Name2 (NI) 12232**] Physical Exam: Admission exam by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: VS T:96.6 P:75 BP: 107/54 RR: 20 O2Sat:100% GENERAL: Awake and alert, responding to questions. HEENT: Pupils equal. MM dry. Op clear. NECK: supple, JVD flat CARDIOVASCULAR: RRR, faint 2/6 systolic murmur, left PMI. LUNGS: rales at b/l bases. ABDOMEN: NDNT, no palpapble pulse, no bruit, non-tender, hyperactive BS. EXTREMITIES: warm and well perfused. NEURO: non focal. GUIAC positive Pertinent Results: Admission labs: pH 7.44 pCO2 29 pO2 111 HCO3 20 Lactate:1.6 . 135 I 102 I 13 --------------< 204 3.2 I 20 I 0.6 . Trop <0.01 x3 Ca: 9.0 Mg: 1.3 P: 4.7 ALT: 6 AP: 54 Tbili: 0.4 Alb: 3.6 AST: 17 [**Doctor First Name **]: 108 Lip: 17 . 9.7 6.2 >---< 240 28.1 PT: 12.2 PTT: 28.3 INR: 1.0 . ECG: NSR, prolonged QT, TWI V1-V3, no St changes. . ESR: 150 CRP: 78 to 36 anti-CCP positive RF: 342 [**Doctor First Name **] positive . Q-Fever, Histo, Bartonella, Brucella negative. Lyme negative Crypto negative HIV negative RPR negative CSF ([**2178-11-18**]): WBC 1, RBC 22, negative cultures . Total chol 158, trig 124, HDL 41, LDL 92 . Cortisol stim: adequate. . Imaging: MRI Chest ([**2178-12-2**]): Extensive type B intramural hematoma extending from the takeoff of the left subclavian artery through the entire visualized thoracic and upper abdominal aorta. Additionally noted on the current exam is marked delayed crescentic enhancement of the entire aortic wall in the region affected by the intramural hematoma, compatible with associated engorgement of the vaso vasorum. Lack of circumferential enhancement argues strongly against aortitis. . AP Wrist Hand ([**2178-11-28**]): Generalized osteopenia. No definite fracture or other traumatic injury. The erosion of the right triquetrum and the ulnar styloid process may be early indicators of rheumatoid arthritis disease. However, no further findings to corroborate such a diagnosis are noted. . Shoulder Xray ([**2178-11-28**]): Severe diffuse osteopenia, likely secondary to osteoporosis. Given the severity of the osteopenia, the sensitivity is decreased for detecting subtle nondisplaced fracture. . CTA Chest, Abdomen, Pelvis with and without contrast ([**2178-11-23**]):1. Stable appearance of the chest, abdomen and pelvis with type B intramural hematoma and associated penetrating ulcer. 2. Improving ground-glass opacities. 3. Stable 4-cm infrarenal abdominal aortic aneurysm. 4. Stable left common iliac artery aneurysm. . WHITE BLOOD CELL STUDY ([**2178-11-23**]): No definite evidence for acute peri-aortic infection. . CXR ([**2178-11-18**]): Borderline interstitial pulmonary edema is new. Large heart is stable. There is no change in the mediastinal contour of the generalized thoracic aorta. Small bilateral pleural effusion, stable. No pneumothorax. . HEAD CT ([**2178-11-17**]): There is no intracranial hemorrhage. There is no midline shift, mass effect or hydrocephalus. There is a lacune within the left thalamus. There are multiple foci of low attenuation within the periventricular and subcortical white matter of both cerebral hemispheres most consistent with chronic microvascular ischemic changes. There is atherosclerotic disease within the anterior and posterior circulations. . CTA Chest, Abdomen, Pelvis ([**2178-11-17**]): 1. Unchanged appearance of extensive Type B intramural hematoma from the subclavian artery origin to the upper abdominal aorta. The associated posterior penetrating ulcer at the diaphragmatic hiatus is stable. No new dissection. 2. Findings suggestive of congestive failure/volume overload with bilateral pleural effusions and septal thickening. 3. Four-cm infrarenal abdominal aortic aneurysm. 4. Mild aneurysmal dilation of the left common iliac artery. 5. Dense coronary vascular calcifications. . Renal Ultrasound ([**2178-11-16**]): Normal arterial and venous waveforms seen within the main renal arteries and veins bilaterally. Good flow demonstrated within parenchymal branches of the mid and lower poles bilaterally, upper pole is not well visualized secondary to patient respiration. . CTA Chest ([**2178-11-14**]): 1) Extensive acute tupe B intramural hematoma extending from the origin of the subclavian artery throughout the entire thoracic and upper abdominal aorta. Assessment of the distal abdominal aorta and iliacs is suboptimal on this study. 2) Prominent posterior penetrating ulcer at the level of the hiatus. 3) 3.7cm distal AAA. 4) Evidence of volume overload with bilateral pleural effusions. 5) Prominent subcarinal nodes, likely reactive. . ECHO ([**2178-11-13**]): 1. The left atrium is normal in size. The left atrium is elongated. The interatrial septum is aneurysmal. 2.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%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is moderately dilated. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The descending thoracic aorta is mildly dilated. 5.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.The pulmonary artery systolic pressure could not be determined. 8.There is no pericardial effusion. . EKG: Sinus rhythm. A-V conduction delay and A-V nodal Wenckebach. Diffuse non-specific ST-T wave flattening. . CXR ([**2178-11-12**]): 1. Tortuous aorta dilated up to 4.9 cm to the level of the thoracic aortic arch. This exam cannot prove or rule out the possibility of aortic dissection or aneurysmatic rupture. If clinically suspected further evaluation with chest CTA is recommended. 2. Small bilateral pleural effusions. . Brief Hospital Course: 72 yo F with intramural hematoma of thoracic aorta. Hospital course by problem: . 1. Chronic TAA: Initially, surgical intervention was not felt to be indicated as it was a type B hematoma. Her BP was managed initially with labetolol and Nipride for goal SBP<140 and >100 given likely hx of chronic elevated BP and risk for hypoperfusion. She was ruled out for an acute MI. Her Hct dropped to 23.9 on [**11-14**] and developed acute abdominal pain radiating to her back, so a CTA was repeated and showed possible large intramural hematoma in descending thoracic aneurysm. Vascular Surgery was notified and upon review of the scans w/ Radiology, felt the aneurysm was not significantly changed. We changed her antihypertensives and had good BP control with labetalol (changed to Toprol XL upon dispo), amlodipine, and valsartan. . 2. Intramural hematoma with penetrating ulcer: The etiology was unclear. Initially, the ulcer was thought [**3-12**] atherosclerotic disease. However, the patient became febrile during her stay and rheum and ID were consulted. She had a negative workup for infectious cause. Her rheum workup was above and notable for positive [**Doctor First Name **], anti-CCP, and RF in the setting of an elevated ESR and CRP. An MRI was obtained and revealed a pattern which was not consistent with aortitis. Thus, her fever and inflammatory response was thought to be [**3-12**] rheumatoid arthritis and the patient did not have an underlying aortitis. The patient was discharged with good blood pressure control and plans to return on [**12-18**] for surgical intervention of her penetrating aortic ulcer. Additionally, we started atorvastatin for goal LDL<70 and for it's anti-inflammatory activity. She has VNA to assist with medication compliance as well as frequent blood pressure checks. . 3. Fevers: As above. The patient had intermittent fevers and confusions for approx 6 days in the middle of her stay. CSF analysis and head CT showed no pathology. ID workup was negative. The fever was thought [**3-12**] inflammatory state. The mental status change was thought [**3-12**] ICU delirium and it improved rapidly after she was transferred to the floor. . 4. CHF: EF>55% by ECHO. No evidence of heart failure on chest Xray. No shortness of breath and oxygen saturation in high 90's. We continued lasix low salt diet . 5. Hyponatremia: Labs were consistent with SIADH. The patient had resolution of her hyponatremia prior to discharge. . 6. Osteoporosis: All of her bone films mentioned severe osteopenia. We started the patient on alendronate, calcium, and vitamin D during her admission and continued it upon discharge. Medications on Admission: ( pt does not know, report from OSH ED) Calcium Kcl Sucralfate 1mg Isosorbide 30mg Metoprolol 50 Felodipine 5 Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). Disp:*4 Tablet(s)* Refills:*2* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: - atherosclerotic aortic disease with hematoma, dissection, ulceration - rheumatoid arthritis - hypertension - AAA - osteoporosis Secondary: - CHF - hyperlipidemia Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with upper back pain. You had a thoracic aortic anuerysm and elevated blood pressure. We controlled your blood pressure. You were evaluated by the surgeons, infectious disease specialists, and rheumatologists and we determined that you will need surgical correction of your aorta in a few weeks. You also likely have rheumatoid arthritis and will need to see rheumatology as an outpatient. . Please take your medications as instructed. It is very important for you to take your blood pressure meds. Please keep your followup appointments as directed. Please adhere to a cardiac healthy diet. . If you develop severe chest or back pain, have difficulty breathing, or become severely nauseated please contact your doctor and return promptly to the emergency department. Followup Instructions: Please bring your daughter to all of your appointments. . You are scheduled to have an operation on [**2178-12-18**] at 10:30am. Please arrive at the hospital no later than 8:30 am. Please have nothing to eat for 12h prior to your surgery. . Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 69075**] on Monday, [**12-7**] at 11:15. The office phone number is [**Telephone/Fax (1) **] and fax [**Telephone/Fax (1) 69076**] . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 2206**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2178-12-16**] 11:30

[ "428.0", "401.9", "714.0", "293.0", "428.30", "733.00", "276.2", "272.4", "280.0", "427.31", "441.01", "440.0", "253.6", "792.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "03.31" ]

icd9pcs

[ [ [] ] ]

11335, 11392

7450, 10124

283, 300

11609, 11618

2022, 2022

12475, 13104

1452, 1513

10284, 11312

11413, 11588

10150, 10261

11642, 12452

1528, 2003

234, 245

328, 1044

2038, 7427

1066, 1166

1182, 1436

21,111

149,436

30666

Discharge summary

report

Admission Date: [**2177-5-1**] Discharge Date: [**2177-5-5**] Date of Birth: [**2100-12-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 76-yo-woman referred from [**Hospital3 3583**] w/ NSTEMI. She was feeling well until 20 hours ago, when she developed subacute onset substernal chest pain radiating to both shoulders, L>R, w/ no dyspnea, palps, nausea, or diaphoresis. The pain persisted throughout the day, prompting her to present to [**Hospital3 3583**] 12 hours ago. There, she was found to have ST depressions on EKG leads V2-V6, CK 1000 w/ elevated trop I. She was treated w/ ASA 325 mg and nitro gtt. Concern for possible aortic dissection precluded further anti-platelet therapy, and she was transferred to [**Hospital1 18**] for further care. . In our ED, BP was 160 and HR 100. She complained of continuing chest pain, [**3-4**] severity. Repeat CK was 1893 w/ MB 271 and trop 3.07. Cardiology consultants recommended further therapy w/ plavix 600 mg, metoprolol 25 mg PO, heparin gtt, and integrillin gtt. Chest pain resolved w/ medical therapy, and she is now admitted to the CCU for ongoing management. . Currently, she denies any chest pain, palps, dyspnea. ROS reveals no fever, chills, weight loss, abd pain, hematuria, diarrhea, melena, or hematochezia. She does have intermittently productive cough for 6 weeks, which seems to have started after she began lisinopril therapy. Past Medical History: - HTN - hyperlipidemia - chronic kidney disease: unknown baseline renal fxn - COPD - Hypothyroid - PVD: s/p LE PCI - GERD Social History: smoked 50 pack-years, but quit 1 year ago. There is no history of alcohol abuse. Retired Accounts Payable manager for Ocean Spray. Family History: Father had MI in his 40s; no h/o sudden death. Physical Exam: VS: T 98.0, BP 148/68, HR 74, RR 12, O2 98% 2L/m Gen: obese woman sitting up in bed, pleasant and conversational, in NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa, no JVD. CV: irreg irreg s1/s2, no s3/s4/m/r Pulm: poor air movement throughout w/ diffuse exp wheezing b/l, no crackles. Abd: obese, +BS, soft, NTND. No abdominial bruits. Ext: warm, dopplerable PT pulses b/l w/ dopplerable right DP, left DP not dopplerable, no edema. Neuro: a/o x 3 Pertinent Results: LABS ON ADMISSION: [**2177-5-1**] 12:40AM WBC-7.1 RBC-3.95* HGB-11.6* HCT-35.3* MCV-89 MCH-29.3 MCHC-32.8 RDW-14.3 [**2177-5-1**] 12:40AM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-1.8 [**2177-5-1**] 12:40AM CK-MB-271* MB INDX-14.3* [**2177-5-1**] 12:40AM cTropnT-3.07* [**2177-5-1**] 12:40AM CK(CPK)-1893* [**2177-5-1**] 12:40AM GLUCOSE-126* UREA N-27* CREAT-1.4* SODIUM-140 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [**2177-5-1**] 01:19PM WBC-9.6 RBC-3.68* HGB-11.0* HCT-33.2* MCV-91 MCH-30.0 MCHC-33.2 RDW-14.1 [**2177-5-1**] 01:19PM CK-MB->500 cTropnT->25.00 [**2177-5-1**] 01:19PM CK(CPK)-5865* [**2177-5-1**] 01:19PM GLUCOSE-165* UREA N-23* CREAT-1.4* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 . On the day of discharge: [**2177-5-5**] 05:15AM BLOOD WBC-8.3 RBC-3.23* Hgb-9.4* Hct-28.7* MCV-89 MCH-29.1 MCHC-32.7 RDW-14.1 Plt Ct-354 [**2177-5-5**] 05:15AM BLOOD Glucose-115* UreaN-48* Creat-2.1* Na-137 K-4.5 Cl-102 HCO3-25 AnGap-15 [**2177-5-5**] 05:15AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.2 . CARDIAC CATH: COMMENTS: 1. Coronary angiography in this right dominant system demonstrated an LMCA free of angiographically significant disease. The LAD had minimal, non flowlimiting disease. The RCA was without angiographically apparent disease. The LCX was totally occluded proximally. 2. Limited resting hemodynamics revealed elevated systemic arterial pressures. 3. Initial access was attempted via the right femoral artery, but this was unsucessful due to severe PVD. The right radial artery was then prepped and accessed without incident. 4. PCI FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. PCI of LCX . ECHOCARDIOGRAM: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal and mid-segments of the inferior, inferolateral and lateral walls (left circumflex coronary artery distribution). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg) and Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are three moderately thickened aortic valve leaflets. There is mild valvular aortic stenosis (valve area 1.2-1.9 cm2). The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. There is moderate calcification of the posterior mitral annulus and moderate thickening of the mitral valve chordae, but no mitral stenosis. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate regional left ventricular systolic dysfunction c/w CAD. Mild calcific aortic stenosis. . Brief Hospital Course: The patient was admitted to the CCU following her cardiac catheterization for a circumflex artery ST elevation MI. Her circumflex artery was re-opened and a bare metal stent was placed. Despite a massive CK and troponin elevation, she was hemodynamically stable. An echocardiogram revealed a left ventricular ejection fraction between 30% to 35%. The patient was started on low dose ASA (as she was also anticoagulated for AFIB) and plavix. Home prevastatin was discontinued and atorvastatin 80mg was started. The patient could likely do with a repeat echocardiogram in 6 weeks. . She had minor probelms with oxygenation secondary to volume overload from intra and post-cath IV fluids as well as COPD. She was diuresed and her COPD was treated with inhaled bronchodialtors and steroids. . There was some concern on an OSH chest X-ray for a pneumonia, but she was not initiated on antibiotic therapy as clinically she did not appear to have a pneumonia. . She had a 12 hour long episode of atrial fibrillation 2 days prior to discharge. She was loaded on amiodarone, given and taught how to use lovenox, started on coumadin, and discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor to test for recurrent Afib and assess her QT interval. . On the day of discharge the patient's creatinine was slightly elevated from baseline at 2.1. This was likely related to contrast nephropathy and aggressive diuresis. The patient's lisinopril was decreased. The patient was not sent on lasix. . Follow up was arranged with the patient's PCP and with Dr. [**Last Name (STitle) 3321**] in the department of Cardiology. Medications on Admission: 1. Albuterol PRN 2. Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **] 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Lisinopril 20 qd 5. Omeprazole 20 qd. 6. Prevastatin 40 qd 7. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Please take 2 tablets 3 times a day for 3 days. Then take 2 tablets 2 times a day for 5 days. Then take 2 tablets once a day until you see Dr. [**Last Name (STitle) 3321**]. . Disp:*100 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily): Please ask your primary care doctor on [**Last Name (STitle) **] if you need to continue taking this. Disp:*qs injection* Refills:*0* 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Please review the dosage of this medication with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]. . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Posterior ST-elevation Myocardial Infarction - note that the EKGs showed ST depression in the anterior leads, but that these are actually posterior elevations. Discharge Condition: Vital signs stable. Patient is chest pain free. Discharge Instructions: Please take your medications as prescribed. Please follow up with your primary care doctor as detailed below. . Please return to the hospital if you should have chest pain, shortness of breath, palpitations, or any other concerning symptoms. . Please notify your primary care physician regarding your worsening leg pain. He will likely need to have you see the vascular surgeon who has seen you in the past. . You will be taking several new medications including plavix, coumadin and lovenox for the short term. Please take these medications as prescribed and review them with your primary care provider. . Please ensure that your INR and kidney function are checked when you see your primary care physician on [**Location (un) **]. . You will follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3321**]. He may want to get a repeat ECHOcardiogram in 6 weeks to determine how well your heart is functioning. Followup Instructions: Please follow up with your Nurse [**Last Name (Titles) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13470**] on [**Last Name (NamePattern1) 20212**] [**2177-5-7**] at 1:30 pm - you need to have your INR and renal function checked. . Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3321**], [**6-4**] at 10AM in [**Location (un) 3320**] - you were given the address. Completed by:[**2177-5-6**]

[ "530.81", "427.31", "403.90", "V17.3", "440.20", "244.9", "496", "272.4", "410.61", "585.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.20", "36.06", "00.40", "00.45", "88.56", "00.66", "37.22" ]

icd9pcs

[ [ [] ] ]

9282, 9341

5511, 7167

326, 351

9545, 9595

2550, 2555

10615, 11106

1951, 1999

7436, 9259

9362, 9524

7193, 7413

4171, 5488

9619, 10592

2014, 2531

276, 288

379, 1641

2570, 4154

1663, 1787

1803, 1935

41,438

131,522

40601

Discharge summary

report

Admission Date: [**2193-3-7**] Discharge Date: [**2193-3-26**] Date of Birth: [**2115-11-30**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: pancreatitis Major Surgical or Invasive Procedure: intubation x 2 extubation x 1 tracheostomy placement History of Present Illness: The patient is a 77 yo woman with a history of ovarian cancer who presented to [**Hospital3 **] Hospital on [**2193-2-26**] with left chest pain/COPD exacerbation. A chest CT on admission showed a large complex mass between the stomach and pancreas. She was receiving treatment for a COPD flare (cetriaxone, azithromycin, prednisone, alb/atrov nebs/morphine) with a plan for outpatient evaluation of this mass when she developed a sudden onset of severe abdominal pain on hospital day 4, with a lipase >[**2181**]. She has had several CT scans and an MRI which show that the mass is complex, and from what they can see, doesn't seem to be the source of pancreatitis. Most recent CT continues to show severe, necrotizing pancreatitis. They are unable to biopsy mass due to pancreatitis. GI there thinks she needs an EUS to evaluate the mass and to see if it is somehow implicated in this severe pancreatitis. She has no history of ETOH abuse, and no gallstones. She has been afebrile and has not received antibiotics. She had a PICC placed for initiation of TPN. Of note, her hospital course has been complicated by a fall, resulting in an anculated and displaced wrist fracture. She underwent a closed reduction of the wrist fracture under local anesthetic. She was transferred here for a possible EUS for further evaluation of pancreatic mass in the setting of acute necrotizing pancreatitis. Review of Systems: (+) Per HPI (-) Denies starting new medications. All other review of systems negative. Past Medical History: mild dementia h/o ovarian ca gout bipolar - not active major depression nephrolithiasis thalassemia minor, s/p right hemiarthroplasty ?COPD - has not carried this diagnosis before, but clinically presented with COPD flare and improved with treatment Allergies: NKDA Social History: Lives with her daughter. Denies smoking, drinking or any drugs. Family History: Vertebral malignancy Physical Exam: Physical Exam on Admission: VS: 98.0 183/92 117 22 95%3L repeat: 98.3 150/86 104 16 93%3L GEN: Moderate-severe distress due to pain; audible wheezes HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: loud expiratory wheezes bilaterally GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present; right arm with stent/bandage in place NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**3-21**] motor function globally DERM: no lesions appreciated Pertinent Results: Labs on Admission: [**2193-3-8**] 03:20AM BLOOD WBC-20.0* RBC-5.58* Hgb-11.2* Hct-37.3 MCV-67* MCH-20.1* MCHC-30.1* RDW-15.9* Plt Ct-383 [**2193-3-8**] 03:20AM BLOOD Neuts-87* Bands-3 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2193-3-8**] 03:20AM BLOOD PT-12.4 PTT-20.1* INR(PT)-1.0 [**2193-3-8**] 03:20AM BLOOD Glucose-131* UreaN-60* Creat-0.8 Na-150* K-4.5 Cl-114* HCO3-28 AnGap-13 [**2193-3-8**] 03:20AM BLOOD ALT-14 AST-10 LD(LDH)-272* AlkPhos-64 TotBili-0.8 [**2193-3-8**] 03:20AM BLOOD Lipase-150* [**2193-3-8**] 03:20AM BLOOD proBNP-798* [**2193-3-8**] 07:56PM BLOOD CK-MB-6 cTropnT-0.12* [**2193-3-8**] 03:20AM BLOOD Albumin-2.7* Calcium-9.4 Phos-3.1 Mg-2.5 [**2193-3-8**] 07:56PM BLOOD TSH-0.11* [**2193-3-8**] 07:56PM BLOOD VitB12-1252* [**2193-3-15**] 03:56AM BLOOD Hapto-288* . Urine Studies on Admission: [**2193-3-8**] 07:56PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024 [**2193-3-8**] 07:56PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2193-3-8**] 07:56PM URINE RBC-8* WBC-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2193-3-8**] 07:56PM URINE CastHy-1* [**2193-3-8**] 07:56PM URINE Hours-RANDOM UreaN-1258 Creat-80 Na-12 K-53 Cl-33 [**2193-3-8**] 07:56PM URINE Osmolal-671 . Labs prior to death: [**2193-3-25**] 04:40AM BLOOD WBC-17.2* RBC-3.71* Hgb-9.8* Hct-31.6* MCV-85 MCH-26.4* MCHC-31.0 RDW-22.2* Plt Ct-384 [**2193-3-20**] 03:47AM BLOOD Neuts-87* Bands-0 Lymphs-9* Monos-2 Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2193-3-25**] 04:40AM BLOOD PT-13.9* PTT-24.7 INR(PT)-1.2* [**2193-3-25**] 04:40AM BLOOD Glucose-129* UreaN-98* Creat-2.5* Na-143 K-4.0 Cl-108 HCO3-20* AnGap-19 [**2193-3-25**] 04:40AM BLOOD ALT-111* AST-67* LD(LDH)-369* AlkPhos-442* TotBili-3.3* [**2193-3-17**] 07:30PM BLOOD CK-MB-1 cTropnT-0.15* [**2193-3-25**] 11:14AM BLOOD Type-ART Rates-/25 Tidal V-500 PEEP-10 FiO2-70 pO2-59* pCO2-33* pH-7.42 calTCO2-22 Base XS--1 Intubat-INTUBATED Vent-SPONTANEOUS . PERTINENT IMAGING STUDIES: [**2193-3-8**] CXR: No previous images. Left subclavian PICC line extends to at least the upper portion of the SVC where it is difficult to assess in the mediastinum. Low lung volumes may account for some of the prominence of central vessels. However, there is some increased opacification in the retrocardiac region on the left with poor definition of the hemidiaphragm. This raises the possibility of lower lobe pneumonia and possible effusion. . [**2193-3-11**] CTA Torso: 1. Peripancreatic fluid collections and inflammation consistent with a known underlying pancreatitis with no significant pancreatic necrosis identified. High-density material is present within a "pseudocyst" projecting off the pancreatic tail into the lesser sac and is consistent with internal hemorrhage. The amount of blood within the cyst is essentially unchanged dating back to [**2193-2-27**] exam and would not account for recent hematocrit drop. There is suggestion of a possible small residual pseudoaneurysm off the splenic artery measuring 3-4 mm. This may self thrombose, but depending on patient's clinical status a dedicated angiogram could be performed (would recommend waiting until at least tomorrow given the high contrast dose of current exam). The vasculature remains patent without any thrombosis. 2. Interval increase in size to moderate left and small right pleural effusions result in near complete atelectasis of the left lower lobe and partial atelectasis of the right lower lobe. Interval increase in amount of intra-abdominal and pelvic ascites as well as degree of soft tissue anasarca. 3. Bilateral hypoattenuating renal lesions, some of which are too small to characterize and others which are clearly simple cysts, unchanged from outside exams. 4. Tip of OG tube within the gastric antrum. . [**2193-3-13**] LENIs: Limited examination due to soft tissue edema and swelling. Among the calf veins, only the left posterior tibial veins were seen. No DVT seen within visualized vessels. . [**2193-3-13**] RUQ U/S: No ultrasound evidence of cholecystitis. . CXR [**2193-3-15**]: Dense opacification at the left lung base is probably due to a combination of small left pleural effusion and substantial left lower lobe atelectasis, given leftward mediastinal shift, rather than pneumonia. Mild cardiac enlargement is stable. Upper lungs are clear of consolidation, but there is still mild residual left perihilar edema, and the hilar vasculature is still dilated. ET tube and right internal jugular line, left PIC catheter are in standard placements. Nasogastric tube passes below the diaphragm and out of view. No pneumothorax. . [**2193-3-18**] Wrist x-ray: In comparison with study of [**3-5**], overlying cast greatly obscures detail. There appears to be some increased bone formation about the previously described fracture of the distal radius with continued separation of the ulnar styloid process. . [**2193-3-18**] Head CT: No evidence of an acute intracranial abnormality. . [**2193-3-18**] CT Torso: 1. Interval development of large right lateral abdominal wall/flank extraperitoneal hematoma. Active extravasation cannot be assessed without intravenous contrast. 2. Unchanged hemorrhagic pseudocyst near the pancreatic tail without any findings of new interval bleeding. Overall, slight decrease in the quantity of eripancreatic/intraabdominal/intrapelvic fluid. 3. Slight decrease in soft tissue anasarca. Decrease in bilateral pleural effusions, which are now small. 4. Unchanged non-obstructive right lower pole renal calculi. 5. Single new right upper lobe ground-glass opacity is nonspecific and may represent area of developing pneumonitis. . [**2193-3-20**] RUQ U/S: 1. No evidence for portal or hepatic vein thrombosis. 2. Gallbladder sludge. . [**2193-3-24**] CT Torso: 1. Stable bilateral pleural effusions and adjacent compressive atelectasis; however, underlying infectious process cannot be completely excluded in the correct clinical setting. 2. Stable ground-glass opacity in the right peripheral upper lung zone. Ground-glass opacity in the left upper lobe, new since [**2193-3-18**]. Findings may represent infectious process, other considerations are edema versus hemorrhage. 3. Hemorrhagic pseudocyst near the pancreatic tail is slightly decreased in size compared to the most recent prior without evidence of new interval bleeding; however, active extravasation cannot be excluded in the absence of IV contrast. 4. Stable amount of free fluid within the abdomen with fluid collections noted along the lesser curvature and liver hilum relatively unchanged since [**2193-3-18**]. 5. Stable to slightly decreased right lateral abdominal wall/flank extraperitoneal hematoma/ hemorrhagic fluid, this is contiguous posteromedially with the enlarged right psoas muscle. Active extravasation cannot be evaluated in the absence of IV contrast. 6. Stable soft tissue anasarca. 7. Stable left renal hypodensity likely consistent with cyst. Stable nonobstructive renal calculi in the right kidney. Brief Hospital Course: HOSPITAL COURSE This is a 77yo F w dementia, and COPD who was transferred to [**Hospital1 18**] for pancreatitis, and atrial fibrillation and subsequently developed respiratory distress in the setting of PNA and fluid overload. Her course was complicated by multiple pneumonias, a retroperitoneal hematoma and acute renal failure. Ultimately she was made comfortable and died on [**2193-3-26**] at 9:30am. Hospital course by problem list: . # Respiratory Failure: Pt was intubated on [**2193-3-8**] in the setting of AMS and hypoxic respiratory failure. She was found to have a PNA and worsening fluid overload in the setting of aggressive fluid hydration for pancreatitis. She was treated w a course of Vanc/Zosyn for VAP and then was diuresed (once she was medically stable. She was s/p 1 failed trial of extubation thought to be [**12-19**] continued fluid overload and poor nutritional state. She extubated and re-intubated on [**2193-3-16**]. A trach was placed on [**2193-3-22**]. Subsequently she developed a new VAP on CT of the chest and was placed back on abx. Oxygen requirments continued to worsen and she was made comfortable on [**2193-3-25**]. . # Sepsis: She was intermittently septic requiring pressors during her hospitalization. Likely causes were from ventilator-acquired PNA. Ultimately prior to her death, her WBC rose and she required more ventilatory support, suggesting a pneumonia as the cause for her sepsis and death. . # Acute Pancreatitis: Imaging on admission demonstrated acute pancreatitis c/b with internal hemorrhaging. No clear inciting etiology was identified. She was managed conservatively with bowel rest and fluid resuscitation. Patient remained intermittently febrile throughout admission, with periodic decreases in Hct, eventually thought to be secondary to an infected hemorrhagic psuedocyst. Underlying cause of pancreatitis was never fully understood. Her pancreatitis seemed to improve during her admission because lipase trended down to normal. . # RP Bleed: She developed a spontaneous retroperitoneal bleed in her right flank which was seen on CT scan on [**2192-3-18**]. Her hematocrit dropped to 21 and she was transfused several units of PRBCs. The bleed stopped spontaneously without intervention. . # Hyperbilirubinemia: Patient's tbili rose over course of admission, predominantly direct on fractionation. RUQ u/s w/o signs of cholecystitis. This was thought to be [**12-19**] medication (Zosyn) or TPN related. Patient completed 10d of zosyn, TPN was switched to fat-free, and then patient was transitioned to tube feeds. Her T. bili trended down after the TPN was stopped. Her LFTs trended up, thought to be due to medications, but these were stable. . #. Atrial Fibrillation: Patient w/ new onset atrial fibrillation this admission, requiring amiodarone gtt. She was loaded with amio and then placed on an amiodarone gtt for a 10g load. She converted back to sinus rhythm and the amiodarone was stopped. She was placed on diltiazem PO to control her rate. . # Cardiac Ischemia: Patient developed ST elevations and troponin elevation on [**3-9**] in setting of new onset afib, w subsequent downtrending of troponins. Her elevated troponins was likely due to demand ischemia. She was not thought to have an ST elevation MI. . #. Right wrist fracture: Due to fall at OSH. Closed reduction at OSH, no plan for surgical intervention. Orthopedics saw her and changed her splint during this admission. She was not placed in a cast. . #. Acute Renal Failure: Creatinine rose intermittently during her hospitalization in the setting of a lasix gtt and also getting IV contrast. Ultimately her renal failure was likely from underlying sepsis and ATN. . #. End of Life Care: Ms. [**Known lastname 75058**] was made DNR early on her hospitalization. She required ventilator support and failed a trial of extubation. She had a trach placed on [**2193-3-22**]. When she developed a new VAP and clinically became worse, her family decided to focus her care on comfort. Antibiotics were discontinued on [**2193-3-25**]. She expired on [**2193-3-26**] at 9:30am. An autopsy was requested by her family. Medications on Admission: Home medications: aricept depakote 2 tabs QHS (for the past 2 years) allopurinol namenda "respiratory medications" Medications from [**Hospital3 **] Hospital: advair 250 1 inh [**Hospital1 **] albuterol nebs q4h prn whieezing/sob aricept 10 mg po daily colace 100 mg po bid prn D5 1/2 NS @ 125cc/h dilaudid 3 mg q2h prn severe pain, 2 mg q2h prn mod pain dulculoax 10 mmg PR prn namenda 10 mg po daily robitussin elixir 5 cc q4h prn cough singulair 10 mg po hs solu-medrol 40 mg IV q12h tylenol 650 mg op q4h prn pain valproic acid 250 mg per 5 cc 500 mg po bid zorfan 4 mg IV q6h prn n/v allopurinol 300 mg po daily (not on abx) Discharge Medications: pt expired Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired

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icd9cm

[ [ [] ] ]

[ "96.72", "99.15", "31.1" ]

icd9pcs

[ [ [] ] ]

14987, 14996

10081, 10508

317, 371

15050, 15062

3016, 3021

15121, 15134

2294, 2316

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15017, 15029

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1815, 1905

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399, 1796

7971, 10058

10522, 14270

3858, 5018

1927, 2196

2212, 2278

5035, 7961

2,268

177,372

11769

Discharge summary

report

Admission Date: [**2191-2-11**] Discharge Date:[**2191-2-17**] Date of Birth: [**2116-9-11**] Sex: M Service: GENERAL SURGERY- BLUE SERVICE Admitting Diagnois: Klatskin's tumor HISTORY OF PRESENT ILLNESS: Patient is a 74-year-old white male with a recent history of painless jaundice who had undergone endoscopic retrograde cholangiopancreatography in bifurcation consistent with cholangiocarcinoma. He underwent duct dilatation but no evidence of a portal mass and no evidence of a pancreatic mass. He had replacement of biliary stents and did well. He was admitted on [**Hospital1 **] [**First Name (Titles) **] [**2191-2-1**] for percutaneous transhepatic cholangiography. Prior to the percutaneous transhepatic cholangiography, the endoscopic stents were removed. He duct to the bifurcation and a stricture to the left hepatic duct right at the bifurcation consistent with cholangiocarcinoma. Both catheters were passed into the duodenum. On the day after his percutaneous transhepatic cholangiography, he developed a transient rise in his amylase to a peak of 1800 which rapidly returned toward normal. He had no clinical evidence of pancreatitis. His diet was restarted, advanced and he was discharged on [**2191-2-3**]. Patient has done well at home and now returns for elective resection of cholangiocarcinoma. PAST MEDICAL HISTORY: Significant for coronary artery disease in which he had a coronary artery bypass graft in [**2178**], noninsulin dependent diabetes mellitus, which was controlled with Starlix, hypertension and benign prostatic hypertrophy. He also had an appendectomy in the past. ALLERGIES: He is allergic to Indocin which put him into anaphylactic shock. PREOPERATIVE PHYSICAL EXAMINATION: He was in no apparent distress. He had a pulse of 58. Blood pressure of 185/100. He was pleasant, alert and oriented. He had no cervical lymphadenopathy. His lungs were clear to auscultation bilaterally. He had a regular rate and rhythm, normal S1, S2. He has somewhat two soft nontender abdomen, no hepatosplenomegaly. No edema of his extremities. Prior to the surgery, he was cleared by Cardiology by Dr. [**Last Name (STitle) 13179**]. He came in on [**2191-2-11**] for a removal of a Klatskin tumor, cholecystectomy, and bile duct excision, Roux-en-Y hepaticojejunostomy. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit for hemodynamic monitoring. Patient did well overnight and remained hemodynamically stable. He was extubated and given a unit of packed red blood cells to maintain his hematocrit above 30. Patient was transferred out of the unit, continued to do well. He remained afebrile. His vital signs remained stable and his pain was controlled. The remainder of the [**Hospital 228**] hospital course was uneventful. His vital signs continued to remain stable. He continued to be afebrile and his laboratory values of which his liver LFTs were slightly elevated postoperatively continued to trend downward. Patient began to tolerate a regular diet, was ambulating. He had a cholangiogram on postoperative day number five which showed a patent anastomosis and no evidence of a leak. His pathology results came back on the 24th which showed evidence of adenocarcinoma, poorly differentiated involving the common bile duct, the gallbladder. There was a positive node and the distal margin was also positive. He had a transient period of oliguria related to IV Toradol that resolved with discontinuation of the Toradol. There was no significant change in serum CR. Patient was discharged home in stable condition. DISCHARGE DIAGNOSIS: Advanced most likely cholangiocarcinoma versus gallbladder carcinoma. FOLLOW-UP: Patient will follow-up with Dr. [**Last Name (STitle) **] for further management of his tumor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D., Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 2649**] MEDQUIST36 D: [**2191-2-17**] 12:07 T: [**2191-2-17**] 12:07 JOB#: [**Job Number 37207**]

[ "V45.81", "155.1", "196.2", "272.0", "600.0", "156.0", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "51.22", "87.54", "51.69", "51.37" ]

icd9pcs

[ [ [] ] ]

3652, 4097

1751, 3630

222, 1347

1370, 1728

7,666

138,444

426

Discharge summary

report

Admission Date: [**2158-6-13**] Discharge Date: [**2158-6-21**] Date of Birth: [**2099-4-13**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Levaquin / Opioid Analgesics Attending:[**First Name3 (LF) 826**] Chief Complaint: Recurrent high fevers, HTN, increased O2 req Major Surgical or Invasive Procedure: Central venous catheter insertion History of Present Illness: 59 yo M w/ PMH ESRD s/p renal tx in [**2155**], on immunosuppressants, HTN, DM who presented to OSH with fevers/fatigue and tx to [**Hospital1 18**] for concern of sepsis. He experienced fatigue after working outside in hot weather, and later that day, was noted to have a fever to 104. He went to [**Hospital **] Hosp where he was febrile to 104. He was given levofloxacin and IVFs and transferred to [**Hospital1 18**] where he was admitted to the ICU for sepsis. . He denies current f/c/sweats. He denies cp/sob/cough. He denies n/v/abd pain. He denies dysuria. He denies URI sx/sore throat/myalgias. He denies LAD/swelling/rash. . Past Medical History: 1. Congestive heart failure with EF 65% on [**2158-6-13**] 2. Type 2 diabetes with triopathy, controlled. 3. Hypertension. 4. Hypercholesterolemia. 5. History of seizure disorder. 6. History of hepatitis C - no therapy - [**11-21**] bx -Minimal portal and lobular mononuclear cell inflammation, consistent with involvement by chronic viral hepatitis C ( Grade 1 activity). 7. End-stage renal disease, status post cadaveric renal transplant, creatinine 1.2-1.5 in [**2155-2-16**]. 8. Peripheral [**Year (4 digits) 1106**] disease. 9. Post-Op AFIB s/p DCCV in [**2-22**] 10. Rt rectus femoris intramuscular hematoma - [**2-22**] (INR 4.2) 11. ? enlarged LN in his neck s/p bx - 2-3 years ago, pt reports nl 12. EBV IgG positive in [**2154**]/CMV IgG positive . PAST SURGICAL HISTORY: 1. Right AK [**Doctor Last Name **]-PT with nonreversed saphenous vein on [**2154-5-15**] by Dr. [**Last Name (STitle) **]. 2. Left AV fistula. 3. Cadaver renal transplant in [**2155-2-16**]. Induction with Thymoglobulin and Tacrolimus 4. Cholecystectomy. 5. Parathyroidectomy in [**8-18**] by Dr. [**Last Name (STitle) **] - path c/w hypercellular parathyroid 6. Status post second toe amputation in [**12-18**]. 7. Right first toe amputation. 8. Aortic Valve Replacement [**2157-12-15**] - Well seated aortic bioprosthesis with high-normal gradient and trace aortic regurgitation ([**2158-6-13**]). Social History: denies smoking; rare alcohol; distant h/o IVDA (>40yrs ago). Lives w/girlfriend who is a PT. Family History: Father, mother and brother w/ DM. Father died of MI @54. Mother died of stomach CA. Physical Exam: 1. Congestive heart failure with EF 65% on [**2158-6-13**] 2. Type 2 diabetes with triopathy, controlled. 3. Hypertension. 4. Hypercholesterolemia. 5. History of seizure disorder. 6. History of hepatitis C - no therapy - [**11-21**] bx -Minimal portal and lobular mononuclear cell inflammation, consistent with involvement by chronic viral hepatitis C ( Grade 1 activity). 7. End-stage renal disease, status post cadaveric renal transplant in [**2155-2-16**]. 8. Peripheral [**Year (4 digits) 1106**] disease. 9. Post-Op AFIB s/p DCCV in [**2-22**] 10. Rt rectus femoris intramuscular hematoma - [**2-22**] (INR 4.2) 11. ? enlarged LN in his neck s/p bx - 2-3 years ago, pt reports nl 12. EBV IgG positive in [**2154**]/CMV IgG positive Pertinent Results: [**2158-6-20**] 07:13AM BLOOD WBC-5.8 RBC-3.87* Hgb-9.4* Hct-29.3* MCV-76* MCH-24.3* MCHC-32.1 RDW-25.6* Plt Ct-109* [**2158-6-15**] 06:02AM BLOOD Neuts-72.4* Bands-6.7* Lymphs-9.5* Monos-5.7 Eos-4.8* Baso-0 Myelos-1.0* NRBC-2* [**2158-6-17**] 04:07AM BLOOD Neuts-58 Bands-2 Lymphs-16* Monos-14* Eos-4 Baso-0 Atyps-0 Metas-4* Myelos-2* NRBC-3* [**2158-6-20**] 07:13AM BLOOD PT-11.6 INR(PT)-1.0 [**2158-6-15**] 06:02AM BLOOD Fibrino-677*# D-Dimer-1004* [**2158-6-15**] 06:02AM BLOOD FDP-0-10 [**2158-6-13**] 02:35AM BLOOD Glucose-230* UreaN-42* Creat-2.2* Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 [**2158-6-20**] 07:13AM BLOOD Glucose-88 UreaN-28* Creat-1.1 Na-146* K-4.2 Cl-114* HCO3-26 AnGap-10 [**2158-6-13**] 02:35AM BLOOD ALT-25 AST-24 LD(LDH)-399* AlkPhos-55 TotBili-0.5 [**2158-6-15**] 06:02AM BLOOD LD(LDH)-387* TotBili-0.4 [**2158-6-16**] 12:40AM BLOOD proBNP-[**Numeric Identifier 3634**]* [**2158-6-13**] 02:35AM BLOOD Albumin-3.1* Calcium-7.9* Phos-2.2* Mg-1.7 [**2158-6-20**] 07:13AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3 [**2158-6-15**] 06:02AM BLOOD calTIBC-273 VitB12-378 Folate-12.2 Ferritn-201 TRF-210 [**2158-6-13**] 02:35AM BLOOD CRP-59.5* [**2158-6-20**] 07:13AM BLOOD rapmycn-8.3 [**2158-6-13**] 02:29AM BLOOD Lactate-2.0 [**2158-6-15**] 09:03PM BLOOD Lactate-1.5 [**2158-6-16**] 12:40AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST [**2158-6-16**] 03:05PM BLOOD B-GLUCAN-Test [**2158-6-16**] 2:00 pm BRONCHOALVEOLAR LAVAGE Site: LUNG RIGHT LUNG. GRAM STAIN (Final [**2158-6-16**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2158-6-18**]): ~9000/ML OROPHARYNGEAL FLORA. YEAST. 10,000-100,000 ORGANISMS/ML.. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2158-6-19**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [**2158-6-16**] 1:44 pm BRONCHOALVEOLAR LAVAGE LEFT LOWER LUNG. GRAM STAIN (Final [**2158-6-16**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final [**2158-6-19**]): Test cancelled by laboratory due to lack of branching gram positive rods in the gram stain. Gram stain is an equally sensitive means of detecting Nocardia in a primary specimen. Culture may be a more sensitive means of detecting Nocardia and should be considered. PATIENT CREDITED. RESPIRATORY CULTURE (Final [**2158-6-18**]): OROPHARYNGEAL FLORA ABSENT. YEAST. ~[**2151**]/ML. LEGIONELLA CULTURE (Final [**2158-6-23**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2158-6-19**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2158-6-18**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2158-6-19**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [**2158-6-16**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-FINAL INPATIENT [**2158-6-15**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2158-6-15**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2158-6-15**] URINE URINE CULTURE-FINAL INPATIENT [**2158-6-13**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2158-6-13**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2158-6-13**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2158-6-13**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL EMERGENCY [**Hospital1 **] [**2158-6-13**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] Echocardiogram on [**2158-6-13**]: LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. IMPRESSION: Well seated aortic bioprosthesis with high-normal gradient and trace aortic regurgitation. Pulmonary artery systolic hypertension. Mild mitral regurgitation. If clinically indicated, a TEE would be better able to define a structural abnormality involving the aortic valve. CT Chest on [**2158-6-13**]: IMPRESSION: 1. Three parenchymal abnormalities new over six months, the largest in the left lower [**Year (4 digits) 3630**] and two in the right upper and right middle lobes. Given their nodular appearance and patient's symptoms of infection, Nocardia infection would be the most likely diagnosis, especially for the left lower [**Year (4 digits) 3630**] consolidation. Alternatively, the two, smaller right lung lesions could be PTLD. 2. Cardiomegaly. Status post aortic valve replacement and CABG. Sternal dehiscence with peristernal fat stranding and collections might represent osteomyelitis. If this diagnosis is plausible clinically, MRI or radionuclide scanning would be be helpful to confirm. Echocardiogram on [**2158-6-16**]: Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. There is symmetric left ventricular hypertrophy. 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 aortic arch is mildly dilated. A bioprosthetic aortic valve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation seen. Renal transplant ultrasound on [**2158-6-16**]: IMPRESSION: Unremarkable renal transplant in the left iliac fossa with some mild fullness of the collecting system, which is reduced when compared with the previous ultrasound from [**11-21**]. Brief Hospital Course: # Pneumonia: Patient improved on Vancomycin/Meropenem started empirically for sepsis broad spectrum coverage. However, culture-data and fungal organism tests remained negative. He was therefore transitioned to oral levofloxacin and discharged on this regimen, with specific instruction to contact his physician immediately if he had recurrence of any symptoms or fevers. Due to finding of incidental lung nodules, will repeat chest CT in 1 month. . # HYPERTENSION: Continued metoprolol. . # Renal transplant: Initially with renal failure that resolved with treatment of sepsis and hydration. Continued sirolimus and cellcept. . # DM - Continued RISS, standing insulin. . # Prophylaxis: Pantoprazole, pneumoboots for DVT prophylaxis, bowel medications as necessary. . # CODE: FULL code Medications on Admission: Bactrim 400-80mg 1tab po daily Cellcept 500mg 1tab po bid Rapamune 1mg 1tab po daily Prednisone 5mg 1tab po daily Lamivudine 100mg 1tab po daily Valcyte 450mg 1tab po daily Ecotrin 325mg 1tab po daily Florinef 0.1mg 1tab po bid Folic Acid 1mg 1tab po daily Lasix 80mg po bid Insulin NPH 50u [**Hospital1 **] Humalog insulin SS Metoprolol 100mg 1tab po bid Omeprazole 40mg 1tab po daily Pravastatin 80mg 1tab po qhs Viagra 50mg 1tab po daily prn Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) Units Subcutaneous at bedtime. Disp:*3 vials* Refills:*2* 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Rapamune 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Insulin Syringe-Needle U-100 1 mL 31 x [**5-31**] Syringe Sig: One (1) Miscellaneous once a day. Disp:*30 syringes* Refills:*2* 11. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Viagra 50 mg Tablet Sig: One (1) Tablet PO once a day as needed. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 16. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home Discharge Diagnosis: Sepsis Secondary diagnoses: chronic renal insufficiency Renal transplant Type 2 diabetes mellitus Hypertension Hypercholesterolemia Gastroesophageal reflux disease Discharge Condition: Vital signs stable, afebrile, breathing comfortably and tolerating PO diet. Discharge Instructions: You were admitted for possible infection of the blood stream and also pneumonia. You were treated with IV antibiotics, and then switched to antibiotics by mouth. Please complete the entire course of antibiotics as prescribed, even if you no longer have symptoms. If you notice fevers, chills, worsening cough, chest pain, shortness of breath, or lightheadedness, please call your physician or report to the emergency room. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] would like to see you in the office in the next 2-3 weeks. His office will call you to let you know when the appointment will be scheduled. Please call ([**Telephone/Fax (1) 817**] with any questions or concerns. You also have an appointment with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD on [**2158-7-3**] at 8:30 AM. Please call ([**Telephone/Fax (1) 3635**] with any questions or to change your appointment. You have been scheduled for a follow-up CT scan, because the one done while in the hospital had some findings that need to be followed up. The CT scan is scheduled for [**7-21**] at 12:45 PM in [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] on [**Location (un) 830**]. Please call [**Telephone/Fax (1) 327**] to reschedule your appointment or with any other questions or concerns. Completed by:[**2158-6-24**]

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icd9cm

[ [ [] ] ]

[ "33.24", "38.93" ]

icd9pcs

[ [ [] ] ]

12870, 12876

10210, 11002

349, 385

13085, 13163

3442, 5185

13637, 14585

2584, 2669

11497, 12847

12897, 12905

11028, 11474

13187, 13614

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12926, 13064

6781, 6941

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265, 311

413, 1051

1073, 1832

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62,458

121,271

46487

Discharge summary

report

Admission Date: [**2115-11-2**] Discharge Date: [**2115-11-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Lightheadedness Major Surgical or Invasive Procedure: placement of a [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] [**Male First Name (un) 8997**] [**Male First Name (un) **] pacemaker History of Present Illness: This is a [**Age over 90 **] year old female with a past medical history of hypertension, dCHF, and hyperlipidemia who presents with one day of lightheadedness. She noted onset of her symptoms this morning in the bathroom with sudden onset of short episodes of lightheadedness. She has never had something like it. She did note some palpitations after she felt the episodes of lightheadedness and some ankle edema starting yesterday. She denies any chest pain, SOB, abd. pain, N/V/D, diaphoresis. She has felt faint but has not lost consciousness. EMS was called via Lifeline and noted on arrival that her heart rate varied from 30-130 with ?a.fib/flutter on the strip. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or syncope. . In the ED, initial vitals were 97.8, 140, 140/110, 30, 100% NRB. She was noted to have a variable heart rate, mostly an irregular narrow complex tachycardia to 130s with long conversion pauses of up to 6 seconds with some brief intervals of NSR (4-6 beats). During the sinus pauses, she had symptoms of lightheadedness and abdominal flushing. She also developed bursts of a stable wide complex tachycardia, thought to be abberancy. She received 2gm of calcium gluconate empirically. She then received 5mg IV metoprolol with little effect on her heart rate. She was prepped for a temporary pacer wire and the introducer was placed in the ED. She remained HD stable. Shortly after the introducer placement she switched to atrial bigeminy at a rate around 70. She is transferred to the CCU for further management. Past Medical History: 1. CARDIAC RISK FACTORS: Hyperlipidemia, Hypertension 2. CARDIAC HISTORY: 3. OTHER PAST MEDICAL HISTORY: 1. History of colon cancer, status post colostomy in [**2077**]. 2. Pulmonary hypertension. 3. Hypertension. 4. Recurrent urinary tract infections 5. Arthritis. 6. Diastolic CHF 7. Depression 8. Hyponatremia . PAST SURGICAL HISTORY: 1. Cataract surgery bilaterally. The left eye surgery was complicated by a nicked cornea for which she follows with a corneal specialist once a month. 2. Hernia at the site of her colostomy, this was surgically repaired. 3. Hysterectomy at age 49. 5. Partial colectomy in [**2077**]. 6. Right lower extremity melanoma 7. ORIF of her right ulnar fracture s/p MVA in [**10-24**] Social History: She lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and has an aide who comes to help 3 days a week. Daughter [**Name (NI) 98763**] in her care. No pets. Denies any tobacco, alcohol, or illicit drug use. She is a retired worker, used to work at Filene's Basement in sales. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 98.2, 131/72, 72, 100% 2L GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP flat CARDIAC: PMI located in 5th intercostal space, midclavicular line. Bigeminy rhythm, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Trace-1+ LE 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: Admission labs (10/17/9): WBC-5.9 RBC-4.27 Hgb-12.7 Hct-37.9 MCV-89 MCH-29.7 MCHC-33.5 RDW-13.5 Plt Ct-204 PT-12.3 PTT-24.3 INR(PT)-1.0 Glucose-94 UreaN-21* Creat-1.0 Na-139 K-5.1 Cl-102 HCO3-30 AnGap-12 CK(CPK)-45; cTropnT-<0.01 Calcium-9.4 Phos-3.8 Mg-2.1 . TSH-2.0 . Discharge labs (10/20/9): WBC-6.0 RBC-3.93* Hgb-11.8* Hct-35.2* MCV-89 MCH-30.1 MCHC-33.7 RDW-13.7 Plt Ct-154 Glucose-95 UreaN-21* Creat-1.0 Na-137 K-4.2 Cl-101 HCO3-27 AnGap-13 . ECG [**11-2**]: Supraventricular tachycardia, which may be atrial flutter, is new as compared with previous tracing of [**2115-3-14**]. . ECG [**11-3**]: Sinus rhythm. Left atrial abnormality. Delayed precordial R wave transition. Compared to the previous tracing of [**2115-11-2**] sinus rhythm has appeared. . ECG [**11-4**]: Sinus rhythm followed by a premature atrial contraction, followed by what looks like an episode of atrial tachycardia with 2:1 conduction. Delayed precordial R wave transition which may be due to lead placement. Compared to the previous tracing of [**2115-11-3**] atrial tachycardia is now present. . [**11-2**] CXR: Mild-to-moderate cardiomegaly is unchanged. Right IJ catheter tip is seen in the right brachiocephalic vein. There is no evidence of pneumothorax or pleural effusion. The lungs are grossly clear. The aorta is tortuous. . [**11-5**] CXR: As compared to the previous examination, there is no relevant change. Unchanged position of the leads, unchanged coarse, unchanged left pectoral position of the pacemaker device. Unchanged minimal left suprabasal atelectasis. No evidence of pneumothorax. . MRSA SCREEN (Final [**2115-11-5**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . Brief Hospital Course: This is a [**Age over 90 **] year old female with a history of hypertension, diastolic CHF who presents with new onset tachyarrhythmia with long conversion pauses. . # Tachycardia: In the ED, tachycardia and then with long conversion pauses. Unclear if this was a.fib/flutter with abberancy vs. another SVT. Long conversion pauses concerning for tachy-brady syndrome; and presyncope. Remained hemodynamically stable. No signs of ischemic cause, likely age related conduction degradation in setting of dCHF. Stable in atrial bigeminy when came to the CCU. Patient had Cordis placed in ED, and we were prepared to float temporary pacer wire if became tachycardic and unstable, to manage pauses/bradycardia, but this never was the case. Pacer pads remained in place in the CCU. Patient rate controlled with 25mg po metoprolol TID (home medication). For this arhythmia, patient had a pacemaker placed by the EP service on [**2115-11-4**] - St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 35095**] DR [**Last Name (STitle) **] pacemaker. Patient was on heparin gtt for prophylaxis given underlying afib/flutter concern (Guiac negative), and was discharged on coumadin. Patient to be on antibiotics (keflex) for 48 hours post-procedure. Patient to be on amiodarone for treatment of atrial tachycardia. Procedure was without complications - no hematoma, no complications on CXR. . # PUMP: History of very well controlled dCHF on no diuretics. No signs of decompensation; beta-blocker and lisinopril (held one day) continued. . # Coronaries: No signs of ischemia currently. Cardiac enzymes. No ischemic changes on EKG. Continued ASA 81, simvastatin, metoprolol. . # Depression: Stable, continued lexapro. . # Osteoarthritis: Stable, PRN tylenol, continued calcium carbonate, MVI. . # Hyperlipidemia: Continued simvastatin. . # Insomnia: Continued PRN alprazolam. . FEN: Heart healthy diet . ACCESS: PIV's, right IJ cordis . PROPHYLAXIS: -DVT ppx with Heparin gtt -Pain management with tylenol -Bowel regimen . CODE: full . HCP [**Name (NI) **] [**Name (NI) 98764**] (daughter)[**Telephone/Fax (1) 98765**]; involved in patient's care. . Major procedure: St.[**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) 35095**] DR [**Last Name (STitle) **] [**Name (STitle) **] pacemaker placed on [**2115-11-4**] for presyncope/tachy-brady syndrome. Medications on Admission: ALPRAZOLAM - 0.5 mg mouth at bedtime as needed for insomnia AMLODIPINE 5 mg by mouth daily ESCITALOPRAM 20 mg Tablet - 1 Tablet(s) by mouth daily LISINOPRIL - 10 mg by mouth daily METOPROLOL TARTRATE - 25 mg by mouth three times a day SIMVASTATIN - 10 mg by mouth daily ACETAMINOPHEN 325 mg by mouth prn as needed for pain ASPIRIN - 81 mg by mouth once a day CALCIUM CARBONATE - 500 mg by mouth three times a day CRANBERRY - (OTC) - Dosage uncertain MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO three times a day. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days. 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 11. Cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day. 12. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. Gatifloxacin 0.3 % Drops Sig: One (1) gtt Ophthalmic TID (3 times a day). 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day. 16. Outpatient Lab Work Please check INR at Friday [**11-9**]. 17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: last dose to be given [**11-9**]. 18. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 3 days: Last dose 10/27. 19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: start on [**11-13**] and continue indefinitely. Discharge Disposition: Extended Care Facility: [**Hospital 98766**] Living Center Discharge Diagnosis: Atrial fibrillation/Atrial Flutter Chronic Diastolic congestive Heart Failure Hypertension Hyperlipidemia Discharge Condition: stable. Discharge Instructions: You had an irregular heart rate with some pauses that required a pacemaker. You also had some atrial fibrillation that makes you at risk for a stroke. Because of this, we have started you on Warfarin (coumadin) to prevent blood clots. This medicine will make you bruise easily and may make your nose or gums bleed. Please call Dr. [**Last Name (STitle) **] or [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] notice any blood or dark stool, bleeding that doesn's stop or weakness and fatigue. Weigh yourself every morning, call [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**] NP if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet . Medication changes: 1. Start Coumadin to prevent blood clots. You will need to have your coumadin level (INR) checked frequently. 2. Start amiodarone to prevent the rapid heart rates. You will need to taper the dose so that you end up taking 200 mg daily. 3. Stop Norvasc 4. Cephalexin: an antibiotic to prevent infection at the pacer site . No lifting more than 5 pounds with your left arm for 6 weeks. No lifing your left arm over your head for 6 weeks. You may shower and wash your hair after one week. Do not get the pacemaker dressing wet. the dressing will be taken off at the device clinic in 1 week. Please call your doctor or return to the hospital if you develop fever >101.5, chest pain, difficulty breathing, lightheadedness or other symptoms that concern you. Followup Instructions: electrophysiology: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-11-11**] 12:00. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**]. Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-11-11**] 1:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: Tues [**1-21**] at 1:00pm. Primary Care: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2115-12-2**] 12:00 Completed by:[**2115-11-5**]

[ "427.81", "427.32", "272.4", "401.9", "416.8", "428.0", "427.31", "V10.05", "428.32" ]

icd9cm

[ [ [] ] ]

[ "37.83", "38.93", "37.72" ]

icd9pcs

[ [ [] ] ]

10769, 10830

6219, 8587

277, 429

10980, 10990

4518, 6196

12594, 13357

3521, 3636

9182, 10746

10851, 10959

8613, 9159

11014, 11797

2805, 3183

3651, 4499

2533, 2533

11817, 12571

222, 239

457, 2437

2564, 2782

2459, 2513

3199, 3505

26,031

188,239

1972

Discharge summary

report

Unit No: [**Numeric Identifier 10850**] Admission Date: [**2142-2-23**] Discharge Date: [**2142-3-2**] Date of Birth: [**2092-11-2**] Sex: M Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Mr. [**Known lastname **] was originally seen in Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office on [**2142-2-1**]. He has had increasing dyspnea on exertion for the past 2 months. He is a 49 year old male with known coronary artery disease, status post coronary artery bypass graft x4 in [**2140**], now with dyspnea on exertion and palpitations. Murmur was noted on examination and he was referred for echocardiogram which revealed mitral regurgitation. PAST MEDICAL HISTORY: Mitral regurgitation. Status post coronary artery bypass graft x4 at [**Hospital6 2121**] in [**2140**]. Previous PCI to the right coronary artery. Inferior myocardial infarction in [**2132**]. Question of asthma on no medications. Hypercholesterolemia. Paroxysmal atrial fibrillation in [**2139**], and 11-12 years ago. Left arm fistula in [**2141-5-27**]. LDL plasmapheresis every 2 weeks at [**Location (un) 5450**] Kidney Center. Episodic dizziness for which a neurology workup was negative, question whether this was due to statins. MEDICATIONS ON ADMISSION: When he was seen initially were: 1. Coreg 12.5 mg p.o. twice a day. 2. Aspirin 325 mg p.o. once a day. ALLERGIES: He is allergic to Lipitor and Mevacor, both of which give him muscle aches. Albumin causes profound hypotension with bradykinin response. FAMILY HISTORY: He had a positive family history of coronary artery disease. SOCIAL HISTORY: He lives with his wife as a mortgage salesman. He had a 20 pack year history of smoking and quit 20 years ago. He had [**3-1**] drinks every weekend of beer and wine. He does exercise regularly. REVIEW OF SYMPTOMS: His review of systems is negative for stroke or transient ischemic attack or any bleeding disorder. PHYSICAL EXAMINATION: On examination, his heart rate was 84 and regular, respiratory rate 22, blood pressure on the right 130/70, left arm had a fistula and no pressure taken, 5 feet 10 inches tall, 195 pounds. He was well appearing in no apparent distress. He had unremarkable skin. HEENT examination was within normal limits as was he examination of his neck. His lungs were clear bilaterally with a well healed sternotomy incision. His heart was regular rate and rhythm with S1 and S2 tones and a grade II/VI systolic ejection murmur. His abdomen was benign. He had warm extremities with no edema and a left forearm fistula present and no obvious varicosities and no cerebrovascular accident, transient ischemic attack or chronic headache problems. [**Name (NI) **] had 2+ bilateral femoral, DP and PT pulses with 2+ right radial pulse and a left AV fistula. No carotid bruits were heard at that time. HOSPITAL COURSE: He was admitted to the hospital for preoperative workup to be continued on [**2142-2-23**]. He was in sinus rhythm in the 80s at this time with a pressure of 145/72. His examination was virtually unremarkable with no change from his prior examination 2 weeks prior. Additional laboratory work was done including a urinalysis with a plan to do a cardiac catheterization, which was performed on [**2142-2-23**]. This showed patent LIMA graft as well as patent vein grafts. The left main native had 70% stenosis, LAD had a 60% stenosis, RCA had an 80% stenosis, and all 4 grafts were widely patent. He remained in the hospital in preparation for his mitral valve surgery and his examination was unremarkable. His catheterization site was clean, dry and intact. Preoperatively his laboratories were as follows: White count 5.7, hematocrit 36.5, platelet count 219,000. Sodium 140, potassium 4.0, chloride 104, bicarbonate 30, BUN 17, creatinine 1.0 with a blood sugar of 102. PT 12.7, PTT 29.1 with an INR of 1.0. His chest x-ray showed prior evidence of coronary artery bypass graft with no acute cardiopulmonary process. EKG showed sinus rhythm at 66 with no acute ischemic disease. Prior echocardiogram in [**2141-12-27**], showed moderate to severe mitral regurgitation with an ejection fraction of 30-35%. Cardiac catheterization also showed an ejection fraction of 35% with inferior hypokinesis and 3+ mitral regurgitation. Th[**Last Name (STitle) 1050**] went to the operating room on [**2142-2-26**]. Please refer to the anesthesia note which states a very difficult intubation. Steroids were initiated. The patient underwent a right thoracotomy for mitral valve repair with a 28 millimeter [**Doctor Last Name 405**] annuloplasty band by Dr. [**Last Name (Prefixes) **]. He was transferred to the Cardiothoracic ICU in stable condition on a Levophed drip at 0.07 mcg/kg/minute and a Propofol drip at 25 mcg/kg/minute. On postoperative day #1, he remained on a Neo-Synephrine drip at 0.6 mcg/kg/minute and Propofol drip. He remained intubated for the day. He was receiving Decadron to decrease any potential inflammation in his airway from his difficult intubation. Postoperative laboratories were as follows: White count 14.0, hematocrit 31.2, platelet count 265,000. Potassium 4.1, BUN 16, creatinine 1.1. He had slightly decreased breath sounds. He was hemodynamically stable with a pressure of 108/52 and a heart rate of 75 and sinus rhythm. He had some Amiodarone given to him for some ectopy and he had a CPAP trial with weaning to extubation. Electrophysiology service was asked to evaluate the patient for his ventricular ectopy following his minimally invasive mitral valve repair. The patient was continued on his Amiodarone. He was also seen and evaluated by case management and physical therapy rehabilitation services. On postoperative day #2, he did have an echocardiogram done. He remained on Amiodarone drip at 0.5. He was continued on aspirin and began Lasix diuresis and finished his perioperative Vancomycin. He was in sinus rhythm at 81 with blood pressure 124/50. His hematocrit was stable at 28.8, creatinine stable at 1.2. His chest tubes were put to water seal, his pleural tubes. He continued on p.o. Amiodarone after he was extubated with plan for outpatient electrophysiology workup and he was transferred to the floor on postoperative day #2. On postoperative day #1, the patient was extubated with anesthesia present given the difficulty the team had intubating him in the operating room. A Swan- Ganz was also discontinued on [**2142-2-27**]. A central line remained in place. The patient was switched over to p.o. Percocet for pain. He had a rash on his trunk and his thighs that was being monitored. He was evaluated again by physical therapy to begin his ambulation and advancing his activity level on the floor. He was encouraged to take more p.o. fluids. The patient did receive some IV medications for some nausea. His AV fistula had a bruit and a thrill postoperatively. He did complain of some nausea with Motrin on postoperative day #3. Carvedilol was restarted on postoperative day #3. The patient was encouraged to use his incentive spirometer, cough and deep breathe, and increase his ambulation. His Ibuprofen was discontinued. His epicardial pacing wires were removed without incident. He was alert and oriented and cooperative with the team on postoperative day #4, the day of discharge. The patient had his temperature of 98.1, sinus rhythm at 80, blood pressure 126/55, respiratory rate 18, saturating 99% in room air. He weighed 94.4 kilograms. He was alert and oriented and nonfocal on his examination. His lungs were clear bilaterally. The heart was regular rate and rhythm. His thoracotomy incision was clean, dry and intact. He had positive bowel sounds. Extremities were warm with trace peripheral edema. His central venous line was removed and he was discharged to home with visiting nurse services. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: 1. To make an appointment with Dr. [**Last Name (STitle) 10851**], his primary care physician, [**Name10 (NameIs) **] approximately 1-2 weeks postdischarge. 2. To make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately 2-3 weeks postdischarge, his heart failure specialist. 3. To make an appointment to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in approximately 3-4 weeks, electrophysiologist, [**Telephone/Fax (1) 10852**], for follow-up for EP evaluation. 4. To make an appointment to see Dr. [**Last Name (Prefixes) **] in the office at 4 weeks postoperative for his surgical visit. DISCHARGE DIAGNOSES: Status post coronary artery bypass graft x4 in [**2140**]. Status post right thoracotomy and minimally invasive mitral valve repair with [**Doctor Last Name 405**] annuloplasty band. Prior RCA PTCA. Inferior myocardial infarction. Question asthma. Paroxysmal atrial fibrillation. Hypercholesterolemia. Left arm AV fistula. LDL plasmapheresis q.2weeks. MEDICATIONS ON DISCHARGE: 1. Potassium chloride 20 mEq p.o. twice a day for 7 days. 2. Colace 100 mg p.o. twice a day. 3. Enteric-coated aspirin 81 mg p.o. once a day. 4. Amiodarone 200 mg p.o. once a day. 5. Percocet 5/325 one to two tablets p.o. p.r.n. q.4-6hours as needed for pain. 6. Carvedilol 3.125 mg p.o. twice a day. 7. Lasix 20 mg p.o. twice a day for 7 days. CONDITION ON DISCHARGE: The patient was discharged to home in stable condition with VNA services on [**2142-3-2**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2142-4-17**] 15:40:54 T: [**2142-4-17**] 18:58:50 Job#: [**Job Number 10853**]

[ "424.0", "V70.7", "412", "427.31", "423.1", "272.0", "V17.3", "414.01", "V45.81", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.33", "88.57", "37.12", "37.23", "88.56", "88.72", "88.53" ]

icd9pcs

[ [ [] ] ]

1561, 1623

8601, 8962

8988, 9338

1288, 1544

2883, 8579

1981, 2865

713, 1261

1640, 1958

9363, 9711

45,753

175,791

37982

Discharge summary

report

Admission Date: [**2181-8-17**] Discharge Date: [**2181-8-30**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2009**] Chief Complaint: Acute Right SDH Major Surgical or Invasive Procedure: [**8-17**]: Right Sided Craniotomy for subdural hematoma evacuation History of Present Illness: [**Age over 90 **] year old female history of dementia, HTN, glaucoma, s/p fall 1 week prior to admission, now presenting with increasing lethargy and unresponsiveness. She was taken to OSH where imaging revealed a large right sided SDH, and she was then transferred to [**Hospital1 18**] for definitive neurosurgical care. Past Medical History: Dementia HTN Glaucoma CAD s/p stent and Pacemaker Depression Social History: non-contributory Family History: non-contributory Physical Exam: On Admission: T: 100.1 BP: 100/41 HR:68 R:14 100% O2Sats Gen: Intubated not responsive, does not open eyes,slight grimace and nox stim HEENT: NC/AT Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro:Mental status: Does not open eyes, slight grimace to sternal rub. Cranial Nerves: Patient appears to have gag reflex, corneal reflexes intact. L pupil 3mm and fixed, Right pupil surgical. VOR intact Motor: Patient not moving or withdrawing arms. Withdraws legs b/l to nox stim. -Sensory: Patient has intact sensation to pain at LE, chest and UE. Patient has b/l Babinski -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Coordination and gait not tested Exam on Discharge: XXXXXXXXXXX Pertinent Results: Labs on Admission: [**2181-8-17**] 03:00PM BLOOD WBC-11.7* RBC-3.26* Hgb-7.0* Hct-23.2* MCV-71* MCH-21.4* MCHC-30.0* RDW-16.8* Plt Ct-296 [**2181-8-17**] 03:00PM BLOOD Neuts-83.6* Lymphs-10.6* Monos-5.2 Eos-0.4 Baso-0.2 [**2181-8-17**] 03:00PM BLOOD PT-13.5* PTT-28.0 INR(PT)-1.2* [**2181-8-17**] 03:00PM BLOOD Glucose-148* UreaN-23* Creat-0.7 Na-139 K-3.4 Cl-107 HCO3-24 AnGap-11 [**2181-8-17**] 08:30PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.0 [**2181-8-18**] 03:53AM BLOOD Phenyto-15.1 Labs on Discharge: XXXXXXXXXXX ------------------- IMAGING: ------------------- Head CT [**8-17**]: FINDINGS: There is a right crescentic hyper-attenuating area layering over the convexity, likely a subdural hematoma. At the level of the lateral ventricles superiorly (series 2, image 19), it measures approximately 1.5 cm, similar to the study from approximately three hours prior. Again, there is effacement of the right lateral ventricle with leftward midline shift of approximately 7 mm, similar to prior. No new focus of intracranial hemorrhage is seen. Some of the subdural extends into the parafalcine area on the right. There is mild edema, and the ventricles, sulci, and cisterns appear similar to prior. Basal cisterns are preserved. There is no depressed skull fracture. Mastoid air cells and visualized paranasal sinuses are unremarkable. Scleral plaques are seen. IMPRESSION: Stable appearance to right convexity subdural hematoma with unchanged leftward midline shift. Head CT [**8-17**](Post-op): FINDINGS: The patient is status post right-sided craniectomy for evacuation of a large right-sided subdural hematoma. Most of this hematoma has been evacuated although residual amount of hemorrhage is seen overlying the right frontal lobe. There is extensive pneumocephalus extending along the right hemisphere and also over the left frontal lobe in addition to the right anterior temporal lobe. A small focus of air is also seen anterior to the left temporal lobe. There is still a mild leftward shift of midline structures of 4 mm, decreased from 7 mm. No intraparenchymal hemorrhage is seen. [**Doctor Last Name **]-white matter differentiation is preserved. Visualized paranasal sinuses and mastoid air cells remain clear. IMPRESSION: Status post right-sided craniectomy for evacuation of subdural hematoma. Small amount of hemorrhage remains overlying the right frontal lobe and right occipital lobe. Decrease in leftward shift of midline structures, now 4 mm down from 7 mm. CXR [**8-17**]: IMPRESSION: Satisfactory placement of a new right central venous catheter with no pneumothorax. Stable small right pleural effusion and left lower lobe atelectasis. CXR [**8-21**]: The Dobbhoff tube tip continues to be in proximal stomach. The pacemaker leads terminate in right ventricle. The right subclavian line tip is at the level of cavoatrial junction. Cardiomediastinal silhouette is unchanged including mild cardiomegaly. Bibasal atelectasis and bilateral pleural effusions are unchanged. No overt infection is present. Loose bodies are demonstrated in the right glenohumeral joint. Rt Foot [**8-21**]: FINDINGS: There is a comminuted, slightly angulated fracture of the proximal phalanx of the fourth digit. The proximal phalanx of the fifth digit is not well seen and the possibility of a fracture in this region cannot be unequivocally excluded. Brief Hospital Course: #) Course with neurosurgery: Patient is a [**Age over 90 **]F who was transferred to [**Hospital1 18**] after OSH imaging revealed a right sided acute SDH. This finding was likely resultant from a fall that the family reports occurred one week prior to admission. The family was extensively counseled, and elected for decompressive craniotomy and evacuation of blood products. She went to the OR on the evening of [**8-17**]. Procedure was uneventful, and she was returned to the ICU post-operatively. On [**8-18**], Aspirin was started given her history of CAD with stend and pacemaker placement. CXR imaging performed in the emergency department revealed a consolidation consitent with a likely pneumonia and antibiotics were started. On [**8-19**] bronchoscopy was performed for confirmation and GNR were isolated. She was continued on Ceftriaxone for this purpose. On [**8-20**] she was sucessfully extubated. She was requiring oxygen. On [**8-21**] her right lateral foot and 4th digit was noted to be ecchymotic and exquisitely tender. X-ray imaging revealed a comminuted, slightly angulated fracture of the proximal phalanx of the fourth digit. Transfer orders for the Step Down unit were performed. . On transfer to medicine service: . #) Altered mental status: since her evacuation, patient had a difficult time waking up, and arrived to us with sluggishly reactive pupils, periodically spontaneously opening her eyes, withdrawing to pain and moving all four extremities. Her mental status was complicated by hypernatremia, hypoxia related to volume overload and possible infection, in addition to her recent SDH and midline shift. As her hypernatremia corrected, her mental status initially improved after a few days, then she again became more unresponsive, not opening her eyes spontaneously and having more difficulty supporting herself in bed. . #) Hypoxia: throughout her stay on the medicine service, patient had a perisistent tachypneia and oxygen requirement. Initially, her chest x-ray showed severe pulmonary edema and large bilateral pulmonary effusions, which improved with IV diuresis, however the effusions remained and her oxygen requirement also did not improve. An echocardiogram was done earlier in her hospital course, which showed right sided heart strain, and concern for PE, however given recent SDH, patient would not be anticoagulated, so no further imaging was obtained. Patient had also had a persistent leukocytosis, and given the coarse breath sounds on pulmonary exam, she was started on levaquin for presumed pnuemonia. She had been receiving nebulizer treatments, and morphine to help with her tachypneia during her stay. . #) Hypernatremia: patient initially had a sodium of 155, daily free water deficits were calculated and free water was repleted via her dobhoff tube, once her sodium normalized, her mental status did not improve with correction of her sodium. . #) Goals of Care: on transfer of care to medicine palliative care had been consulted, and it was clear that the goals of care from the daughter's point of view were comfort oriented. As the patient's mental status improved and then deteriorated again, we had a family meeting where the decision was made on [**2181-8-29**] to make the patient comfort measures only, and she was started on a morphine drip with ativan, and passed away at 0520 on [**2181-8-30**]. Medications on Admission: Amlodipine 5mg QD Aricept 5mg QD ASA 81mg QD Citalopram 20mg QD Effexor 75mg QD Lamotrigine 25mg QD Plavix 75mg QD Simvastatin 10mg QD Timolol 0.5% eye drop each eye QHS Lorazepam 0.5mg QD PRN Discharge Medications: None-patient expired Discharge Disposition: Expired Discharge Diagnosis: Acute Right Subdural Hematoma Comminuted, angulated fracture of the proximal phalanx of the fourth digit. Respiratory failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[ "96.6", "33.24", "38.93", "01.31", "96.71" ]

icd9pcs

[ [ [] ] ]

8720, 8729

5047, 6307

235, 305

8899, 8909

1667, 1672

8965, 8976

792, 810

8675, 8697

8750, 8878

8457, 8652

8933, 8942

825, 825

180, 197

2169, 5024

333, 658

1176, 1615

1634, 1648

1686, 2150

6322, 8431

680, 742

758, 776

20,689

129,027

21675

Discharge summary

report

Admission Date: [**2101-8-28**] Discharge Date: [**2101-9-22**] Date of Birth: [**2048-6-2**] Sex: M Service: [**Doctor First Name 147**] Allergies: [**Male First Name (un) 26129**] Attending:[**First Name3 (LF) 1556**] Chief Complaint: splenic laceration Major Surgical or Invasive Procedure: Exploratory Laparotomy [**2101-8-28**] Emergency cricothyroidotomy [**2101-8-28**] Splenectomy [**2101-8-28**] Tracheostomy 8.0 [**2101-8-28**] History of Present Illness: This is a 54 year old male transferred from an OSH status-post a motorcycle crash earlier in the evening. He was found to have a grade 4 splenic laceration on OSH CT and was transferred to [**Hospital1 1535**] for emergent exploratory laparotomy on [**2101-8-28**]. All other imaging from the OSH was reportedly negative. Past Medical History: R elbow surgery '[**85**] Appendectomy Lower back pain Social History: Pt admits to alcohol dependency. He lives with his fiance and daughter. [**Name (NI) **] owns a paving company. Family History: Non-contributory Physical Exam: On admission: v/s SBP 80, 93, 95% on room air Gen: aggitated middle-aged man, intoxicated, awake Head: normocephalic, atraumatic Neuro: CN 2-12 grossly intact, obeys commands, can answer questions, GCS 15 CV: sinus rhythm, no murmurs Pulm: coarse bilateral breath sounds Abd: distended, firm, tender in the left upper quadrant, no palpable masses Extr: warm, no edema, right leg with palpable 5x5 cm hematoma Motor: moves all 4 extremities purposefully Rectal: normal tone, guaic negative Back: non-tender, no step-offs Pertinent Results: [**2101-8-28**] 03:20AM FIBRINOGE-587* [**2101-8-28**] 03:20AM PLT COUNT-87* [**2101-8-28**] 03:20AM PT-27.4* PTT-95.6* INR(PT)-4.7 [**2101-8-28**] 03:20AM WBC-4.6 RBC-1.26* HGB-4.0* HCT-12.7* MCV-101* MCH-31.7 MCHC-31.4 RDW-13.0 [**2101-8-28**] 03:20AM ASA-NEG ETHANOL-80* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2101-8-28**] 03:20AM AMYLASE-27 [**2101-8-28**] 03:20AM UREA N-4* CREAT-0.2* [**2101-8-28**] 03:22AM GLUCOSE-66* LACTATE-0.7 NA+-145 K+-1.4* CL--131* TCO2-10* [**2101-8-28**] 03:30AM FIBRINOGE-99*# [**2101-8-28**] 03:30AM PT-15.5* PTT-39.5* INR(PT)-1.5 [**2101-8-28**] 03:30AM PLT COUNT-167# [**2101-8-28**] 03:30AM WBC-11.4*# RBC-3.33*# HGB-10.9*# HCT-31.3*# MCV-94# MCH-32.6* MCHC-34.7# RDW-14.4 [**2101-8-28**] 03:30AM ASA-NEG ETHANOL-143* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG RADIOLOGY: [**2101-8-28**] CT: Post splenectomy. A small amount of fluid and free air are expected post- operative findings. Bibasilar and small right apical atelectatic changes. No evidence of aortic dissection or aneurysm. [**2101-8-28**] C-spine plain film: No fractures. Mild cervical spine anterolisthesis. Degenerative changes. [**2101-9-6**] RLE ultrasound: Approximately 6 x 1.6 cm hypoechoic structure deep to a wound in the right lower extremity these features are non-specific and may be due to an abscess a hematoma or local area of inflammation. [**2101-9-7**] CT head: negative [**2101-9-11**] CT: 1. Mild Ascites. 2. Bilateral pleural effusions, left more than right, and left basilar atelectasis. MICROBIOLOGY: [**2101-8-31**] MRSA screen: MRSA + [**2101-9-6**] RESPIRATORY CULTURE-FINAL {PANTOEA (ENTEROBACTER) AGGLOMERANS, YEAST} CARDIOLOGY: [**2101-8-31**] Echocardiogram: Normal biventricular systolic function. Mild mitral regurgitation NEUROLOGY: [**2101-9-14**] EEG: This is a mildly abnormal EEG obtained in wakefulness and drowsiness due to the presence of generalized delta frequency slowing that was more pronounced during periods of drowsiness. This finding suggests deep midline subcortical dysfunction. This is a relatively non-specific finding with regard to an evaluation for seizures. There were no lateralizing or epileptiform abnormalities seen. Rare ectopy was noted on the cardiac monitor. Brief Hospital Course: This is a 54 year old man who presented from an outside hospital with a grade 3 splenic laceration status-post a motorcycle crash. Upon arrival to [**Hospital1 18**] he was found to be hypotensive with a hematocrit of 12 and was immediately transfused with 6 units of PRBC. Plain film imaging was done and the patient was taken emergently to the operating room where he underwent an exploratory laparotomy with splenectomy. Of note, due to inability to secure an airway the patient underwent an emergency cricothyroidotomy with tracheostomy tube placement. The patient was transferred to the intensive care unit post-operatively where he remained for 18 days. His post-operative course was notable for hypotension which initially required pressor support (an echocardiogram was done which was normal) and ventilary dependence. He was started on trophic tube feeds via a post-pyloric dobhoff tube on post-operative day 4. He was treated empirically with Zosyn for 2 weeks for presumed aspiration pneumonia. He had a right groin hematoma (secondary to traumatic femoral line placement) which was drained at the bedside on post-operative day 10. He was weaned off his ventilary support after 2 weeks. He was cleared from his C-collar by post-operative day 17. A neurology consultation was requested for altered mental status and aggitation on post-operative day 18; workup with EEG revealed non-specific deep midline subcortical dysfunction. He passed a swallow study and his diet was advanced to a regular diet on post-operative day 20. Physical therapy worked with the patient throughout his hospital course and found him to progress to near baseline by discharge. He was discharged to home on post-operative day 25 with a visiting nurse aid for tracheostomy tube care. Upon discharge he had scheduled follow-up with trauma surgery to have his trach removed. Medications on Admission: levothyroxine sertraline Discharge Medications: 1. oxygen 28-40% via trach mask 2. suction machine with 14 French suction catheters Suction as needed 3. compressor with heat between 28-40% to keep secretions moist 4. trach #7 Portex 5. Ambu Bag 6. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] medical Discharge Diagnosis: Splenic laceration Tracheostomy Discharge Condition: good Discharge Instructions: Keep the tracheostomy site clean and dry. Suction as needed as instructed. Followup Instructions: Call the trauma clinic at ([**Telephone/Fax (1) 376**] as soon as possible to schedule an appointment. The clinic meets on Tuesdays. You should schedule an appointment for next Tuesday, [**9-27**]. Completed by:[**2101-12-30**]

[ "518.0", "865.00", "511.9", "276.3", "789.5", "958.4", "682.6", "507.0", "291.81" ]

icd9cm

[ [ [] ] ]

[ "99.04", "31.1", "41.5", "88.72", "33.24", "38.91", "38.93", "96.04", "96.72", "86.04", "96.6", "99.07", "33.21", "99.05" ]

icd9pcs

[ [ [] ] ]

6308, 6362

3941, 5802

330, 475

6438, 6444

1624, 3057

6567, 6797

1049, 1067

5877, 6285

6383, 6417

5828, 5854

6468, 6544

1082, 1082

272, 292

503, 826

3066, 3918

1097, 1605

848, 904

920, 1033

71,386

187,489

49473

Discharge summary

report

Admission Date: [**2165-5-14**] Discharge Date: [**2165-5-21**] Date of Birth: [**2083-5-23**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Confusion, Head bleed Major Surgical or Invasive Procedure: none History of Present Illness: [**Known firstname 29843**] [**Known lastname 79285**] is an 81 yo right handed Italian man with a history of coronary artery disease, hypertension and diabetes who presents with altered mental status today. The history is primarily obtained from the patient's son as the patient has little insight into why he is here. This morning, the patient was noted to be in the shower much longer than usual (normally showers and dresses within 10 minutes but was in the bathroom for nearly 40 minutes). His daughter-in-law knocked on the door and found him in the bathroom looking confused. She helped him upstairs to his bedroom to get dressed. A little while later, his son came home and found the patient in his room wearing underwear and a winter coat. At that point the patient was brought to [**Last Name (un) 103520**] hospital for evaluation. There, vitals where felt to be normal however a head CT identified a large (4cm) left frontal hemorrhage with intraventricular extension. He was transferred here for further evaluation. The patient's family describes Mr. [**Known firstname 29843**] as a very independent man and he has been in good health recently. He was complaining of a right calf pain over the last 3 days and his grandson feels as though he as been quieter than normal over the last few days. He attended his grandaughters wedding on Saturday and was felt to be himself. Currently, the patient denies headache, changes in vision, vertigo, tinnitus or hearing difficulty. His family feels his speech is not slurred. He denies weakness, numbness or parasthesiae. He has no bowel or bladder incontinence or retention. Denied difficulty with gait. On general review of systems, the patient denied recent fever or chills, cough, shortness of breath, chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Complete ROS was negative. Past Medical History: Hypertension Diabetes CAD, s.p stenting 5-7 years ago Social History: Lives alone in an apartment above his son. [**Name (NI) **] 2 sons in the area. He has no history of smoking or alcohol use. Grandson found condoms in his wallet today and suspects he is sexually active. Family History: Father died at age 30 secondary to drowning Mother died of old age. Physical Exam: T 98.4 BP 144/67 HR RR O2% General: Awake, cooperative, NAD. Head and Neck: no cranial abnormailites, no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm, normal s1/s2. No murmurs, rubs, or gallops appreciated. Abdomen: soft, non-tender, normoactive bowel sounds, no masses or organomegaly noted. Extremities: Right foot is cool to touch compared to left with decreased caillary refill compared to the right. There is swelling of the right calf (~2-3cm larger circumference than the left). 2+ ankle edema bilareally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to Hospital in [**Last Name (LF) 86**], [**First Name3 (LF) **] and initial reports year as [**2125**]; chooses [**2164**] from a list. Appears somewhat inattentive and is unable to relate history well. Language is fluent with intact repetition but impaired comprehension. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric per family. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. Visual fields full to confrontation. Unable to view fundus but now hemorrhages appreciated. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: slight right facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid bilaterally. XII: right Tongue deviation -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No rigidity. No adventitious movements, such as tremors, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to double simultaneous stimuli. -Deep tendon reflexes: [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. -Gait: Not Tested Pertinent Results: [**2165-5-16**] 05:25AM BLOOD Glucose-126* UreaN-15 Creat-0.7 Na-131* K-3.8 Cl-94* HCO3-27 AnGap-14 [**2165-5-16**] 11:44AM BLOOD Glucose-209* UreaN-18 Creat-0.8 Na-129* K-4.1 Cl-93* HCO3-25 AnGap-15 [**2165-5-17**] 11:15AM BLOOD Glucose-140* UreaN-23* Creat-0.8 Na-133 K-4.1 Cl-96 HCO3-28 AnGap-13 [**2165-5-18**] 06:55AM BLOOD Glucose-153* UreaN-30* Creat-0.8 Na-135 K-3.8 Cl-98 HCO3-26 AnGap-15 [**2165-5-20**] 01:35PM BLOOD WBC-8.1 RBC-4.69 Hgb-14.1 Hct-41.9 MCV-89 MCH-30.0 MCHC-33.6 RDW-13.7 Plt Ct-193 [**2165-5-17**] 11:15AM BLOOD WBC-9.1 RBC-5.10 Hgb-15.0 Hct-44.7 MCV-88 MCH-29.4 MCHC-33.6 RDW-13.7 Plt Ct-221 [**2165-5-16**] 05:25AM BLOOD Neuts-75.2* Lymphs-17.7* Monos-5.9 Eos-0.7 Baso-0.5 [**2165-5-13**] 10:08PM BLOOD Neuts-75.1* Lymphs-18.1 Monos-5.3 Eos-1.3 Baso-0.3 [**2165-5-20**] 01:35PM BLOOD Plt Ct-193 [**2165-5-20**] 01:35PM BLOOD PT-12.2 PTT-26.6 INR(PT)-1.0 [**2165-5-18**] 06:55AM BLOOD CK-MB-2 cTropnT-<0.01 [**2165-5-14**] 12:11PM BLOOD CK-MB-2 cTropnT-<0.01 [**2165-5-14**] 02:50AM BLOOD cTropnT-<0.01 [**2165-5-13**] 10:08PM BLOOD cTropnT-<0.01 [**2165-5-20**] 01:35PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1 [**2165-5-16**] 11:44AM BLOOD Osmolal-286 Imaging: CT [**2165-5-13**]: Again seen is a left frontal lobar hemorrhage and surrounding edema. There is extension into the frontal [**Doctor Last Name 534**] of the left lateral ventricle, unchanged. Mild rightward of midline structure, including left subfalcine herniation, is similar to the prior study. Blood products layer in the occipital horns of the lateral ventricles, as before. The frontal horns of the lateral ventricles are compressed, as before. There is no depressed skull fracture. The mastoid air cells and visualized paranasal sinuses are unremarkable. IMPRESSION: Stable appearance of left frontal lobar hemorrhage with intraventricular extension and left subfalcine herniation. Consider MR [**First Name (Titles) **] [**Last Name (Titles) **]e for underlying lesion that might include tumor, amyloid angiopathy, or vascular malformation. CTA: NON-CONTRAST HEAD CT: A left frontal lobar hematoma, with surrounding edema, is unchanged since the [**2165-5-13**] CT examination. There is extension of blood into the frontal [**Doctor Last Name 534**] of the left lateral ventricle, stable, with dependent blood layering in the occipital horns of the lateral ventricles. There is no blood in the anterior interhemispheric fissure or suprasellar cistern. No new focus of hemorrhage is identified. There is continued mild left subfalcine herniation, unchanged. A small osteoma is present within the right frontal sinus (3:111). CTA: This examination is somewhat limited due to motion-related artifact. No large aneurysm or AVM is detected. The cavernous and supraclinoid portions of the ICA are calcified bilaterally, without evidence of hemodynamically significant stenoses. No significant stenosis is seen within the carotid, vertebral, basilar and arterial branches. IMPRESSION: 1. Stable left frontal lobar hematoma, with intraventricular extension and mild left subfalcine herniation. 2. No evidence of an AVM. No large aneurysm is seen, although evaluation is limited due to significant motion-related artifacts. The lack of blood within the suprasellar cistern or the anterior interhemispheric fissure decreases the likelihood of a ruptured aneurysm from the anterior vasculature. MRI should be considered to evaluate for amyloid angiopathy, cavernous malformation, or underlying mass. If there remains a clinical concern for a small aneurysm, a MRA can also be considered. CT [**2165-5-15**]: A left frontal intraparenchymal hematoma is redemonstrated, with a neighboring region of edema, measuring approximately 6.2 x 3.8 cm. Mild neighboring mass effect includes sulcal effacement within the left frontal lobe. There is trace hemorrhagic extension into the body of the left lateral ventricle (2:19), and the occipital horns of both lateral ventricles (2:15). There is also a 4 mm rightward shift of midline structures (2:20). All of these findings are unchanged since the [**2165-5-14**] study. A new trace amount of hyperdense blood is seen within the right temporal lobe with a possible component of subarachnoid hemorrhage (2:15). There is no new mass effect or large vascular territorial infarction. The quadrigeminal and suprasellar cisterns remain preserved. The paranasal sinuses, mastoid air cells, and middle ear cavities remain clear. IMPRESSION: 1. No change in left frontal lobe hematoma, with trace intraventricular extension. There is no new mass effect. 2. New trace blood within the right temporal lobe with a possible component of subarachnoid hemorrhage. Echo: The left atrium is moderately dilated. The left atrial volume is severely increased. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with inferior akinesis and inferolateral hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate left ventricular hypertrophy with moderate regional left ventricular systolic dysfunction consistent with coronary artery disease. Mild aortic stenosis. At least moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. Brief Hospital Course: Mr. [**Known lastname 79285**] was admitted to Neurology ICU stroke team for evaluation and management of IPH. He was transfered from outside hospital after he presented there for evaluation of confusion and found to have IPH. Neuro He was closely monitered in ICU for neuro checks every 1 hour. He was closely monitered for signs of raised ICP secondary to bleed and possible associated edema. He was monitered for clinical evidence of seizures. all anticoagulants as well as antiplatelets were held. He was not continued on prophylactic antoconvulsants as there is no data that it improves outcome. Repeat CT scans were done for monitering of progression of bleed or for monitering for signs of edema, which did not show any evidence of either. MRI was done for more evaluation which showed possilbe small embolic strokes however there was no clinical evidence or any embolic source identified. The mosy likely mechanism of bleed was though to be amyloid. Cards He was closely monitered on telemetry which did not show any evidence of arrhythmia. He was ruled out for ACS by EKG and cardiac enzymes. Blood pressure goal was 120-160 systolic. Endo He was closely followed up regards to blood sugars and RISS was used for control of blood sugars. Pulm Chest X ray was obtained which did not show any evidence of acute process. Gen care he was put on bowel regime, pneumboots for DVT prophylaxis. SC heparin was added after 48-72 hrs of presentation. He was tranferred to the floor: On the floor the patient continued to do well His issues were as follows: Hyponatremia: The patient developed a mild hyponatremia. His urine lytes were noted to have an elevated sodium and were consistent with SIADH. He was fluid restricted with an improvement in his sodium. He sodium should be monitored periodically and his fluid restriction should conitnue (800-1000cc fluid a day) until his sodium remains stable Cardiac The patient had an echocardiogram which showed depressed LV function (LV=35%). The patient has had no clinical signs of fluid retention. There was no evidence of embolic source for any possible infarct. The patient also developed bigeminy. His cardaic enzymes were normal during this period, it is not clear if he has had this in the past. He was re-started on his beta-blockers to good effect. He will need to follow with his outpatient cardiologist on discharge from rehab. He was seen by PT who recommended rehab. Medications on Admission: Vytorin 10-80 mg tabs 1 po qd Lasix 40mg qd Aromasin 25mg 1 po qd Hydocan syrp 1 tsp qid prn Actos 30mg qd Metformin 1000mg [**Hospital1 **] Vicodin 5-500mg qid prn Celebrex 200mg qd Atenolol 25mg qd Ecotrin 81mg qd Cozaar 100mg tab qd Discharge Medications: 1. Vytorin [**8-/2135**] 10-80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Losartan 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: left frontal intraparenchymal intracranial hemorrhage Discharge Condition: MS: awake, alert, oriented to person, place, knows year, has problems with month. CN: no deficits Motor: full strength at UE/LE [**Last Name (un) **]: decreased vibration/pinprick at feet bilaterally Gait: stooped, broad based, steady. Discharge Instructions: You were admitted with a headache and confusion. You were brought to another hospital and on an image of your brain they noted a bleed in the left side of your brain and the bleeding extended to the ventricles (spaces) of your brain. You were sent here for further evaluation. You were first placed in the neuro ICU for monitoring and blood pressure control. You did well and were transferred out to the floor. We obtained an MRI which did not show any evidence of underlying masses but there was a concern of small strokes. To further evaluate this we obtained an echocardiogram of your heart which showed a depressed LV function (EF = 35%) but no evidence of thrombus. You were also noted to have a low sodium and it was thought to be a syndrome called SIADH which can happen with brain bleeds. To correct this abnormality your fluids were restricted. Your aromasin was held (for increased risk of stroke) Please make all follow up appointments. Please take all medications as prescribed. If you have any of the symptoms listed below please call your doctor or return to the nearest emergency room. Followup Instructions: Please follow up with : Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2165-6-17**] 4:00 [**Hospital Ward Name 23**] 8 - [**Hospital1 18**] [**Hospital Ward Name **] Please follow up with : [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 103521**] on discharge from rehab.

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icd9cm

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icd9pcs

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54723

Discharge summary

report

Admission Date: [**2186-7-28**] Discharge Date: [**2186-8-1**] Date of Birth: [**2105-2-15**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 2569**] Chief Complaint: left sided weakness, left sided facial droop transferred from OSH for eval for intra-arterial tPA Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 111885**] is an 81 year-old right-handed gentleman with a history of hyperlipidemia, a-fib s/p ablation currently on coumadin, essential tremors, who presents after he fell in the bathroom and found to have dense right sided weakness. . Mr. [**Known lastname 111885**] reports having been in his usual state of health last night. He went to bed at 10:30pm, which is when he was last well seen by his wife. [**Name (NI) **] also reports waking up this morning at 06:27am and walking to the bathroom. He again did not notice anything wrong (this however is not reliable as he does not believe there is any weakness now as part of his right MCA syndrome). He said he fell on the bathroom floor but was not sure why, and his wife heard him about 5-10 minutes later and called 911 immediately. He was taken to [**Hospital6 3105**], where he received an NIHSS of 9 (breakdown not available on the provided notes) and his head CT did not show acute infarcts by report. . Patient is on coumadin which was stopped on Tuesday due to an elevated INR. His INR yesterday was 2.6, and today's was 2.7 at the OSH. He was therefore not an IV rTPA candidate, and was transferred to [**Hospital1 18**] for possible IA rTPA. Of note, Mr. [**Known lastname 111885**] had 2 cataract surgeries, over the last 2 weeks and has been taking the coumadin on and off. There were instances in the past where his INR was very elevated (up to 16), and his PCP was considering making the switch to Pradaxa. . On arrival to [**Hospital1 18**] ED, a CODE STROKE was called. NIHSS by neurology was 12 (1 for best gaze, 2 for visual palsy, 4 for left motor arm, 4 for left motor leg, and 1 for dysarthria). Exam was notable for dense L flaccid plegia, nosoagnosia, visual extinction on the L, R gaze preference, impaired body position sensation on the L. Patient immediately was sent for CTA for further characterization of his stroke. Past Medical History: -AFib s/p ablation (on coumadin) -Hyperlipidemia -Essential tremor -CAD s/p angioplasty (no h/o MI, only prior angina) -Carotid ultrasound obtained day prior to admission. Per PCP, [**Name10 (NameIs) **] was for routine follow up. -Had TTE in the last year, which showed preserved EF (per PCP) Social History: He is a retired electrical engineer, lives with his wife and is completely independent in his ADLs. He smoked a long time ago but the duration and quantity are unclear. [**Name2 (NI) **] very rarely drinks a beer or a scotch. Family History: His father had a stroke at age [**Age over 90 **] years. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: P: 72 R: 16 BP: 117/70 SaO2: 100% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to spell "earth" backwards. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was mildly dysarthric. Able to follow both midline and appendicular commands on the right side of his body. He has at least a partial left sided neglect and denies any weakness on that side. He is able to recognize his own left hand, able to count the correct number of people in the room on both sides of his bed. He has a right gaze preference. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch with no extinction on double simultaneous stimulation. VII: left sided facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 1 0 0 0 0 0 0 0 0 0 0 0 0 0 -Sensory: No deficits to light touch, pinprick, No extinction to DSS. He has loss of proprioception on the left side. Graphestesia and object recognistion are impaired on the left. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 3 3 3 1 1 R 2 2 2 1 1 Plantar response was mute on the right and extensor on the left. -Coordination: No dysmetria ( only tested on the right) -Gait: unable to stand. . DISCHARGE PHYSICAL EXAM: -Vitals: 98.4, 150/84 [109-150/68-84], 66-85, 18, 96% RA -Neuro: AAOx3, pt somewhat abullic. Dense hemiplegia affecting left face, left arm and left leg. Can occasionally wiggle left toes. Pertinent Results: ADMISSION LABS: -WBC-10.1 RBC-4.63 HGB-15.3 HCT-46.5 MCV-100* MCH-33.0* MCHC-32.9 RDW-14.4 -GLUCOSE-135* NA+-142 K+-4.0 CL--104 TCO2-24, UREA N-24*, CREAT-1.0 -PT-34.2* PTT-37.6* INR(PT)-3.3* -Serum tox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG -Urine tox: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG -Urinalysis: BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 -VIT B12-383 . MODIFIABLE STROKE RISK FACTOR LABS: -Triglyc-93 HDL-62 CHOL/HD-2.4 LDLcalc-66 -%HbA1c-6.5* eAG-140* -TSH-1.5 . LABS ON DISCHARGE: -WBC-8.2 RBC-4.37* Hgb-14.4 Hct-43.2 MCV-99* MCH-33.0* MCHC-33.4 RDW-14.5 Plt Ct-167 -PT-18.3* PTT-34.6 INR(PT)-1.7* =================================== Imaging: . NONCONTRAST HEAD CT ([**7-28**]): There is a hyperdense middle cerebral artery on the right with obscuration of the lentiform nucleus on the right consistent with infarction. There is no evidence of hemorrhage, edema, or mass effect. The ventricles and sulci are normal in size and configuration. No fracture is identified. . CT PERFUSION ([**7-28**]): There is a matched perfusion defect in the right MCA territory with delayed transit time and reduced blood flow and blood volume. . HEAD AND NECK CTA ([**7-28**]): There is abrupt termination of the right superior M2 division of the MCA consistent with an occlusion. There is an early branching pattern of the right MCA. The left carotid and bilateral vertebral arteries and their major branches are patent with no evidence of stenosis. There is a calcified plaque at the proximal right internal carotid artery with 25% stenosis. On the right, the proximal internal carotid artery measures 3 mm in diameter on the right and the distal internal carotid artery measures 4 mm in diameter. On the left, the proximal internal carotid artery measures 5 mm in diameter, and the distal cervical internal carotid artery measures 4 mm in diameter. There is no evidence of aneurysm formation. CONCLUSION: Right MCA infarct with occlusion of the superior M2 division of the right MCA. . TTE: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). 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 regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. Mild to moderate ([**12-19**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild moderate mitral regurgitation with normal valve morphology. Mild aortic regurgitation. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No patent foramen ovale identified. CHEST X-RAY ([**7-28**]): No focal infiltrate. . NONCONTRAST HEAD CT ([**8-1**], our read): expected evolution of right MCA infarct with known hemorrhagic conversion. No new acute intraparenchymal hemorrhage. Brief Hospital Course: Mr. [**Known lastname 111885**] is an 81 year-old right-handed gentleman with a history of hyperlipidemia, a-fib s/p ablation currently on coumadin, essential tremors, who presented to an OSH after he fell in the bathroom and had severe left sided weakness. . # NEURO: Patient's initial CT at OSH was normal. His exam was concerning for a dense right MCA infarct. Repeat head CT in our ED showed the right MCA infarct. CTA revealed a right M2 superior division cutoff. Even with the assumption that he was last well seen at 6:30 am as he reports he had no trouble then (which is not reliable due to presence of neglect), he was not an IV tpa candidate due to an elevated INR. Given the infarct progression and finding on his head CT, he was also not a candidate for IA intervention as the risks outweighed the benefits. Most likely, infarct was embolic in setting of afib despite appropriate INR. . Mr. [**Known lastname 111885**] was initially admitted to the neurology ICU because his systolic blood pressures were in the low 100s and it was thought he may need vasopressors to attain adequate cerebral perfusion. However, once A-line was placed, saw that MAPs were ~100, so patient never requited pressors. His coumadin was stopped because embolic stroke despite being on coumadin for afib indicated coumadin failure. In ICU he underwent stroke risk factor workup including TTE (showed no PFO/ASD), full lipid panel (showed LDL 66) and A1C (mildly elevated to 6.4%). . On HD #3, patient was transferred from ICU to floor. MRI was performed, confirming presence of right MCA infarct. Of note, the MRI also showed some hemorrhagic conversion of the stroke, but regardless it was decided to continue anticoagulating patient as his neuro exam was stable. Repeat head CT on day of discharge showed no increase in hemorrhage. Once his INR drifted below 2, he was started on therapeutic Lovenox 70mg SC BID. Plan is for him to stay on Lovenox until INR <1.5, and then switch to Pradaxa 150mg [**Hospital1 **]. INR on day of discharge was 1.7. His home cilostazole should also be continued, as patient has CAD and requires anti-platelet therapy. He was also started on Fluoxetine, which has been shown to help with motor recovery after cortical strokes. . On discharge, neuro exam was stable to mildly improved from admission: patient AAOx3 with abullic affect, and dense left face/arm/leg hemiplegia. He is able to briefly wiggle his toes at times. Per PT recs, he was discharged to an acute rehab facility. He continues to require a dysphagia diet on discharge. He will follow up with Dr. [**First Name (STitle) **] in outpatient neurology clinic in 2 months. . # CV: patient's home propranolol 120mg PO daily (for essential tremor) was temporarily decreased to 1/2 dose during hospitalization due to need to maintain adequate cerebral perfusion pressure after stroke. Restarted on home dose at discharge. . ===================== TRANSITIONS OF CARE: - please D/C Foley when pt arrives to rehab facility, and check post-void residuals - please HOLD morning dose of Lovenox until INR is checked on [**2186-8-2**]. If INR is >1.5, give AM dose of Lovenox and recheck INR on [**2186-8-3**]. If INR is <1.5, STOP Lovenox and START Dabigatran. - will follow up in stroke clinic with Dr. [**First Name (STitle) **] - Full Code, HCP is [**Name (NI) 501**] [**Name (NI) **], daughter, and number is [**Telephone/Fax (1) 111886**]. ===================== [ AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack ] 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - () No 4. LDL documented? (x) Yes (LDL = 66) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (x) No (if LDL >100, Reason Not Given: ) 6. Smoking cessation counseling given? () Yes - (x) No (Reason (x) non-smoker - () unable to participate) 7. Stroke education given? (x) Yes - () No 8. Assessment for rehabilitation? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No (if LDL >100, Reason Not Given: ) 10. Discharged on antithrombotic therapy? (x) Yes (Type: (x) Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A Medications on Admission: -Cilostazole 100mg daily -Propranolol ER 120mg daily -Atorvastatin 20mg daily -Eye drops: Durezol 0.05% 1gtt TID (remaining 1 day for right eye, 1 wk for left eye) Nevanac 0.1% 1gtt TID (remaining 1 day for right eye, 1 wk for left eye) Vigamox 0.5% 1gtt TID (remaining 1 day for right eye, 1 wk for left eye) Discharge Medications: 1. Vigamox *NF* (moxifloxacin) 0.5 % OS TID Duration: 1 Weeks * Patient Taking Own Meds * 2. Durezol *NF* (difluprednate) 0.05 % OS TID Duration: 1 Weeks * Patient Taking Own Meds * 3. Fluoxetine 20 mg PO DAILY 4. Propranolol LA 120 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Durezol *NF* (difluprednate) 0.05 % OS TID Duration: 1 Weeks * Patient Taking Own Meds * 7. Nevanac *NF* (nepafenac) 0.1 % OS TID Duration: 1 Weeks * Patient Taking Own Meds * 8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 9. Enoxaparin Sodium 70 mg SC BID Please STOP enoxaparin once INR is <1.5. Pt will then be switched to dabigatran. 10. Dabigatran Etexilate 150 mg PO BID To be started AFTER INR is <1.5 (pt should remain on Enoxaparin until then). 11. Outpatient Lab Work Please check INR on [**2186-8-2**]: ---If INR is <1.5, please STOP enoxaparin and START dabigatran (Pradaxa). ---If INR is >1.5, please CONTINUE enoxaparin and recheck INR daily until INR <1.5. 12. PleTAL *NF* (cilostazol) 100 mg ORAL DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: ACUTE ISSUES: 1. Stroke CHRONIC ISSUES: 1. Atrial fibrillation 2. Hyperlipidemia 3. Essential tremor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro exam on discharge: dense hemiplegia affecting left face, left arm, and left leg. Discharge Instructions: Dear Mr. [**Known lastname 111885**], You were admitted to the hospital for weakness in your left face, arm and leg. You were found to have a large stroke on the right side of your brain. This stroke was likely due to your atrial fibrillation, which can cause blood clots to form in the heart and travel to the brain. We made some changes to your blood thinner medications to help prevent another blood clot from forming and leading to a stroke in the future. . Please attend the outpatient neurology appointment listed below to follow up on your hospitalization. . We made the following changes to your medications: 1. STOPPED Coumadin 2. STARTED enoxaparin (Lovenox) 70mg subcutaneous injection twice daily -- this will be replaced with a stronger blood thinner called dabigatran (Pradaxa) once the Coumadin is out of your system. 3. STARTED Fluoxetine 20mg by mouth daily Followup Instructions: Department: NEUROLOGY When: MONDAY [**2186-10-2**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

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Discharge summary

report

Admission Date: [**2116-5-31**] Discharge Date: [**2116-6-12**] Date of Birth: [**2075-3-13**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 1990**] Chief Complaint: N/V/D Major Surgical or Invasive Procedure: Mechanical Intubation Central Venous Catheter Insertion (Right Internal Jugular) Arterial Line Placement (Left Radial Artery) PICC line placement (peripherally inserted central catheter) History of Present Illness: 41 y/o female with PMHx congenital hepatic fibrosis, polycystic kidney disease who presented to an OSH with profuse diarrhea starting this morning. She notes feeling "under the weather" for the past couple days as well. She was tachycardic to 140 with lactate of 4.5 at OSH initially. Received 6L IVF with improvement in tachycardia to 125 with N/V/D. Vomiting bilious emesis without blood. Diarrhea similar without evidence of gross bleeding. Labs were notable for a WBC of 3.3 with 13% bandemia, HCT of 35, plateltets of 38k. Patient was acidotic with CO2 of 13 and an AG of 14. Lactate noted to be 4.0. Patient was in [**Last Name (un) **] with creatinine of 2.8. At the OSH ED she was given vanco/zosyn as well as 4 L NS and PO APAP. EKG showed sinus tachycardia with minimal ST depressions in V4-V6 and a troponin of 0.03. Given concern for severe sepsis, she was transferred to [**Hospital1 18**] for further management. . In the ED, initial VS were HR 120, RR 30, BP 104/79, satting 100% on RA. T was 101.2. Labs showed leukopenia with WBC of 1.4 (baseline [**5-8**]) with 66% neuts, 20% bands, 3% atyps, anemia to 30.1 (baseline 34), and platelets to 27 (baseline 100), Ca of 6.1, Mg of 1.0, K of 2.8, bicarb of 13, Cr of 2.4. Coags showed PT: 27.3, PTT: 43.7, INR of 2.6. Lactate was 2.5. She was given 2 amps Calcium gluconate, 2gm mag sulfate, ipratropium, and flagyl 500mg IV. She had a CT A/P that showed her right colon is completely collapsed which could be c/w colitis, but no clear infectious etiology. . On arrival to the MICU, patient is alert but in moderate respiratory distress speaking in broken sentences. Past Medical History: congenital hepatic fibrosis polycystic kidney disease portal hypertension with splenomegaly one cord of grade [**2-3**] varices in the lower third of the esophagus Gastric varices Old portal vein thrombosis history of DVTs in the setting of taking oral contraceptives history of cholecystectomy asthma history of back surgery with S1 procedure with noted chronic back pain. Failed pregnancy requiring a D&C. s/p tubal ligation Chronic kidney disease (baseline Cr 1.6-1.7) Social History: Works as bank teller. Lives alone. No new sexual contacts. [**Name (NI) **] IVDU Family History: Brother with reported history of clotting disease with unknown cause Mother is noted to have died at age 52 from uterine cancer and also had clotting disorder(unknown type). Mother's mother with history of colon cancer, died at age 62 Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented, moderate respiratory distress/fatigued HEENT: Pale. Sclera anicteric, Dry MM, oropharynx with thick mucous, no oral petechiae, EOMI, PERRL Neck: supple, JVP flat, no LAD CV: Tachycardic, otherwise normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds, right worse than left. RLL with very depressed breath sounds. No crackles or wheezes. Abdomen: NBS. soft, but TTP in the epigastric region without rebound. No organomegaly appreciated. GU: clear urine Ext: warm, bounding pulese. Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, MAE Skin: No evidence of petechiae on upper/lower extremities or on back. Abdomen with ? cherry angiomas. Discharge PE: VS: Tm 99.8 Tc 98.6 126/78 (126-148/73-84) 87 (81-116) 20 100RA UO: -1050 8h/ -[**2054**] 24h 2 BMs overnight, 8 BMs in last 24h General: middle aged woman, well appearing, well nourished, sleeping comfortably in bed, NAD HEENT: EOMI, PERRL CV: RRR, S1 S2, no murmurs/rubs/gallops lungs: CTA b/l, no wheezes/rhonchi/crackles appreciated abdomen: soft, nontender, nondistended, +BS, no hepatomegaly appreciated extremities: trace LE edema b/l, warm, well perfused, 2+ DP pulses R arm with PICC: 2+ radial pulses, no increased swelling noted Neuro: normal muscle strength and sensation throughout, CN 2-12 grossly intact Pertinent Results: Admission Labs: [**2116-5-31**] 04:30PM BLOOD WBC-1.4*# RBC-3.19* Hgb-9.9* Hct-30.1* MCV-94 MCH-31.2 MCHC-33.0 RDW-13.3 Plt Ct-27*# [**2116-5-31**] 04:30PM BLOOD Neuts-66 Bands-20* Lymphs-10* Monos-1* Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 [**2116-5-31**] 04:30PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+ [**2116-5-31**] 04:30PM BLOOD PT-27.3* PTT-43.7* INR(PT)-2.6* [**2116-5-31**] 04:30PM BLOOD FDP-10-40* [**2116-6-1**] 05:00PM BLOOD Parst S-NEGATIVE [**2116-5-31**] 04:30PM BLOOD Glucose-94 UreaN-32* Creat-2.4* Na-141 K-2.8* Cl-113* HCO3-13* AnGap-18 [**2116-5-31**] 04:30PM BLOOD ALT-23 AST-35 LD(LDH)-188 AlkPhos-20* TotBili-1.4 [**2116-6-1**] 01:19AM BLOOD CK-MB-2 cTropnT-<0.01 [**2116-5-31**] 04:30PM BLOOD Albumin-2.6* Calcium-6.1* Phos-3.5 Mg-1.0* [**2116-5-31**] 04:30PM BLOOD Hapto-40 [**2116-6-2**] 09:37AM BLOOD Cortsol-88.2* [**2116-6-1**] 05:04AM BLOOD HIV Ab-NEGATIVE [**2116-6-1**] 11:47PM BLOOD Vanco-14.9 [**2116-5-31**] 06:32PM BLOOD Type-ART pO2-88 pCO2-26* pH-7.30* calTCO2-13* Base XS--11 Intubat-NOT INTUBA [**2116-5-31**] 04:30PM BLOOD Lactate-2.5* [**2116-6-1**] 10:33AM BLOOD Lactate-6.3* [**2116-6-1**] 01:32AM BLOOD freeCa-1.03* IMAGING Portable CXR FINDINGS: As compared to the previous radiograph, the patient has received a right internal jugular vein catheter. The tip of the catheter projects over the right atrium and should be pulled back by approximately 5-6 cm to ensure correct position in the superior vena cava. IV team was paged at the time of observation and dictation, 8:09 a.m., [**2116-6-1**]. There is no evidence of complications, notably no pneumothorax. Unchanged retrocardiac atelectasis and moderate cardiomegaly, no evidence of pneumonia. Discharge labs: [**2116-6-12**] 06:29AM BLOOD WBC-4.9 RBC-2.55* Hgb-7.9* Hct-23.7* MCV-93 MCH-30.8 MCHC-33.1 RDW-13.7 Plt Ct-92* [**2116-6-12**] 06:29AM BLOOD Glucose-90 UreaN-20 Creat-1.3* Na-139 K-4.0 Cl-112* HCO3-21* AnGap-10 [**2116-6-12**] 06:29AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.9 Micro: [**2116-5-31**] 4:30 pm BLOOD CULTURE **FINAL REPORT [**2116-6-6**]** Blood Culture, Routine (Final [**2116-6-6**]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2116-6-1**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**Last Name (LF) **],[**First Name3 (LF) **] -CC7D- @ 10:45 [**2116-6-1**]. Brief Hospital Course: Ms. [**Known lastname 32357**] is 41F with a h/o PCKD, congenital hepatic fibrosis with portal hypertension and esophageal varices, h/o DVTs, s/p cholecystectomy, admitted with septic shock, klebsiella bacteremia, and respiratory failure following a prodrome of n/v/diarrhea. # Septic Shock [**3-5**] Klebsiella bacteremia: Presented from OSH initially with nausea/vomiting/diarrhea and fevers. Transferred with profound sepsis and evidence of shock with end organ ischemia including elevated lactate and renal failure. On arrival to [**Hospital1 18**], right internal jugular vein line was emergently placed, and patient was intubated for respiratory failure given overhwhelming metabolic acidosis and inability to maintain respiratory compensation. Left radial arterial line was placed as patient was necessitating support with norepinepherine and vasopressin. Initially continued on broad spectrum antibiotics with Vancomycin and Piperacillin/Tazobactam. Continued to spike and ID consult was performed. Antimicrobial coverage was initially broadened with doxycylcine as well as IV metronidazole, PO Vancomycin as patient was having large volume diarrhea and empiric therapy for C.Difficile and potential zoonoses. As she continued to spike fevers, GNR's were growing in her blood stream and Piperacillin/Tazobactam was switched with meropenem to empirically cover ESBL GNR's. Outside hospital cultures were growing Klebsiella Pneumoniae resistant to piperacillin/tazobactam. Lactate levels continued to increase, at one point >6, with no hemodynamic improvement. Surgery was consulted at that time for potential exploratory laporatomy given concern for diffuse bowel necrosis. However, prior to surgery, patient sufferred a STEMI, and the decision was made to hold off on exploratory laporatomy. As no other source of infection was identified and organ perfusion began to improve with aggressive hydration, her antimicrobial therapy was weaned to just meropenem, then switched to ceftriaxone once in house sensitivities came back. No source was identified, although abdominal CT scan showed possible right sided colitis. As no source was revealed, a tagged WBC scan was pursued which was negative. Lactate continued to downtrend and renal function improved over the next several days. Patient was extubated and off pressors by HD 10. The patient also had a WBC scan which was negative. On transfer to the general medicine floor, the patient was continued on IV Ceftriaxone, with end date [**2116-6-19**]. # Hypercarbic Respiratory Failure: Intubated on HD#1 given overwhelming acidosis and inability to maintain respiratory compensation. She was extubated on [**2116-6-7**] without issue. Barriers to extubation were volume overloaded status, as she was aggressively volume resuscitated in the setting of severe sepsis. # STEMI: On admission, patient fell into multiple bouts of SVT to 180's which broke with adenosine. She was briefly placed on a diltiazem gtt for rate control while on pressors. On HD#2, patient sufferred a STEMI with evidence of cardiac biomarker elevation consistent with an inferior lateral myocardial infarction. Empiric heparin was started for 48 hours then discontinued. Cardiology was following and it was decided that she was too sick for catheterization at this time. TTE was performed which confirmed this, with a new EF of 40%. As her platelets continued to increase, a baby aspirin was initiated. As she became more hemodynamically stable, beta blockers were initiated as well as a statin. As her renal function continued to change, an ACE-I was not initiated. Upon discharge, the patient was initiated on lisinopril and continued on her atorvastatin, metoprolol, and aspirin. As per cards, there is no need for urgent cath at this time and she should follow up with an outpatient stress test. #[**Last Name (un) **]/CKD: baseline creatinine 1.6-1.7, underlying PCKD. Acute kidney injury likely a result of pre renal failure progressiving to acute tubular necrosis from hypotension. Renal initially consulted for potential dialysis, although was not necessary to puruse. As sepsis resolved with hemodynamic improvement, creatinine continued to improve to baseline values. While on the floor, the patient was auto-diuresing well, with creat trending down to 1.2. Because of this improvement in her creat, lisinopril was restarted upon discharge. #Anemia/Thrombocytopenia: Has baseline thrombocytopenia of about [**Numeric Identifier **] platelets. Initially profoundly thrombocytopenic with accompanying anemia initially concerning for DIC. Hematology/Oncology was consulted in the emergency room, and voiced no schistocytes evidence on peripheral smears. As sepsis involved, platelets continued to improve. Her anemia remained stable, but she was given blood transfusions in the setting of HCT< 27 and new STEMI. While on the floor, the patient's crit and platelets were trended. #Hypernatremia: After massive fluid resuscitation, started to have evidence of hypernatremia around HD6/7. Fluid water deficit was calculated to >4.5 liters. Free water boluses were started with her tube feeds, and IV D5W was started with sodium monitoring. No evidence of diabetes insipidus was seen on urine studies. Sodium corrected to 140 by HD #11, and while on the general medicine floor, her sodium was trended. #Left arterial thrombus: Arterial line was placed per above for hemodynamic monitoring. Evidence of flattened a-line with blood clot seen on ultrasound. Vascular surgery was consulted given thrombus and also evidence of distal ischemia on fingers/toes in the presence of pressor use. Vascular suggested topical nitropaste for improved perfusion, and empiric heparin gtt would also adequately treat thrombus along with STEMI per above. Perfusion improved with nitropaste, and heparin gtt was discontinued given thrombocytopenia. #Right Upper Extremity Superficial Thrombus: RUE found to have non-occlusive basillic and occlusive cephalic vein thrombus, after developing R arm swelling the setting of placing right PICC line. This edema resolved the following day. As per the PICC team, ok to continue using the PICC as long as the patient does not develop any new R arm swelling, tenderness, or pain. She will be discharged with PICC to complete treatment with ceftriaxone. At the time of discharge both of her arms were equal in size. Transitional Issues: - The patient will need to continue Ceftriaxone, end date [**2116-6-19**]. She will need the PICC line removed once antibiotic course is completed. Please check LFT's on [**2116-6-17**]. - The patient is s/p STEMI while in the MICU. She will need an outpatient stress test. Her metoprolol and lisinopril need to be titrated up as necessary. - The patient was just started on Lisinopril; it was initially being held due to [**Last Name (un) **]. Please check her creatinine and lytes on [**2116-6-17**]. - The patient is anemic and thrombocytopenic related to her recent sepsis. Please check her CBC on [**2116-6-17**]. Medications on Admission: bupropion 150mg lansoprazole 15mg sertraline 50mg Discharge Medications: 1. ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous once a day: STOP [**2116-6-19**]. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 5. lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO once a day. 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: primary diagnosis: Klebsiella sepsis ST elevation myocardial infarction colitis Acute on Chronic Renal Failure Thrombocytopenia Arterial Thrombus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Needs assistance. Discharge Instructions: Dear Ms. [**Known lastname 32357**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were transferred to [**Hospital1 18**] because you were very ill and found to have a bacterial infection in your blood. While you were in the intensive care unit you were intubated (had a tube down your throat helping breathe for you) and needed medications to maintain your blood pressures. We gave you antibiotics which treated the infection and you were ultimately able to breathe on your own and maintain your own blood pressures. While you were in the intensive care unit, you sufferred a heart attack. The cardiologists were contact[**Name (NI) **] and it was decided to not go ahead and do any procedures at that time because you were so sick. However, we did start you on medications that will help optimize your heart function. You will need to have a stress test performed as an outpatient to help decide if you need further procedures. We made the following changes to your medications: START Ceftriaxone 2 grams daily through your veins (END DATE [**2116-6-19**]) START metoprolol 75 mg by mouth daily START atorvastatin 80 mg daily START aspirin 81 mg daily START lisinopril 5 mg daily Followup Instructions: Name:[**Name6 (MD) 32358**] [**Name8 (MD) **],MD Specialty: Priamry Care Location: [**Hospital1 **] FAMILY PRACTICE Address: 1020 [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 23011**] Phone: [**Telephone/Fax (1) 32359**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Department: CARDIAC SERVICES When: THURSDAY [**2116-6-25**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2116-6-13**]

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icd9cm

[ [ [] ] ]

[ "48.23", "96.6", "38.97", "96.04", "38.91", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

15589, 15661

7696, 14120

275, 464

15851, 15851

4414, 4414

17252, 17924

2754, 2993

14868, 15566

15682, 15682

14793, 14845

15993, 16997

6194, 7673

3008, 3759

14141, 14767

17026, 17229

3773, 4395

229, 237

492, 2140

4430, 6177

15701, 15830

15866, 15969

2162, 2636

2652, 2738

26,268

127,187

7624

Discharge summary

report

Admission Date: [**2106-8-6**] Discharge Date: [**2106-8-15**] Date of Birth: [**2037-4-7**] Sex: M Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 18741**] is a 69-year-old male with a history of cirrhosis, hepatocellular carcinoma, diabetes mellitus, chronic renal insufficiency, esophageal and rectal varices with a history of prior GI bleed who presented on [**2106-8-6**] to the Emergency Department with bright red bleeding per rectum. Mr. [**Known lastname 18741**] was recently admitted to the [**Hospital6 256**] between [**2106-7-29**] and [**2106-8-2**] for GI bleed. On this previous admission, he was found to have large rectal varices and was deemed not to be a good candidate for TIPS procedure by GI. The patient had been well after being discharged on [**2106-8-2**] for one to two days and then had a large bloody bowel movement. He presented to his PCP [**Last Name (NamePattern4) **] [**2106-8-6**] with a hematocrit of 25 and was sent to the Emergency Department. On the day of admission, his hematocrit was 25 down to 32 on this discharge day, [**2106-8-2**]. The patient denied any chest pain, shortness of breath, nausea, vomiting, diaphoresis, and was given 1 unit of packed red blood cells in the Emergency Department and 2 more packed red blood cells the next day. He was given 2 units of fresh frozen plasma and 1 unit of platelets. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Cirrhosis first diagnosed in [**2094**]. 3. Hypertension. 4. Chronic renal insufficiency with a baseline creatinine of 3.0. 5. Hepatocellular carcinoma status post radiofrequency ablation. 6. History of variceal bleeding. 7. History of diverticular bleeding. 8. Status post partial colectomy in [**2098**]. 9. History of hemorrhoids. 10. Peripheral neuropathy. SOCIAL HISTORY: Mr. [**Known lastname 18741**] is a retired police officer. He has a remote history of smoking but reports that he quit in [**2072**]. He also has a history of alcoholism but says that he quit drinking in [**2095**]. FAMILY HISTORY: He has a sister who died at age 56 secondary to complications and diabetes. His mother is deceased secondary to stomach cancer. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Propanolol 60 mg q.d. 2. Lasix 40 mg b.i.d. 3. Aldactone 50 mg b.i.d. 4. Protonix 40 mg b.i.d. 5. Trazodone 25 mg q.d. 6. Lactulose 30 mg t.i.d. 7. NPH 30 units in the a.m., 20 units in the p.m. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.9 degrees Fahrenheit, pulse rate of 60, blood pressure 132/77, respiratory rate 16, oxygen saturation 100% on room air. General: Mr. [**Known lastname 18741**] is a thin, pleasant male, in no apparent distress. HEENT: Pupils equal, round, and reactive to light. His extraocular muscles were intact. There was scleral icterus found. His oropharynx and nasopharynx showed no erythema or signs of bleeding. His mucous membranes were moist. Neck: Supple, without lymphadenopathy or thyromegaly. Heart: Heart rate regular with normal rate and rhythm, no murmurs, rubs, or gallops heard. His heart sounds were distant. Lungs: Clear bilaterally to auscultation without crackles. Abdomen: The abdomen demonstrated distention, positive fluid wave, and positive bowel sounds times four. Extremities: There was no clubbing or edema. He had 2+ pulses throughout. LABORATORY/RADIOLOGIC DATA: CBC revealed a white count of 4.5, hemoglobin 9.7, hematocrit 28.6, and a platelet count of 58,000. Chemistries revealed a sodium of 138, potassium 3.7, chlorine 104, bicarbonate 20, BUN 54, creatinine 2.4, glucose serum level 69. He had a PT of 15.7, PTT 36.0, and an INR of 1.6. EKG showed normal sinus rhythm of 62 with positive PACs. The chest x-ray demonstrated mediastinal lymphadenopathy with no infiltrates. HOSPITAL COURSE: GASTROINTESTINAL: Mr. [**Known lastname 18741**] is with a history of gastrointestinal bleed in the past with a history of esophageal and rectal varices. On [**2106-8-6**], he was given 1 unit of packed red blood cells followed by serial hematocrits taken t.i.d. He was started on Protonix 40 mg IV. He was given propanolol 80 mg and he was started on a drip of Octreotide 15 micrograms per hour. Two more units of packed RBCs were given on [**2106-8-7**]. He was maintained on Lactulose 30 mg t.i.d. A nitroglycerin drip was started to reduce .................... stress. Embolization was discussed. The patient was started on Flagyl 500mg and ciprofloxacin 200 mg IV. The patient underwent a thrombin injection on [**2106-8-12**] and was transferred to [**Hospital Ward Name 1827**] XII Unit. RENAL: Mr. [**Known lastname 18741**] has a history of chronic renal insufficiency with a BUN and creatinine on admission of 54 and 2.6 respectively. Throughout the admission, Mr. [**Known lastname 18741**] received IV fluid boluses of normal saline in order to raise his urine output. However, urine output was not significantly raised and on [**2106-8-10**], normal saline infusions were stopped as this had led to an increase in his ascites. ENDOCRINE: Mr. [**Known lastname 18741**] has diabetes mellitus and due to this fact, he was placed on a sliding scale of regular insulin during his hospital stay. DISCHARGE DIAGNOSIS: 1. Gastrointestinal bleed. 2. Cirrhosis. 3. Hepatocellular carcinoma. 4. Chronic renal insufficiency. 5. Diabetes mellitus. DISCHARGE MEDICATIONS: 1. Lactulose 10 gram/15 milliliter syrup 30 mg oral t.i.d. 2. Spironolactone 25 mg tablets oral b.i.d. 3. Hydrocortisone acetate 1% ointment one application rectal five times per day. 4. Pantoprazole 40 mg tablet one tablet oral once a day. 5. Metronidazole 500 mg tablet one tablet three times a day. 6. Propanolol 80 mg capsule, one capsule once a day. 7. Trazodone 50 mg tablet oral at bedtime. DISPOSITION: Mr. [**Known lastname 18741**] will be discharged to a hospice facility and will follow-up with Dr. [**MD Number(4) 9138**] as necessary. [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 16181**], M.D. [**MD Number(1) 11871**] Dictated By:[**Last Name (NamePattern1) 27804**] MEDQUIST36 D: [**2106-8-13**] 05:09 T: [**2106-8-13**] 20:05 JOB#: [**Job Number 27805**]

[ "155.0", "571.2", "403.91", "285.1", "250.00", "455.2", "789.5" ]

icd9cm

[ [ [] ] ]

[ "45.43", "45.24", "49.45" ]

icd9pcs

[ [ [] ] ]

2086, 2270

5498, 6369

5345, 5475

3903, 5324

2293, 2520

2535, 3885

1436, 1832

1849, 2069

60,887

136,220

38657

Discharge summary

report

Admission Date: [**2200-1-25**] Discharge Date: [**2200-1-30**] Date of Birth: [**2134-6-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory distress, hypoxia, intubated Major Surgical or Invasive Procedure: Intubation History of Present Illness: 65 yo M with PMH of heavy tobacco use, COPD on nightly oxygen who was found unresponsive earlier this evening. Daughter is a chef for a function facility and father came to watch event. Appeared ashen and unwell on arrival. Found sitting on toilet after not coming out for 8 minutes, unresponisve and cyanotic. Given O2 and called EMS. Per OSH report, EMS found patient sitting on toilet, hypertensive, agonal breathing and unresponsive. Given Albuterol, Combivent. They attempted intubation the field without success. Bag-masked until OSH, then intubated at [**Hospital1 **]. Intial VS SBP 210/105, HR 102, 100% on 100%/Ambu. [**Hospital1 **] PE notable for bilateral tight wheezing. Ceftriaxone, Azithromycin, Xopenex given. EKG SR 96 bpm, normal axis, large peaked Ts V3, inverted TW II, III/AVF, V6. Initial Troponin I 0.1 (indeterminate), WBC 13.6. CT Brain without acute abnormality, ICH or mass effect. In the last week with increased SOB (prompting steroid burst) and chills. Today with increased cough, hoarse voice and shortness of breath. No prior influenza or recent pneumonia vaccination. Per daughter had never seen him go to the doctor until two months with 'episodes' of shortness of breath, turning purple and tripoding to breath. In our ED patient was given 2.5L NS in ED. Patient was briefly on Propofol but this was discontinued for hypotension; now on Fentanyl/Midazolam for sedation. CTA with pulmonary effusions, edema but no thrombus. RIJ placed for progressive hypotension, but Norepinephrine only started upon leaving the ED with VS 83/57. Upon arrival to the MICU, patient is intubated, tolerating ventilator well. Past Medical History: Tobacco Use - heavy per daughter, 1-1.5 ppd COPD - O2 QHS Social History: Social History: (Per wife & daughter) - Tobacco: 1-1.5 ppd since age 17 - Alcohol: None - Illicits: None Family History: Father with DM, with resultant heart problems. Mother with 'stomach problems'. [**Name2 (NI) 6419**] parents are deceased. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 98.1 BP: 109/65 P: 61 24 / 100 on 50% General: Sedated, unarouable, tolerating ventilator HEENT: Sclera anicteric, MMM, ET, OG tube Neck: supple Lungs: Diffuse wheeze anteriorly with poor air movement, no clear ronchi or localizing rales anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly distended, with bowel sounds present, no grimace to deep palpation GU: Foley in place Ext: warm, well perfused, 2+ pulses, no edema DISCHARGE PHYSICAL EXAM 97.8, 133/64, 71, 19, 93/2L Notable change: breathing much improved with no wheeze, quiet breath sounds throughout Pertinent Results: On admission: [**2200-1-24**] 11:54PM BLOOD WBC-30.9* RBC-4.95 Hgb-15.2 Hct-45.7 MCV-93 MCH-30.7 MCHC-33.2 RDW-13.6 Plt Ct-239 [**2200-1-24**] 11:54PM BLOOD PT-11.3 PTT-21.0* INR(PT)-0.9 [**2200-1-25**] 07:08AM BLOOD Glucose-108* UreaN-20 Creat-0.9 Na-140 K-4.5 Cl-108 HCO3-28 AnGap-9 [**2200-1-25**] 07:08AM BLOOD ALT-123* AST-43* CK(CPK)-68 AlkPhos-58 TotBili-0.4 [**2200-1-25**] 07:08AM BLOOD Calcium-8.0* Phos-3.8 Mg-1.9 [**2200-1-27**] 03:45AM BLOOD Triglyc-312* HDL-42 CHOL/HD-4.8 LDLcalc-99 DISCHARGE LABS: [**2200-1-30**] 04:27AM BLOOD WBC-10.7 RBC-4.39* Hgb-13.5* Hct-39.4* MCV-90 MCH-30.7 MCHC-34.2 RDW-13.1 Plt Ct-155 [**2200-1-30**] 04:27AM BLOOD Glucose-144* UreaN-29* Creat-0.9 Na-137 K-4.4 Cl-100 HCO3-34* AnGap-7* [**2200-1-29**] 03:20AM BLOOD ALT-110* AST-21 LD(LDH)-157 AlkPhos-51 TotBili-0.9 [**2200-1-30**] 04:27AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.4 Portable TTE (Complete) Done [**2200-1-25**] at 1:41:28 PM FINAL The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis (prior myocardial infarction). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2200-1-25**] 1:02 AM 1. Pulmonary edema. 2. Mediastinal and hilar lymph nodes are borderlin enlarged but likely reactive. 3. Right adrenal myelolipoma. 4. Renal hypodensities some cysts some too small to characterize. Correlation with prior imaging or renal ultrasound in 6 months is recommended for further evaluation. CHEST (PORTABLE AP) Study Date of [**2200-1-28**] 9:28 AM As compared to the previous radiograph, the patient has been intubated. The tip of the endotracheal tube projects 5 cm above the carina. The course of the nasogastric tube is unremarkable. The tip of the tube projects over the distal part of the stomach. The lung volumes have slightly increased. The distribution and severity of the pre-described parenchymal changes is unchanged. Unchanged size of the cardiac silhouette. No pneumothorax. Brief Hospital Course: 65 yo M with h/o COPD, tobacco use, found unresponsive and cyanotic while sitting on toilet after several days of progressive SOB; intubated at [**Hospital3 4107**] (first attempted by EMS); admitted to the ICU upon arrival due to persistent hypotension and need for mechanical ventilation. # Respiratory arrest. Etiology uncertain but would consider COPD exacerbation (worsening SOB x several days with steroid burst per PCP); PNA (not visualized on CXR but may be dry); cardiac ischemic event (EKG without concerning changes but no prior); PE (CTA preliminary negative); aspiration (but was upright on toilet) or seizure (but reportedly worsened over several day period). Intubated at [**Hospital1 **]; wheezing and tight on initial exam. CTA negative for PE. Treated with steroid burst, antibiotics for community acquired pneumonia and nebulizer treatment (Ipratroprium / Albuterol). Extubated [**2200-1-26**] and transferred to the regular medical floor on [**2200-1-27**]. On [**2200-1-28**] he had new respiratory distress requiring re-intubation. This was due to a combination of variables including mucous plugging and treatment with high flow oxygen that decreased his intrinsic respiratory drive. He underwent bronchoscopy with removal of thick mucous secretion. On [**2200-1-29**] he was extubated without incident. He continued on nebulizer therapy and was discharged with a planned course of antibiotics and 15 days steroid taper. He was also scheduled to see Pulmonary as outpatient to continue further treatment for his COPD and continued tobacco use. # Hypotension: Initially unclear etiology. Considerations included sepsis (infectious vs cardiogenic; obstructive but no PE on CTA) vs. breath stacking with ventilator / COPD vs new process such as pneumothorax s/p line placement. Resolved with discontinuation of Propofol. # Leukocytosis: [**Month (only) 116**] be reactive vs infectious process. Could also be ischemia vs seizure (low suspicion). Cardiac enzymes were indicative demand ischemia. Though chest imaging never developed a true infiltrate, was treated for community acquired pneumonia. # COPD: Unclear level of control or severity. Also on daily Azithromycin for last 2 months. Treated for exacerbation as above. Discharged with Tiotroprium, Advair, Duonebs and Pulmonary follow-up. # Tobacco Use: Recommended stopping tobacco use and was given a Nicotene patch while inpatient. # Cardiac Dysfunction: As noted above with some elevated troponins (peak 0.11 on [**1-25**]) indicative of demand ischemia. Cholesterol as above. LDL < 100 but could consider addition of statin medication as outpatient to push LDL < 70. Started Aspirin 81 mg daily. # Renal cysts: Noted on CT scan, patient should have repeat ultrasound in 6 months post-discharge. # Hyperglycemia: New and associated with steroid burst. Discharged on insulin sliding scale with plan to discontinue once off steroids or not requiring any coverage. Medications on Admission: Prednisone taper 60mg x 3 --> 40mg x 3 --> 20 mg x 3 days (final day [**1-24**]) Azithromycin 500 mg daily (started in [**Month (only) 404**]) Symbicort ProAir Albuterol Sulfate Home Oxygen at night Clarithryomycin (A couple weeks prior was on this, felt breathing improved) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): [**Month (only) 116**] discontinue if increasingly active. 2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Nebulizer Inhalation every six (6) hours. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q2H (every 2 hours) as needed for Wheezing. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Stop [**2200-2-2**]. 11. Prednisone 10 mg Tablet Sig: Tapered dosing PO once a day for 15 days: 50 mg daily x 3 days, then 40 mg daily x 3 days, then 30 mg daily x 3 days, then 20 mg daily x 3 days, then 10 mg daily x 3 days then stop. 12. Insulin Sliding Scale Please check Fingersticks QACHS while on steroids. Discontinue if not requiring insulin coverage for > 24 hours. Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Location (un) 511**] Siani Discharge Diagnosis: Primary: COPD exacerbation, reactive airway disease, tobacco use Discharge Condition: Hemodynamically stable, afebrile, oxygen saturation 92% on 2L at rest or 3-4L with ambulation. Discharge Instructions: You were admitted with difficulty breathing and low oxygen levels which required ventilation through a breathing tube. You were treated with antibiotics, steroids and medications to improve your breathing. Once improved, you were discharged to a rehab for further recovery. Please take all medications as prescribed. Please keep all outpatient appointment. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2200-3-11**] 8:40 AM Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2200-3-11**] 9:00 AM Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2200-3-11**] 9:00 AM

[ "428.0", "790.29", "934.1", "491.21", "428.21", "E932.0", "285.9", "753.19", "518.81", "486", "401.1", "305.1" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.24", "38.91", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

10732, 10788

5682, 8650

357, 369

10897, 10994

3092, 3092

11403, 11855

2278, 2405

8976, 10709

10809, 10876

8676, 8953

11018, 11380

3613, 5659

2420, 3073

276, 319

397, 2057

3106, 3596

2079, 2139

2171, 2262

30,056

166,383

33238

Discharge summary

report

Admission Date: [**2117-12-13**] Discharge Date: [**2117-12-18**] Date of Birth: [**2045-4-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ampicillin / Sulfa (Sulfonamides) / Solu-Medrol Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2117-12-13**] - AVR (19mm CE Magna Pericardial Valve) History of Present Illness: 72 y/o woman with h/o AS followed by serial echocardiograms. An echo from [**8-7**] showed severe AS with and [**Location (un) 109**] of 0.4cm2. She has thus been referred to Dr. [**Last Name (STitle) **] for elective surgical management. Past Medical History: Hyperlipidemia AS Diverticulitis Sciatica GERD Social History: Retired. Lives with husband. [**Name (NI) 4084**] smoked. Drinks 1 glass of wine daily. Family History: Father with MI in early 60's and died at age 65. Mother died at age 78 Physical Exam: Vitals: BP 127-139/60-70, HR 74, RR 20 General: well developed female in no acute distress. Flat after cath HEENT: oropharynx benign, right cheek bandage s/p biopsy. Glasses. Teeth in good repair. Neck: supple, no JVD, transmitted murmur to carotid noted Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities, extensive spider veins Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2117-12-13**] ECHO PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the 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 complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. [**2117-12-14**] CXR In comparison with the study of [**12-13**], the right and left chest tubes have been removed. No evidence of pneumothorax. All the other surgical tubes have also been removed. Dense streak of apparent atelectasis is again seen at the right base with definitive streaks of atelectasis on the left. [**2117-12-18**] 07:50AM BLOOD WBC-6.3 RBC-2.86* Hgb-8.3* Hct-25.0* MCV-87 MCH-29.0 MCHC-33.3 RDW-13.5 Plt Ct-193 [**2117-12-18**] 07:50AM BLOOD Plt Ct-193 [**2117-12-13**] 04:11PM BLOOD PT-14.1* PTT-49.7* INR(PT)-1.2* [**2117-12-18**] 07:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-138 K-4.8 Cl-100 HCO3-32 AnGap-11 Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2116-12-13**] for elective surgical management of her aortic valve disease. She was taken directly to the operating room where she underwent an aortic valve replacement using a 19mm pericardial valve. Please see separate dictated operative note. Postoperatively she was taken to the intensive care unit for monitoring. She developed atriall fibrillation for which amiodarone was started. She subsequently converted back into a normal sinus rhythm. On postoperative day one, she awoke neurologically intact and was extubated. She was then transferred to the step down unit for further recovery. Mrs. [**Known lastname **] was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She complianed of nausea which resolved after having a bowel movement and She was ready for discharge home on POD #5. Medications on Admission: Protonix 40mg QD Lipitor 10mg QD Aspirin 81mg QD Fish oil MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 5 days. Disp:*10 Packet(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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: AS s/p AVR (19mm CE Magna Pericardial Valve) Hyperlipidemia Diverticulitis Sciatica GERD Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please contact surgeon with any wound issues ([**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 lifting more then 10 pounds for 10 weeks. 5) No driving for 1 month. 6) You may shower and wash incision with soap and water. No lotions, creams or powders to incision until it has healed. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 5310**] in [**12-1**] weeks. ([**Telephone/Fax (1) 5319**] Follow-up with Dr. [**Last Name (STitle) **]. [**Last Name (un) **] in [**1-2**] weeks. [**Telephone/Fax (1) 26647**] Please call all providers for appointments. Completed by:[**2117-12-18**]

[ "427.31", "530.81", "997.1", "424.1", "272.4", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5326, 5364

3205, 4175

350, 409

5497, 5506

1467, 3182

6029, 6410

868, 940

4287, 5303

5385, 5476

4201, 4264

5530, 6006

955, 1448

291, 312

437, 677

699, 747

763, 852

2,562

100,290

27533+57549

Discharge summary

report+addendum

Unit No: [**Numeric Identifier 67318**] Admission Date: [**2116-5-29**] Discharge Date: [**2116-6-10**] Date of Birth: [**2052-9-16**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 64 year old man with a history of hypertension, diabetes, and tobacco use who presented at [**Hospital6 **] with chest, jaw, and arm pain. He has had intermittent chest pain x2 months and it has been associated with nausea and vomiting for the past 3 days. Chest pain has relieved with sublingual Nitroglycerin. On the day of presentation to [**Hospital6 31672**], he took several subinguinal Nitroglycerin tablets prior to presenting to the ER. When he arrived, his chest pain had resolved. He was admitted to the CCU at [**Hospital1 **] and he underwent cardiac catheterization which revealed a left main 20% distal stenosis, LAD with 80-90% proximal ulcerated stenosis, ramus with a 99% stenosis, left circumflex with 70% ostial stenosis, an OM with a 90% proximal tubular stenosis and an RCA with a 60-65% ulcerated stenosis. His EF is 30% with septal and apical hypokinesis. Patient had ST depressions in leads II, III and V2 through 6 which improved after treatment with IV Nitroglycerin. His troponin at [**Hospital1 **] was 1.4 with a CK of 353 and an MB of 4.3. Following his cardiac catheterization, he was put on Integrilin and Heparin and was transferred to [**Hospital1 18**] for surgical evaluation. PAST MEDICAL HISTORY: Patient's past medical history is significant for non-ST MI, hypertension, insulin dependent diabetes mellitus, status post CVA in [**2114**] with no residual, prostate CA status post prostatectomy, testicular CA status post orchiectomy, status post left BKA, history of skin lesions. MEDICATIONS PRIOR TO ADMISSION: 1. Lisinopril 40 q. d. 2. Lopressor 50 t.i.d. 3. Hydrochlorothiazide 25 q. d. 4. Humalog 80 q. a.m., 6 q. p.m. 5. Humulin 30 q. a.m., 16 q. p.m. 6. Metformin 1 gram b.i.d. 7. Celexa 60 mg q. d. 8. Pravachol, no dose specified. 9. Heparin 1300 units per hour IV. 10.Nitroglycerin 40 mg/kg/hr. 11.Integrilin 2 mg/kg/min. ALLERGIES: Patient states no known drug allergies. SOCIAL HISTORY: Lives alone. He is a widower. Positive tobacco, 5 packs per day x40 years. Alcohol use, 6 beers per night plus 1 quart of hard liquor per week. FAMILY HISTORY: Family history is noncontributory. REVIEW OF SYSTEMS: Dentures upper and lower. PHYSICAL EXAMINATION: Elderly man in no acute distress. Vital signs: Heart rate 72, blood pressure 112/51, respiratory rate 20, weight 112 kg. HEENT: Pupils equally round and reactive to light with extraocular movements intact, anicteric, noninjected. Oropharynx is benign. Neck is supple, no lymphadenopathy. Carotids are 2+ bilaterally without bruits. Lungs are clear to auscultation bilaterally with occasional expiratory wheezes. Cardiovascular regular rate and rhythm, no murmurs, rubs or gallops. Abdomen is obese, soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities: Pulses are 2+. No posterior tibial or dorsalis pedis pulses palpable. Left BKA. Neuro is nonfocal. LABORATORY DATA: White count 7.6, hematocrit 37.4, platelets 219. Sodium 138, potassium 3.6, chloride 102, CO2 27, BUN 15, creatinine 0.9, glucose 205. Troponin on hospital day 2 is 0.17 with CK MB of 2. Patient was scheduled for carotid ultrasound which showed less than 40% stenosis bilaterally. HOSPITAL COURSE: Over the next several days, the patient was maintained on the cardiothoracic service on Heparin and Nitroglycerin and Integrilin, giving him a little time to recover from his NST MI and on [**6-2**], he was brought to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, he had a CABG x3 with LIMA to the LAD, saphenous vein graft to ramus and saphenous vein graft to the RCA. His bypass time was 72 minutes with a crossclamp time of 57 minutes. He was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, he was in a sinus rhythm at 96 beats per minute with a CVP of 19 and a mean arterial pressure of 74. He had insulin at 2 units per hour, epinephrine at 0.02 mcg/kg/min, and Neo- Synephrine at 0.5 mcg/kg/min, Milrinone at 0.25 mcg/kg/min, and propofol at 20 mg/hour. Patient did well in the immediate postoperative period. On the day of surgery, he was weaned off his epinephrine drip. Over the next 12 hours, he was weaned from his Milrinone drip. On postoperative day 1, he was weaned from his sedation. His ventilator was weaned and he was successfully extubated following which he had an uneventful postoperative day. He was, following extubation, weaned from his Nitroglycerin, insulin, and amiodarone drips as well. He remained hemodynamically stable throughout these periods. On postoperative day 2, patient's chest tubes were removed. He was begun on diuretics as well as beta blockade and he was transferred from the ICU to Far-2 for continuing postoperative care and cardiac rehabilitation for further hemodynamic monitoring. Over the next several days, the patient had a largely uneventful recovery. However, on postoperative day 3, following the removal of his Foley catheter, he failed to void and his catheter was replaced. He was also begun on Flomax at that time. His activity level was slowly advanced with the assistance of the nursing staff as well as the physical therapy staff. Also on postoperative day 3, the patient was noted to have an erythematous rash, mainly on his back and trunk. He was begun on Sarna lotion and Benadryl at that time. The rash did not improve over the next several days and on postoperative day 5, a dermatology consult was requested. On dermatology's recommendation, the patient's medications were tailored to eliminate all unnecessary possibilities. His Lasix was discontinued. His Vancomycin had been stopped for several days and Hydralazine. Additionally, the patient had a biopsy. By postoperative day 7, the rash appeared to be stable without further progression. The patient's chest x-ray that day showed mild pulmonary edema and the patient was begun on Diuril. Additionally, he was restarted on a low dose of Lisinopril and he was screened for rehabilitation placement with the hopes he could continue his postoperative care in a rehabilitation center. At the time of this dictation, the patient's physical examination is as follows: Temperature 98.3, pulse 69 sinus rhythm, blood pressure 150/66, respiratory rate 20, O2 saturation 93% on room air, finger stick blood sugars at 125 to 200. Lab data: White 21, hematocrit 28, platelets 570. Sodium 140, potassium 5.1, chloride 99, CO2 28, BUN 15, creatinine 1.1, glucose 140, mag 2.5. Physical examination, general, no acute distress, alert and oriented x3, moves all extremities, follows commands. Cardiovascular: Regular rate and rhythm, S1, S2, with no murmur. Sternum is stable. Incision clean and dry. Lungs clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Skin is erythematous rash with some small papules and no mucosal lesions, mainly involving the back, the buttock and the lower trunk. Extremities have no cyanosis, clubbing, or edema. MEDICATIONS: 1. Amiodarone 400 mg b.i.d. 2. Aspirin 81 mg q. d. 3. Bactroban ointment. 4. Celexa 60 mg q. d. 5. Benadryl 25 mg p.r.n. 6. Colace 100 mg b.i.d. 7. Regular insulin sliding scale. 8. Lopressor 75 mg b.i.d. 9. Percocet p.r.n. 10.Milk of magnesia p.r.n. 11.Zocor 40 mg q. d. 12.Sarna lotion b.i.d. 13.Flomax 0.4 q. d. 14.NPH 16 units in the a.m., 8 units in the p.m. [**Last Name (STitle) 67319**] is to discharge to rehabilitation. Follow up will be with Dr. [**Last Name (Prefixes) **] in 4 weeks, with Dr. [**First Name (STitle) **] in 2 to 3 weeks following discharge from rehabilitation and with his primary care in 2 to 3 weeks after discharge from rehabilitation. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2116-6-9**] 17:53:02 T: [**2116-6-9**] 19:10:15 Job#: [**Job Number 67320**] Name: [**Known lastname 11662**],[**Known firstname 126**] Unit No: [**Numeric Identifier 11663**] Admission Date: [**2116-5-29**] Discharge Date: [**2116-6-11**] Date of Birth: [**2052-9-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 674**] Addendum: Pt with paular drug rash post-op, tx w Sarna cream, benadryl, and bactroban with some resolution. skin bx c/apular drug rash. Pt also failed to void x 2 during post-op course. Has been started on Flomax and should have another voiding trial in 1 week. Chief Complaint: transfer from OSH fro CABG, after r/i for MI & cath showed 3vd. Major Surgical or Invasive Procedure: CABG History of Present Illness: as in previous dictation Past Medical History: see previous d/c summary Social History: +tob +etoh Family History: as before Medications on Admission: lisinopril 40 qd lopressor 50 tid hctz 25 qd humalog 8u QA/6u QP humalin 30u QA/16u QP metformin 1000 [**Hospital1 **] celexa 60 qd pravachol 40 qd heparin gtt integrillin gtt ntg gtt Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg QD x 1 wk then 200mg QD. 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 13. Mupirocin Calcium 2 % Cream Sig: One (1) in Topical twice a day. 14. Mupirocin Calcium 2 % Cream Sig: One (1) in Topical once a day. 15. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed units Subcutaneous once a day: 20 units QAM 16 units QPM (preop dose 30uAM/16uPM). 17. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) appl Topical [**Hospital1 **]/PRN as needed for itching for 2 weeks. 18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 weeks. 19. Chlorothiazide 250 mg Tablet Sig: Two (2) Tablet PO once a day. 20. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Mupirocin Calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2 times a day) for 5 days. Discharge Disposition: Extended Care Facility: [**Hospital3 4886**] Long Term Health - [**Location (un) 4887**] Discharge Diagnosis: s/p cabg x3 lima-lad, svg-ramus, svg-rca PMH: HTN, IDDM, CVA, Prostate CA s/p prostatectomy, s/p oorchiectomy Discharge Condition: stable 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 wounds. Followup Instructions: PCP 2-3 weeks after d/c from rehab Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2-3 weeks after d/c from rehab Dr [**Last Name (STitle) **] in4 weeks [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2116-6-11**]

[ "414.01", "410.71", "V10.47", "V49.75", "692.9", "401.9", "250.01", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.12", "86.11" ]

icd9pcs

[ [ [] ] ]

11380, 11471

9049, 9056

11624, 11633

11835, 12147

9202, 9213

9447, 11357

11492, 11603

9239, 9424

3460, 8929

11657, 11812

1772, 2147

2435, 3442

2385, 2412

8946, 9011

9084, 9110

9132, 9158

9174, 9186

7,246

138,724

18015+56908

Discharge summary

report+addendum

Admission Date: [**2131-1-29**] Discharge Date: [**2131-2-15**] Date of Birth: [**2084-10-31**] Sex: M Service: This discharge summary summarizes the hospital course from admission of [**1-30**] through transfer from the ICU on [**2-2**]. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male with a history of chronic pancreatitis, alcohol abuse, who presented with abdominal pain on [**1-29**] and suspected cholangitis. CT of his abdomen at that time showed two new "pseudocysts" and the patient was admitted to the Medical floor. On the [**1-30**], he had an ERCP which revealed spontaneous pus drainage into the duodenum through a fistula and a 2 cm stricture of the common bile duct. His old plastic biliary stent was changed and Surgery was consulted, but he was felt not to be a surgical candidate at that time because of ongoing alcohol abuse and the fact that the abscess at the pancreatic head had spontaneously necessitated into the duodenum. On the floor, the patient had increasing symptoms of alcohol withdrawal, more abdominal pain, and increasing oxygen requirement. Chest x-ray done upon transfer to the ICU demonstrated bilateral pulmonary infiltrates and because of worsening hypoxia secondary to bilateral infiltrates, the patient was transferred to the Fenard ICU for further management with a clinical diagnosis of pancreatitis, induced acute respiratory distress syndrome. PAST MEDICAL HISTORY: 1. Acute pancreatitis secondary to alcohol abuse; status post ERCP with common bile duct biliary stent in [**2130-5-9**] status post biliary stent change in [**2130-6-8**], status post biliary stent change in [**11-11**] secondary to repeated stent migration. In [**2130-5-9**], his ERCP was complicated by hemorrhage and status post embolization of his gastroduodenal artery. 2. Status post secondary to pancreatic insufficiency. 3. Benign prostatic hypertrophy. 4. Recalcitrant alcohol abuse. 5. Depression and anxiety. 6. Status post correction for duplicated renal collecting duct. ALLERGIES: Naprosyn, ibuprofen, and Ativan. FAMILY HISTORY: Has a mother, who died of a cerebral aneurysm. SOCIAL HISTORY: He has a history of tobacco abuse. He claims to drink 10-12 beers a day. He has a history of delirium tremens. MEDICATIONS ON TRANSFER TO ICU: 1. Regular insulin-sliding scale. 2. Ampicillin 1 gram q.3. 3. Gentamicin 120 mg q.8. 4. Metronidazole 500 q.8. 5. Protonix. 6. Viokase. 7. Bupropion. 8. Sertraline. 9. Thiamine. 10. Folate. 11. Dilaudid. 12. Prochlorperazine. 13. Albuterol. 14. Atrovent. 15. Valium prn. VITAL SIGNS: His temperature is 100.2. His heart rate was 114. His blood pressure is 152/78 and he was 96% on 100% nonrebreather. PHYSICAL EXAMINATION: In general, he was confused, disoriented, slightly agitated. Pupils are equal, round, and reactive to light. His jugular venous pressure was flat and his mucous membranes were dry. His heart was tachycardic, S1, S2. His lungs anterolateral showed decreased breath sounds throughout. His abdomen was soft, slightly tender in epigastrium, though bowel sounds were not present. Extremities were without edema. LABORATORIES: White count at that time was 13.8, hematocrit was 32.2, platelets were 212. Sodium was 136, potassium 3.6, chloride 97, bicarb 28, BUN 6, creatinine 0.5, albumin was 3.4, PT was 11.8. ABG showed 7.42, pCO2 of 43, pO2 of 76 on 6 liters shovel mask. Chest x-ray showed diffuse bilateral pulmonary infiltrates, which had developed from [**1-29**]. MRCP showed common bile duct artifact likely secondary to stent, mildly enlarged kidneys with hydronephrosis. One out of eight blood cultures grew gram-positive cocci in pairs and chains from [**1-30**]. HOSPITAL COURSE BY SYSTEMS: 1. Pancreatitis: The patient was maintained on ampicillin, levofloxacin, and Flagyl for a period of 11 days. He did well with regards to his pancreatitis and he is followed by the Hepatobiliary and ERCP service. There were no further events of this pancreatitis nor his abscess. 2. Mental status: The patient was largely confused throughout the hospitalization. Because of his heavy alcohol use, he was maintained on standing benzodiazepines through [**2-6**] at which time benzodiazepines were discontinued. He was seen by the Psychiatry service, who recommended discontinuing benzodiazepines and narcotics and use Haldol prn. Overtime he cleared such that by time of transfer to the floor on [**1-14**], he was mentating, slightly confused. 3. Infectious disease: Patient was continued on ampicillin, levofloxacin, and Flagyl for his peripancreatic abscess. On [**2-8**], he was noted to have a fever spike. Patient was evaluated with CAT scan of his chest, abdomen, and pelvis, which revealed no changes in his pancreas, however, a dense right lower lobe infiltrate. Antibiotics were changed to Vancomycin and ceftazidime for nosocomial pneumonia. Patient defervesced. Antibiotics were discontinued on [**2-13**]. Patient remained afebrile. 4. Pulmonary: Patient had two episodes of intubation during this hospitalization, the second intubation on [**2-9**] to allow adequate sedation for CAT scan. He was extubated without problem. Patient was discharged to the floor on [**2-13**] for further management. [**Last Name (LF) **],[**Name8 (MD) 251**] M.D. [**MD Number(1) 910**] Dictated By:[**Last Name (NamePattern1) 2396**] MEDQUIST36 D: [**2131-2-15**] 15:18 T: [**2131-2-16**] 06:21 JOB#: [**Job Number 49857**] Name: [**Known lastname 2913**], [**Known firstname **] Unit No: [**Numeric Identifier 9236**] Admission Date: [**2131-1-29**] Discharge Date: [**2131-2-16**] Date of Birth: [**2084-10-31**] Sex: M Service: [**Hospital6 534**] ADDENDUM: This Discharge Summary Addendum will cover the hospital course from [**2131-2-13**] through the day of discharge on [**2131-2-16**]. This summary is an Addendum to the prior Discharge Summary covering the hospital course from [**2131-1-29**] to [**2131-2-13**]. The patient was transferred to the [**Hospital6 534**] Service from the [**Hospital Ward Name 5950**] Intensive Care Unit. On total parenteral nutrition. Now off antibiotics and without an oxygen requirement. The patient was confused, delirious, and agitated. He required a sitter for the first two days of his stay on the floor. The patient also requested as needed benzodiazepines which may have in fact contributed to his delirium. After the benzodiazepines were stopped, the patient's mental status returned to baseline. On the day of discharge, the patient was alert and oriented times three. He was able to name several presidents. He was anxious to get home and get back to taking care of his affairs. The patient remained afebrile off of antibiotics with no evidence of acute infection. The patient was transitioned off of total parenteral nutrition and on to a by mouth diet. On the day of discharge, the patient was tolerating a full diet without any abdominal pain. The patient had an elevated creatine kinase value coming out of the [**Hospital Ward Name 5950**] Intensive Care Unit; however, this trended down during his stay on the floor. This was felt likely secondary to struggling in his restraints when in the Intensive Care Unit. The patient was seen by Physical Therapy who cleared him for discharge to home. The patient was seen by the social worker for addiction who provided the patient with information regarding addiction counseling in his area. The patient's blood sugars were well controlled on his NPH. DISCHARGE STATUS: Discharge status was to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to avoid alcohol. 2. The patient was instructed to follow up with Dr. [**Last Name (STitle) 489**]; appointment scheduled on [**3-1**] at 9:30 a.m. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Protonix 40 mg by mouth once per day. 2. Viokase 16 three to four tablets by mouth twice per day (with meals). 3. NPH insulin 10 units subcutaneously in the morning. 4. Trazodone 100 mg to 200 mg by mouth at hour of sleep as needed (for insomnia). DISCHARGE DIAGNOSES: 1. Periampullary abscess. 2. Acute respiratory distress syndrome. 3. Pneumonia. 4. Alcohol abuse; continuous. 5. Pancreatitis; chronic. MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: 1. Endoscopic retrograde cholangiopancreatography with change of biliary stent. 2. Intubation with mechanical ventilation. 3. Peripherally inserted central catheter line placement with total parenteral nutrition. CONDITION AT DISCHARGE: The patient's condition on discharge was good/stable. [**Last Name (LF) **],[**Name8 (MD) 116**] M.D. [**MD Number(1) 392**] Dictated By:[**Last Name (NamePattern1) 2223**] MEDQUIST36 D: [**2131-2-16**] 15:05 T: [**2131-2-17**] 06:53 JOB#: [**Job Number 9238**]

[ "305.01", "576.1", "276.1", "276.5", "291.0", "577.0", "537.4", "486", "577.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "97.05", "51.14", "96.71", "99.15", "96.04", "51.10" ]

icd9pcs

[ [ [] ] ]

2097, 2145

8223, 8638

7906, 8202

7698, 7879

3749, 4035

2738, 3721

8653, 8954

284, 1424

4051, 7665

1446, 2080

2162, 2715

72,666

186,402

42051

Discharge summary

report

Admission Date: [**2157-10-2**] Discharge Date: [**2157-10-13**] Date of Birth: [**2074-4-3**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 83F transferred from [**Hospital3 1443**] Hospital for acute on chronic subdural hematoma. Pt reported that she fell while trying to get to the bathroom from bed, not sure from bed or while walking. She said she hit her head. Fall was unwitnessed at nursing home. Patient was found on the floor by staff complaining of left-sided head pain. It was unclear whether pt loss consciousness, but she seemed to remembered the event, but could not relate how she fell or the circumstances around on. Per the nursing home she was last seen in bed 2 hours prior to being found in the floor. Pt admits more frequent urination, poor po intake, but denied fever, chill, change in vision, CP, palpitation, SOB, N/V/D, dysuria or weakness of her extremities. Per her cousin, pt was quite functinoal at baseline, active in nursing home activities and very talkive. . Pt was initially sent to [**Hospital3 1443**] Hospital, where she was cleared for C-spine. CT-head showed subdural hematoma. Pt was sent to [**Hospital1 18**] or further management. . In the [**Name (NI) **], Pt was afebrile, 92, 92/44, 17-19, 94-96% on 2L. She had WBC of 14.1, Cr 1.2, troponin 0.03 with flat CKMB, EKG consistent with RV pacing with no ST-segment changes, CT-head was stable with no interval worsening, CXR has some haziness in RLL/RML. Pt was evaluated by neurosurgery team. She received vancomycin and zosyn for HCAP and 500 cc NS at 75 cc/hr. . On arrival to the MICU, pt continue to be afebrile with SBP decreased to 80s. After starting NS at 75 cc/hr, her SBP improved to 100s. Past Medical History: Anemia Hypothyroidism CHF (previously uncharacterized, normal TTE while at [**Hospital1 18**] [**2157-9-17**]) History of falls and unstable gait Depression Status post pacer (?heart block) Hyperlipidemia GERD Hx of left humeral fracture Social History: Pt lives at Brighten at [**Location (un) 1468**]. Per her cousin, she was quite active and functional at baseline. Pt worked at government center for a long term. Denies smoking, alcohol or recreational drug use. Family History: Unable to obtain Physical Exam: ADMISSION EXAM General: Somnolent at times, orientedX3, no acute distress HEENT: EOMI, PERRL, Sclera anicteric, dry mucosal membrane, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crackles, R worse than L Abdomen: soft, non-distended, subrapubic tenderness on palpation, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact On discharge: Crackles have improved. Still requiring minimal O2 (~2L), much improved from 5-6L earlier in hospitalization. Excoriations in perianal and coccyx areas, requiring wound care due to frequent stooling and incontinence. Pertinent Results: ADMISSION LABS [**2157-10-2**] 06:53AM BLOOD WBC-14.1* RBC-3.71* Hgb-11.1* Hct-33.1* MCV-89 MCH-29.8 MCHC-33.5 RDW-13.4 Plt Ct-350 [**2157-10-2**] 06:53AM BLOOD Neuts-76.1* Lymphs-19.3 Monos-2.6 Eos-1.4 Baso-0.5 [**2157-10-2**] 06:53AM BLOOD PT-13.0 PTT-21.7* INR(PT)-1.1 [**2157-10-2**] 06:53AM BLOOD Glucose-164* UreaN-56* Creat-1.2* Na-138 K-5.7* Cl-107 HCO3-19* AnGap-18 [**2157-10-2**] 06:53AM BLOOD CK-MB-5 [**2157-10-2**] 06:53AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.4 [**2157-10-2**] 08:53AM BLOOD Lactate-1.2 [**2157-10-2**] 06:53AM BLOOD TSH-0.38 PERTINENT LAB TRENDS: WBC [**2157-10-4**] 07:15AM BLOOD WBC-11.5* [**2157-10-12**] 05:56AM BLOOD WBC-9.8 Na and Creatinine [**2157-10-6**] 07:20AM BLOOD Creat-1.0 Na-146* [**2157-10-8**] 02:36PM BLOOD Creat-1.4* [**2157-10-11**] 02:43AM BLOOD Creat-1.1 Na-143 [**2157-10-13**] 11:51AM BLOOD Creat-1.1 Na-140 Albumin [**2157-10-8**] 06:32AM BLOOD Albumin-3.3* Arterial blood gas [**2157-10-11**] 01:43PM BLOOD Type-ART Temp-36.9 pO2-114* pCO2-35 pH-7.48* calTCO2-27 Base XS-3 (on a non-rebreather) . DISCHARGE LABS: [**2157-10-12**] 05:56AM BLOOD WBC-9.8 RBC-4.07* Hgb-11.5* Hct-36.1 MCV-89 MCH-28.2 MCHC-31.8 RDW-13.8 Plt Ct-346 [**2157-10-13**] 11:51AM BLOOD Glucose-89 UreaN-18 Creat-1.1 Na-140 K-3.9 Cl-103 HCO3-29 AnGap-12 [**2157-10-12**] 05:56AM BLOOD Calcium-8.1* Phos-4.3 Mg-2.1 MICROBIOLOGY: [**2157-10-2**] 9:25 am URINE Site: CATHETER **FINAL REPORT [**2157-10-5**]** URINE CULTURE (Final [**2157-10-5**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S C. Diff - negative x2 MRSA screen - positive Blood and urine cultures - all negative, 2 blood cultures pending on discharge with no growth to date PERTINENT STUDIES CXR ([**10-2**]): IMPRESSION: Mild pulmonary edema superimposed on basilar interstitial lung process with possibly underlying emphysema. Nodular opacity at the right lung base may relate to underlying fibrosis, but an underlying nodule is not excluded and could be further evaluated for on chest CT as clinically appropriate. Possible small bilateral pleural effusions. Reverse C-shaped calcific density projecting over the heart likely represents mitral annulus calcification. This could be confirmed with PA and lateral views. . CXR ([**10-7**]): IMPRESSION: Right PICC line ends at lower SVC. There is no pneumothorax. A single lead from left pectoral pacemaker device ends into the right ventricle. Dense calcification of mitral valve annulus is present. Since [**10-4**], [**2156**], moderate to sever pulmonary edema, moderate to large right and mild left pleural effusions are new. Mild cardiomegaly is stable. Mediastinal and hilar contours are unchanged. . CXR ([**10-11**]): IMPRESSION: AP chest compared to [**10-3**] through 21: Pulmonary edema which improved between [**10-3**] and [**10-4**] returned with a large pleural effusion on [**10-7**] and made it impossible to say whether pneumonia has changed. Today, there is less of a moderate-sized right pleural effusion. Small left pleural effusion is stable. There is at least some pulmonary edema and very heterogeneous opacification in the right lung and at the left lung base, all of which makes it difficult to distinguish edema from pneumonia. Heart is mildly enlarged, predominantly due to a very dilated left atrium as denoted by the heavily calcified mitral annulus which can contribute to mitral regurgitation. No pneumothorax is present. Transvenous right ventricular pacer lead is unchanged in the expected position. . CT HEAD w/o contrast ([**10-2**]) IMPRESSION: 1. Slight increase in the right frontotemporal subdural hematoma, particularly inferiorly at the frontotemporal junction now measuring 12 mm in maximum transverse dimension. No change in mass effect. 2. No evidence of subfalcine or transtentorial herniation. 3. No new intra- or extra-axial hemorrhage outside of the previously described subdural collection. 4. Stable global atrophy and small vessel ischemic changes. . CT HEAD w/o contrast ([**10-4**]): IMPRESSION: Right frontotemporal subdural hematoma, unchanged. . TTE ([**10-12**]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate thickening of the mitral valve chordae. There is moderate functional mitral stenosis (mean gradient 6 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Mild mitral regurgitation. Moderate functional mitral stenosis from annular calcification. Brief Hospital Course: 83F NH resident w/ hx of recurrent falls and recurrent UTI present with new fall, presenting with subdural hematoma and UTI. . ACTIVE ISSUES # Subdural hematoma: Pt presented from OSH with subdural hematoma. She was evaluated by neurosurgery in the ED and was thought to have acute on chronic SDH. No intervention was indicated. Neuro exam was nonfocal. Repeated CT on following days did not reveal interval changes. She was started on dilantin 1 g in the ED, and continued with 100 mg dilantin tid for 10 days while in the hospital. This was discontinued prior to discharge. . # UTI: Pt was incontinent and wore diaper at baseline. UTI appears recurrent per discussion with covering physician at [**Hospital3 1443**]. No evidence of sepsis or pyelonephritis. Pt was initially covered with vancomycin/cefepime for UTI, which was later converted to Zosyn to more completely covered a suspected aspiration pneumonia (see next issue) when urine culture was positive for pan-sensitive enterococcus. She completed a full course of 7 days while in house. # Aspiration pneumonia with concurrent pulmonary edema: Although pt was afebrile and had no cough, she was initially treated with Vancomycin and Zosyn given the concerning chest X-ray findings in the ED. She was evaluated by the speech and swallow team and they witness frank aspiration. Her CXR revealed ?infiltrate in the right lower lobe along with mild pulmonary edema. She was started on Zosyn for an 10-day course. Her pulmonary edema was managed with Lasix and progress was tracked with CXRs that showed improvement. An echocardiogram was done and showed no abnormalities. # Dehydration with hypernatremia: On initial presentation, we appeared dry likely secondary to poor po intake in the setting of UTI. Her ECHO last year was notable for pulmonary hypertension with moderate TR, but preserved LV function per OSH report. She received NS boluses in the MICU, and tolerated well these well. However, she developed pulmonary edema as above, managed with intermittent Lasix dosing. An echocardiogram did not show any abnormalities, not even the ones indicated above (i.e. pulmonary hypertension, moderate TR). Therefore, she was discharged without any standing Lasix due to concern for her poor PO intake. Her sodium was managed initially with D5W, but this contributed to her volume overloaded state and we instead allowed her to drink to thirst to correct her sodium, which was normal on discharge. # s/p fall: Pt had a history of recurrent fall per report from nursing home. The mechanism of all has been felt to be mechanical. EKG on this admission has been stable, and no cardiac enzyme elevation was observed. Pt denied history of seizure. Her TSH was normal. She will require 1:1 assistance with all transfers and has been continually encouraged to ask for help getting out of bed. . CHRONIC ISSUES # Hyperkalemia with diarrhea: Pt takes kayaxelate on Mon and Thurs at home. With her worsening diarrhea in house, we stopped this and it should not be continued unless follow-up show worsening hyperkalemia. Her C. diff toxin tests were negative x2. . # Depression: We continued her citalopram 20 mg daily and initially held mirtazepine to prevent sedation. She should continue on both upon discharge. . TRANSITIONAL ISSUES - Pt declared a code status of DNR/DNI - [**Hospital1 **]-weekly lab draws to ensure stable electrolytes and creatinine - Please encourage PO intake, keeping mind aspiration precautions - Monitor oxygen saturation and please keep above 92% with nasal cannula PRN. - Ms. [**Known lastname 33645**] is very reliant on others for her care. Her respiratory status was of concern to us during this hospitalization. If she continues to require a higher level of care to manage these issues, we would recommend considering hospice care. Medications on Admission: MVI Fluticasone 50mcg spray daily Artificial tears [**Hospital1 **] Senna Loratadine prn Omeprazole 20mg daily Bicarb Citalopram 20mg daily Kayexalate twice weekly (M/Th) Ear drops- 3 drops into right ear for the first 3 days of every month Calcium carbonate 200(500)mg tablet TID Mirtazapine- 30mg PO qHS Refresh tears 0.5% drops- 1 drop each eye TID Lasix 20mg daily (started [**2157-9-25**]) Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. calcium acetate-aluminum sulf Packet Sig: One (1) Packet Topical [**Hospital1 **] (2 times a day) as needed for wound care. 9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Discharge Disposition: Extended Care Facility: Brighten at [**Location (un) 1468**] Discharge Diagnosis: Primary diagnoses: Subdural hemorrhage Aspiration pneumonia Pulmonary edema Delirium Urinary tract infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 33645**], It was a pleasure caring for you at the [**Hospital1 827**]. You were initially admitted after you fell and had some bleeding in your head. The neurosurgeons felt that you were safe to allow this to resolve on its own. You spent a short amount of time in the intensive care unit and then were transferred to the medical floor. You had difficulty with your breathing and required extra oxygen. We gave you some medication to prevent fluid build-up in your lungs and did some tests of your heart to help determine a cause. This test ("echocardiogram") was very normal and you will not be continued on this medication (diuretics). You are also having some difficulty with eating and sometimes choke on your food and drinks. You should continue to drink only thickened liquids and ground solids so that swallowing is easier for you. Otherwise you could develop more difficulty breathing and even a pneumonia, which you did while you were here. You were a little bit confused at times during your hospitalization but are doing much better now after we treated both your pneumonia and urinary tract infections. We have made the following changes to your medications: STOP Lasix, since we do not want to dehydrate you if you're unable to drink enough. STOP Kayexelate, as your potassium is normal and your diarrhea worsened while on it. We have not started any new medications. Please only take the colace and senna if you are constipated. Followup Instructions: While you are at Brighten At [**Location (un) 1468**], you will be seen by their doctor. You will not need to call Dr. [**Last Name (STitle) 3273**] for an appointment unless you leave this facility

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Discharge summary

report

Admission Date: [**2148-4-22**] Discharge Date: [**2148-4-27**] Date of Birth: [**2087-10-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Carcinoid syndrome with liver mets, small bowel carcinoid Major Surgical or Invasive Procedure: [**2148-4-22**] Right hepatic lobectomy, resection of cystic duct mucocele, resection of segment IVB mass, resection of umbilical fissure segment IVB mass, segment IVB mass #2 resection, caudate lobe resection, resection of segment III mass, small bowel resection, intraoperative ultrasound and resection of left lateral segment mass, incisional hernia repair. History of Present Illness: 60 y.o. male who presented [**2147-6-12**] with episodic facial flushing without diarrhea. A 24 hour urine for 5-HIAA was 45.4 and a repeat 24 hour urine in [**10-17**] was 50.3. In [**11-16**] a CT of the abd/pelvis was done revealing a left hepatic lobe 5.2x5.2cm lesion and a right anterior lobe lesion measuring 3.7x 2.8cm. There was fatty infiltration of the liver. An MRI revealed 3.5cm lesion in the dome of the right lobe, a 2.1cm lesion in the anterior segment of the right lobe and a 3rd 4.1cm lesion more caudad to the 2.1 cm lesion. In the posterior right lobe there was a 1.9cm lesion. A 2.4cm soft tissue mass was noted in the right midline. A 5cm lesion was noted in the left lateral segment. An arterial scan revealed five sites of abnormal tracer uptake in the liver. No other activity was noted in the lungs, spleen, GI tract or GU tract. He was referred to Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] who felt that this was most likely a small bowel carcinoid with mesenteric lymph node metastasis and multiple liver mets. In [**2148-1-12**] a triphasic CT demonstrated multiple liver lesions. Liver volume was insufficient (1951cc)to perform the liver resection for these lesions. Right portal vein embolization was done in preparation for right hepatic lobectomy. Repeat CT demonstrated significant hypertrophy of the left lobe. Past Medical History: carcinoid syndrome HTN diagnosed in [**2146**] polio as a child Social History: He is married with two adult children. He has a high school education and is a maintenance manager. Family History: Father died of lung CA Mother died at age 43 from pneumonia He has two sisters, one has breast ca and the other has uterine ca Physical Exam: A&O anicteric, mild facial flushing, op clear, neck supple, no LAD, no bruits S1S2 RR Lungs clear Abd soft, nt/nd, no masses, no HSM Incision C/D/I JP drains intact, draining serosanguinous fluid Ext edema, LUE atrophied with decreased strength Pertinent Results: [**2148-4-22**] WBC-11.1*# RBC-4.16* Hgb-12.2*# Hct-36.0*# Plt Ct-255 [**2148-4-24**] WBC-17.9*# RBC-3.44* Hgb-10.3* Hct-29.5* Plt Ct-190 [**2148-4-27**] WBC-11.2* RBC-3.05* Hgb-9.2* Hct-25.6* MCV-84 MCH-30.1 MCHC-35.8* RDW-15.3 Plt Ct-246 [**2148-4-24**] Neuts-89.6* Bands-0 Lymphs-4.1* Monos-5.9 Eos-0.2 Baso-0.2 [**2148-4-22**] PT-15.7* PTT-40.6* INR(PT)-1.4* [**2148-4-27**] PT-13.6* PTT-32.1 INR(PT)-1.2* [**2148-4-22**] Fibrino-133* [**2148-4-27**] Fibrino-458* [**2148-4-22**] Glucose-153* UreaN-15 Creat-1.0 Na-141 K-4.7 Cl-110* HCO3-20* AnGap-16 [**2148-4-27**] Glucose-89 UreaN-17 Creat-0.6 Na-139 K-3.2* Cl-104 HCO3-27 AnGap-11 [**2148-4-22**] ALT-1079* AST-863* AlkPhos-52 Amylase-60 TotBili-2.9* [**2148-4-23**] ALT-1530* AST-989* AlkPhos-93 TotBili-1.9* DirBili-0.7* IndBili-1.2 [**2148-4-27**] ALT-320* AST-83* AlkPhos-78 TotBili-2.0* [**2148-4-22**] Lipase-89* [**2148-4-23**] Lipase-38 [**2148-4-25**] CK-MB-3 cTropnT-<0.01 [**2148-4-25**] CK-MB-3 cTropnT-<0.01 [**2148-4-25**] CK-MB-3 cTropnT-<0.01 [**2148-4-22**] Albumin-3.2* Calcium-8.5 Phos-5.4*# Mg-1.8 [**2148-4-27**] Calcium-7.4* Phos-3.2 Mg-2.4 [**2148-4-22**] Type-ART pO2-144* pCO2-37 pH-7.43 calTCO2-25 Base XS-1 [**2148-4-23**] Type-ART pO2-177* pCO2-39 pH-7.38 calTCO2-24 Base XS--1 [**2148-4-22**] Glucose-162* Lactate-1.7 Na-138 K-3.9 Cl-105 [**2148-4-23**] Lactate-1.9 [**2148-4-22**] freeCa-1.15 IMAGING: US INTR-OP 90 MINS [**2148-4-22**] 7:30 AM Reason: exp lap right hepatic trisegmentectomy [**Hospital 93**] MEDICAL CONDITION: 60 year old man with exp lap right hepatic trisegmentectomy REASON FOR THIS EXAMINATION: exp lap right hepatic trisegmentectomy INTRAOPERATIVE ULTRASOUND, 90 MINUTES. INDICATION: Guidance for trisegmentectomy of the liver and for localization of mesenteric mass. Two separate intraoperative studies were performed initially, intraoperative ultrasound guidance was provided to Dr. [**Last Name (STitle) **] to document location of masses in both the left and right lobes of the liver. In particular, the proximity of the mass in the left lobe to the left portal and hepatic vein was demonstrated. Several small hypoechoic lesions were also shown to be present in the superficial regions of segment IV-A. Following initial resection of all of the liver lesions, intraoperative ultrasound guidance was used which demonstrated an initial small lesion in the superficial portion of segment II. Cauterization was performed over this lesion to facilitate resection. In addition, ultrasound was also used in the midline to document the presence of hypoechoic lymph nodes in the mesenteric mass from regional metastases. The proximity of these masses to peripheral branch of the superior mesenteric artery was documented. IMPRESSION: Intraoperative guidance provided to Dr. [**Last Name (STitle) **] to localize multiple masses in left and right lobes of liver and to document the proximity of mesenteric lymph nodes to the superior mesenteric artery. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: MON [**2148-4-22**] 7:14 PM CHEST PORT. LINE PLACEMENT [**2148-4-22**] 6:10 PM Reason: please eval line & ETT position; r/o PTX [**Hospital 93**] MEDICAL CONDITION: 60 year old man s/p R hepatic lobectomy, small bowel resection REASON FOR THIS EXAMINATION: please eval line & ETT position; r/o PTX STUDY: Single portable AP chest radiograph. INDICATION: 60-year-old male status post small-bowel resection, evaluate line and endotracheal tube position. COMPARISON: [**2148-4-17**]. FINDINGS: Endotracheal tube tip is approximately 8 cm from the carina with optimal position being 4-5 cm. A new retrocardiac opacity is identified obscuring the left hemidiaphragm which may represent effusion, atelectasis or infiltrate. A new right superior mediastinal soft tissue density is identified with a right IJ catheter sheath in the expected region of the right internal jugular vein, which may represent an extrapleural hematoma from attempted right IJ catheter placement. No definite pneumothorax identified. A chest tube is identified in the low right hemithorax, with apparent termination in the right cardiophrenic angle. A nasogastric tube courses through the mediastinum and into the stomach. The right costophrenic angle is not well visualized, suggesting a small to moderate- sized right pleural effusion. IMPRESSION: 1. Endotrachael tube appears to be placed too high which may be secondary to head positioning. Recommened repeat radiographs with patient in neutral position. 2. New retrocardiac opacity which may represent effusion/atelectasis although new infiltrate cannot be excluded. 3. Soft tissue density in the right superior mediastinum which may represent extrapleural hematoma from attempted central venous catheter placement. Findings relayed to Dr. [**Last Name (STitle) **] at the time of dictation. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 4391**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: WED [**2148-4-24**] 12:00 PM RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2148-4-23**] 10:58 AM CHEST PORT. LINE PLACEMENT Reason: placment of new CVL. [**Hospital 93**] MEDICAL CONDITION: 60 year old man s/p R hepatic lobectomy, small bowel resection s/p rewired RIJ CVL REASON FOR THIS EXAMINATION: placment of new CVL. INDICATION: Recent placement of new central venous line. History of prior small- bowel resection and right hepatic lobectomy. COMPARISON: Prior chest radiograph from [**2148-4-22**]. TECHNIQUE AND FINDINGS: A portable chest radiograph was obtained in semi-upright position. A new right internal jugular central venous line is present since yesterday, with its tip located in the cranial portion of the superior vena cava. No pneumothorax or new pleural effusion is seen. The position of the nasogastric tube and the two abdominal drains appears unchanged. There has been interval removal of the endotracheal tube. The appearance of the cardiomediastinal silhouette, and in particular the right superior mediastinal border, remains stable as compared to yesterday. Again noted is the left cortical retrocardiac opacity, which appears relatively stable. DR. [**First Name (STitle) 16722**] [**Name (STitle) **] D' [**Doctor Last Name **] Approved: TUE [**2148-4-23**] 3:58 PM CARDIAC: ECG Study Date of [**2148-4-22**] 8:10:32 PM Sinus rhythm Short PR interval Possible inferior infarct - age undetermined Nonspecific T wave changes in leads V2-V3 Since previous tracing of [**2148-1-29**], T wave changes present Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. ECG Study Date of [**2148-4-25**] 6:16:06 AM Sinus rhythm Inferior infarct - age undetermined T wave inversion in leads V1-V4 - consider ischemia Since pervious tracing, T wave changes noted Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K. PATHOLOGY: Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 70164**],[**Known firstname 177**] P. [**2087-10-4**] 60 Male [**Numeric Identifier 70165**] [**Numeric Identifier 70166**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc SPECIMEN SUBMITTED: FS PORTAL LYMPH NODE, GALLSTONE, MUCOSCELE WALL, PORTAL LYMPH NODE, RIGHT LIVER LOBE, LEFT LATERAL SEGMENT CARCINOID TUMOR, SEGMENT 4B NODULE, UMBILICAL FISSURE SEGMENT 4B MASS, SEGMENT 4B CEPHALAD, LEFT CAUDATE LOBE, MESENTERIC LYMPH NODE, LEFT INFERIOR LATERAL SEGMENT NODULE, SMALL BOWEL, MORE MARGIN ON INFERIOR LEFT LATERAL SEGMENT NODULE. Procedure date Tissue received Report Date Diagnosed by [**2148-4-22**] [**2148-4-22**] [**2148-4-25**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg DIAGNOSIS: I. Small bowel (A-J): 1. Malignant endocrine cell (carcinoid) tumor of the small intestine, extending to the serosa. 2. Metastatic tumor in the mesentery. 3. Margins free of tumor. II. Right hepatic lobe (K-Q): 1. Metastatic carcinoid tumor, extending to the cauterized margin. 2. Venous emboli of foreign material. III. Segment IVB cephaloid (R-S): 1. Mild steatosis. 2. No tumor. IV. Segment IVB mass, umbilical fissure (T-U): Metastatic carcinoid tumor, extending to cauterized margin. V. Segment IVB nodule (W): Metastatic carcinoid tumor, excised. VI. Left caudate lobe (X-Y): Metastatic carcinoid tumor, excised. VII. Left lateral proximal segment (Z-AB): Metastatic carcinoid tumor, excised. VIII. Inferior left lateral segment nodule (AC-AD): Metastatic carcinoid tumor, excised. IX. Inferior left lateral segment nodule, additional margin (AE-AF): 1. Multiple liver fragments with no tumor. 2. Venous emboli of foreign material. X. Portal lymph node (AG-AK): 1. Tiny focus of metastatic carcinoid tumor. There is no tumor in the frozen section fragment. 2. Hyperplasia and lipogranulomas. [**Doctor First Name 81**]. Portal lymph node ([**Doctor Last Name **]): 1. Hyperplasia and lipogranulomas. 2. No tumor. XII. Mesenteric lymph node (AM): Metastatic carcinoid tumor. XIII. Murocel wall (AN-AO): 1. Chronic inflammation and fibrosis. 2. No tumor. XIV. Gall stones: Mixed stones, gross examination. Clinical: Metastatic carcinoid tumor. Gross: The specimen is received fresh in fourteen parts, all labeled with the patient's name "[**Known lastname 31523**], [**Known firstname **] P" and the medical record number. Part 1 is additionally labeled "small bowel", and consists of a length of small bowel, measuring 45 cm with average diameter of 2 cm. There is an attached mesentery measuring 45 x 5.5 x 1.5 cm. In the middle of the mesentery, abutting the radial resection margin of the specimen is a 5 x 3.5 x 2.2 cm mass, with a homogenous firm tan-yellow cut surface. On the serosal surface of the small bowel is a region of puckering and muscular contraction, measuring 0.9 x 0.5 cm, with a palpable mass underneath. The segment of small bowel is opened on its antimesenteric surface to reveal a tan-yellow circular mass, measuring 1 x 0.9 x 0.2 cm, located 13.5 cm from one stapled margin and 31.5 cm from the other stapled margin. There are otherwise no other gross abnormalities noted on the mucosal surface. Representative sections of the specimen are submitted as follows: A=section through one of the margins, B=section through the other margin, C-F=full thickness section of the mass, entirely submitted in relation to the serosal surface, G-H-representative section of the mesenteric mass, I-J=possible lymph nodes. Part 2 is additionally labeled "right liver lobe", and consists of a right hepatic lobectomy specimen, measuring 17.3 x 13.5 x 8.1 cm. The parenchymal margin is identified with a region of cautery, all together measuring 14.3 x 7.5 cm. There is yellow-[**Doctor Last Name 352**] discoloration throughout the surface of the capsule. The specimen is serially sectioned from superior to inferior to reveal numerous small and large metastatic nodules, varying in appearance from tan-yellow and diffusely necrotic to maroon-red and spongy in texture. The nodules vary in size from 1 cm in length to 5 x 4 x 3.7 cm. Several of the larger metastatic nodules appear to grossly abut the parenchymal margin. Representative sections of the specimen are submitted as follows: K=section of liver through capsule away from tumor nodule, L-P=sections of tumor nodule in relation to parenchymal nodule and capsular surface, Q=sections of biliary and vascular structures deep in the specimen. Part 3 is additionally labeled "segment 4B cephalad", and consists of a segment of liver, measuring 4 x 3 x 2.1 cm with an overlying capsule measuring 4.2 x 3.5 cm. The specimen is serially sectioned to reveal tan-yellow fatty appearing liver parenchyma with no grossly obvious tumor. The smaller liver fragment is sectioned to reveal tan yellow parenchyma with no apparent lesions. Representative sections of the specimen are submitted in R-S. Part 4 is additionally labeled "umbilical fissure segment 4B mass", and consists of two segments of liver parenchyma with overlying capsule, with one measuring 2.5 x 2 x 0.9 cm, and the other measuring 3 x 2.8 x 2.6 cm. The larger segment is serially sectioned to reveal a poorly defined white lesion measuring 0.5 x 0.4 cm, located 0.3 cm away from the parenchymal margin, and 1.6 cm away from the capsular margin. There is an additional soft tan-white lesion, measuring 1.1 x 0.5 x 0.5 cm, that appears to abut the parenchymal margin. Representative sections of the specimen are submitted as follows: T=section through poorly defined region, U-V=section through soft tan-yellow region in relation to margin and capsule. Part 5 is additionally labeled "segment 4B nodule", and consists of a segment of liver parenchyma with overlying capsule, measuring 3.5 x 3 x 1.6 cm. The specimen is serially sectioned to reveal a discreet tan-yellow nodule measuring 0.6 x 0.4 x 0.4 cm, abutting the liver capsule and coming to within 0.5 cm of the closest parenchymal margin. Representative sections of the tumor nodule in relation to the capsule and parenchymal margin are submitted in W. Part 6 is additionally labeled "left caudate lobe", and consists of a segment of liver, measuring 7.6 x 5 x 4.3 cm. The specimen is serially sectioned to reveal a subcapsular tumor nodule, tan to yellow-pink and soft, measuring 2.2 x 2.1 x 1.5 cm, located 0.5 cm away from the closest parenchymal margin and abutting the liver capsule. Representative sections of the mass in relation to the parenchymal margin and capsule are submitted in X-Y. Part 7 is additionally labeled "left lateral segment proximally", and consists of an enucleated tumor mass with overlying liver capsule, measuring 8.4 x 7.5 x 3.5 cm. The tumor mass appears to come within less than 0.1 cm of the parenchymal resection margin. Representative sections of the mass in relation to the parenchymal margin and capsule are submitted in Z-AB. Part 8 is additionally labeled "inferior left lateral segment nodule", and consists of a segment of liver parenchyma and overlying capsule, measuring 2.5 x 2 x 1.9 cm. The specimen is serially sectioned to reveal a tan-yellow tumor nodule, measuring 0.6 x 0.5 cm, located 0.4 cm away from the closest parenchymal margin and 0.4 cm away from the capsule. Representative sections of the nodule in relation to the parenchyma and capsule are submitted in AC-AD. Part 9 is additionally labeled "more margin inferior left lateral segment nodule", and consists of multiple unoriented tan-brown fragments of liver parenchyma aggregating 3.5 x 3 x 0.5 cm entirely submitted in AE-AF. Part 10 is additionally labeled "portal lymph node", and consists of a 2.8 x 2.5 x 1.5 cm tan-yellow segment of fatty tissue with a yellow cut surface. A portion is taken for frozen section, and diagnosis is made by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as follows: "Lymph node with reactive hyperplasia; no tumor seen". The specimen is entirely submitted as follows: AG=frozen section remnant, AH-AK=serially sectioned lymph node. Part 11 is additionally labeled "portal lymph node", and consists of a segment of tan-yellow tissue with surrounding cautery, measuring 2 x 0.6 x 0.5 cm. Entirely submitted in [**Doctor Last Name **]. Part 12 is additionally labeled "mesenteric lymph node", and consists of a small tan-yellow fragment of fibrofatty and lymphoid tissue, measuring 1 x 0.8 x 0.5 cm, bisected and entirely submitted in AM. Part 13 is additionally labeled "mucocele wall", and consists of three fragments of membranous tissue with an inner smooth lining, maroon-red in appearance. The smallest fragment measures 2 x 1 x 0.5 cm. The largest fragment measures 4 x 2.5 x 0.3 cm, and the last fragment measures 2.8 x 2.5 x 1 cm, and contains small yellow excrescences of soft tissue, measuring up to 0.5 x 0.4 cm. Representative sections of the smaller and larger fragment are submitted in AN. Representative sections of the fragment with yellow excrescences are submitted in AO-AP. Part 14 is additionally labeled "gallstones", and consists of two mixed stones, together measuring 2.3 x 2 x 1.5 cm. The specimen is for gross examination only, and has been reviewed by Dr. [**First Name4 (NamePattern1) 3924**] [**Last Name (NamePattern1) **]. OPERATIVE: OPERATIVE REPORT Name: [**Known lastname **], [**Known firstname 177**] P. Unit No: [**Numeric Identifier 70166**] Service: HEPATOBILIARY SURGERY Date: [**2148-4-22**] Date of Birth: [**2087-10-4**] Sex: M Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD 2366 PREOPERATIVE DIAGNOSIS: Carcinoid syndrome, small bowel carcinoid, liver metastases. POSTOPERATIVE DIAGNOSIS: Carcinoid syndrome, small bowel carcinoid, liver metastases. NAME OF OPERATION: Right hepatic lobectomy, resection of cystic duct mucocele, resection of segment IVB mass, resection of umbilical fissure segment IVB mass, segment IVB mass #2 resection, caudate lobe resection, resection of segment III mass, small bowel resection, intraoperative ultrasound and resection of left lateral segment mass, incisional hernia repair. FIRST ASSISTANT: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD (RES) SECOND ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD ANESTHESIA: General endotracheal. PREOPERATIVE STATUS AND DIAGNOSIS: The patient is a 60-year- old male who presented with episodic facial flushing without diarrhea. A 24-hour urine for 5-HIAA was 45.4. A CT scan of the abdomen and pelvis on [**2147-11-22**] demonstrated 2 rounded hypodense lesions in the left lobe of the liver, 1 measuring 5.2 x 5.2 cm, and the second in the right lobe measuring 3.7 x 2.8 cm. There was no evidence of small bowel lesions or lymphadenopathy. An MRI on [**2147-12-2**] demonstrated a 3.5 cm lesion in the dome of the right lobe, a 2.1 cm lesion in the anterior segment of the right lobe, and a third 4.1 cm lesion more caudad to the 2.1 cm lesion. In the posterior right lobe there was a 1.9 cm lesion. There was also a 2.4 cm mass in the mesentery to the right of midline and a 5 cm lesion in the left lateral segment. He was subsequently evaluated as a potential surgical candidate. On review of the scans, it was apparent that he was going to require a right lobectomy or possibly trisegmentectomy with resection of the large lesion in the left lateral segment in order to render his liver free of disease. Therefore, we proceeded with right portal vein embolization which was initially unsuccessful because of recanalization of the portal vein. However, re-embolization was successful with permanent thrombosis of the right portal vein and significant hypertrophy of the left lobe of the liver. Therefore, he is now brought to the operating room for right hepatic lobectomy, possible right trisegmentectomy, resection of the left lateral segment mass, intraoperative ultrasound, and small bowel resection. OPERATIVE FINDINGS: At the time of exploration, he was found to have a large mucocele of the cystic duct with 2 large stones in the cystic duct remnant. In addition, he did have a replaced right hepatic artery arising from the superior mesenteric artery and an accessory left hepatic artery arising from the left gastric artery. He had a known large lesion in the left lateral segment that was able to be enucleated. He had a second lesion anteriorly in the left lateral segment found by intraoperative ultrasound. He had multiple lesions in the right lobe. He also had a lesion in segment IVB near the edge of the liver, a lesion in segment IVB near the umbilical fissure, and lesions in the caudate lobe. The small bowel mass was found in the distal ileum. This was a solitary 2 cm lesion with puckering of the small bowel serosal surface. There was extensive lymphadenopathy at the root of the mesentery that completely encircled and encased the superior mesenteric artery and vein. OPERATIVE PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After the successful induction of general endotracheal anesthesia and placement of Foley catheter and appropriate monitoring and infusion lines, the patient was prepared with Betadine and draped in a sterile routine fashion. A bilateral subcostal skin incision was made and carried down through the subcutaneous tissue. The anterior rectus sheath, rectus muscle, posterior rectus sheath and the peritoneum were incised. The abdominal cavity was entered. The falciform ligament was doubly clamped and divided. The abdomen was thoroughly explored. The adhesions between the liver and the anterior abdominal wall were taken down. A [**Doctor Last Name 634**] retractor was then able to be placed. We initially ran the small bowel and identified the primary small bowel lesion, as well as the extensive mesenteric lymphadenopathy. We then directed our attention to the liver. The falciform ligament was divided down to the level of the suprahepatic vena cava. The right lobe of the liver was then mobilized by dividing the right triangular and coronary ligaments. There had been significant hypertrophy of the left lobe of the liver which was rounded, globular and not easily mobile. The left lateral segment was also mobilized by incising the left triangular and coronary ligaments. The accessory left hepatic artery was identified, and care was taken to avoid injury to this structure. Intraoperative ultrasound was then performed with the findings as noted above. We then proceeded to perform our portal dissection. The duodenum was adherent to the undersurface of the liver, and this was taken down sharply. We were able to identify a large cystic mass with [**Doctor Last Name **] hard stones that was in continuity with the common bile duct. The common bile duct was identified, separated from surrounding structures and circumferentially isolated. The cystic duct remnant was identified and followed from the common duct into the gallbladder fossa. This was opened, and 2 large stones were removed. There was communication with the common bile duct. We were able to completely mobilize this cystic structure and were able to divide this close to the common bile duct and doubly ligate this with 2-0 silk ties. This was now the true cystic duct remnant. No other stones were identified. Attention was then directed to the replaced right hepatic artery which was identified posterior to the common bile duct and posterior to the portal vein. This was identified and circumferentially isolated. In a similar fashion, the portal vein was identified and cleaned of its attachments anteriorly. The right portal vein was identified and circumferentially isolated and looped with a vessel loop. Next, the right hepatic artery was followed up lateral to the common bile duct where it was doubly ligated and divided. In a similar fashion, the right portal vein was doubly clamped with vascular clamps and divided. This was oversewn with running 5-0 Prolene sutures. Because of the extensive adhesions prior, it was not easy to identify the right hepatic duct at this stage, and this was left for the time when we transected the liver. Attention was then directed to the vena cava. Small hepatic veins entering the vena cava were identified, doubly ligated and divided. Several of these were suture ligated with 5-0 Prolene. One large accessory right hepatic vein was stapled with the vascular stapler. The right hepatic vein was quite small and easily isolated and divided using the vascular stapler. The caudate lobe was mobilized up off the vena cava as well. The parenchyma was then divided using the harmonic scalpel with the argon beam for hemostasis. The entire right lobe was removed. This was sent to pathology. The right hepatic duct was identified as we were transecting the liver, and this was doubly ligated with 2-0 silk ties. The caudate lobe was divided. It was not removed in continuity because of the difficulty mobilizing the caudate lobe because of the presence of the accessory left hepatic artery and because of the large globular configuration of the left lobe due to the portal vein embolization. Following resection of the right lobe, our attention was then directed to segment IVB. There was a lesion along the inferior aspect of segment IVB that was resected with a wide- margin using the harmonic scalpel. A second mass in segment IVB near the umbilical fissure was also identified and resected using the harmonic scalpel. There was another segment IVB mass more cephalad that was also resected. The more inferior segment IVB nodule, the first one that was resected, was close to the margin and additional tissue was resected in the area of this nodule. We next turned our attention to the large mass in the left lateral segment. Because of its close proximity to the draining left lateral segment vein and the blood supplying the left lateral segment portal vein, we very carefully enucleated this lesion without violating its capsule. In this fashion, we did not endanger those vessels and did not sacrifice any additional liver tissue. This was sent to pathology for permanent section. There was another left lateral segment nodule in the inferior surface that was identified by ultrasound, and this was similarly resected. Attention was then directed to the small bowel. The mesentery was cleaned of its attachments. The small bowel was divided. The mesentery was divided using the vascular stapler. Our line of resection was carefully selected to remove as many of the mesenteric lymph nodes as possible. However, we were not able to resect down to the level of the superior mesenteric artery which we had identified by ultrasound. There was extensive lymphadenopathy both anterior, posterior and on both sides of the superior mesenteric artery and vein. Therefore, we did not feel that we could adequately resect this without endangering the entire small bowel and superior mesenteric artery. Therefore, we completed the transection. Vessels were suture ligated with 2-0 silk ties. All the mesenteric vessels were securely suture ligated. We then performed a stapled side-to-side small bowel anastomosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler. The enterotomies were closed with 4-0 silk interrupted Lembert sutures. Mesenteric defect was closed using interrupted 3-0 sutures. The abdomen was copiously irrigated with antibiotic-containing saline solution. The resection areas were recauterized with the argon beam for hemostasis. They were covered with BioGlue. Two 19 [**Doctor Last Name 406**] drains were placed through separate stab incisions and secured to the skin using 3-0 nylon. The abdomen was then closed using running #1 PDS for the posterior layer, for the anterior layer and for linea [**Female First Name (un) **]. It should be noted that he had a small incisional hernia from prior surgery in the midline, and this was identified, isolated and closed using interrupted 0 Prolene sutures. Subcutaneous tissue was irrigated, and the skin closed using 4-0 Monocryl subcuticular. Steri-Strips and dressings were placed. The patient tolerated the procedure well and returned to the SICU in stable condition. Sponge, needle and instrument counts were correct. The patient received 5500 cc of crystalloid, 750 cc of albumin and made 325 cc of urine. Estimated blood loss was 500 cc. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern4) 70167**] MEDQUIST36 D: [**2148-4-22**] 17:43:48 T: [**2148-4-22**] 20:00:20 Job#: [**Job Number 70168**] Brief Hospital Course: He was taken to the OR by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**4-22**] for Right hepatic lobectomy, resection of cystic duct mucocele, resection of segment IVB mass, resection of umbilical fissure segment IVB mass, segment IVB mass #2 resection, caudate lobe resection, resection of segment III mass, small bowel resection, intraoperative ultrasound and resection of left lateral segment mass, incisional hernia repair. He was replaced with 5500 of crystalloid, EBL was 2,500mol and uop was 325cc. Please see OP report for further details. He was admitted to the SICU postop intubated. He experienced hypotension likely due to hypovolemia. Albumin was given. U/O was 30cc/hour. Hct was stable. Propofol was weaned. On POD 1, Hct decreased from 36 to 29 that was felt to be dilutional. He received LR boluses. Vital signs were stable. Coags were corrected. Hct stabilized. Bilirubin decreased to 1.9, alt/ast were elevated c/w OR. JPs continued to drain non-bilious fluid. He was extubated on pod 1. Unasyn was stopped after 2 doses postop. On POD 2, pain was controlled, LFTs trended down, HR increased to low 100s after ambulation. Hct was 29.5. A repeat hct was stable at 29.9. NG was removed for 25cc. JPs drained 460/340 non-bilious fluid. He remained npo. On POD 3 ([**4-25**]), he started clears PO, which he tolerated well and had begun to ambulate with nursing staff. He complained of some mild sternum pain and EKG along with cardiac enzymes were performed. These all did not demonstrate any cardiac ischemia. His chest pain eventually resolved on its own and did not return. His foley catheter was removed on POD 4 ([**4-26**]) and he voided without problem. [**Name (NI) **] was evaluated by physical therapy and they recommended ambulating with a cane for added stability. On POD5 ([**4-27**]), his JP drains were still draining out 100, 130cc (lateral and medial, respectively). He was tolerating a regular diet and ambulating well. He was discharged in good condition with his drains intact. Medications on Admission: enalopril, HCTZ Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Enalapril Maleate 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 7 days. Disp:*14 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: 1- Metastatic carcinoid 2- Hypertension Discharge Condition: Stable, afebrile, tolerating a diet, ambulating without assistance, with adequate analgeisa on oral medications with two peri-hepatic drains in place (~100cc x24hr = lateral JP; 130cc x24hr = medial; both serosanguinous in character) Discharge Instructions: Please continue your home medications as previously prescribed. [**Month (only) 116**] shower now, no bath tub/swimming/whirlpool while drains are in place. Followup Instructions: See Dr. [**Last Name (STitle) **] in his [**Hospital 3628**] clinic/office this Wednesday [**2148-5-1**]; please call Monday to confirm your appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

[ "553.21", "197.7", "197.6", "196.2", "576.8", "152.8" ]

icd9cm

[ [ [] ] ]

[ "51.69", "45.62", "50.3", "53.51" ]

icd9pcs

[ [ [] ] ]

33444, 33496

30901, 32989

371, 733

33580, 33815

2801, 4286

34020, 34303

2392, 2520

33055, 33421

8165, 8248

33517, 33559

33015, 33032

33839, 33997

2535, 2782

274, 333

8277, 30878

761, 2172

2194, 2259

2275, 2376

81,285

153,143

4101

Discharge summary

report

Admission Date: [**2148-1-4**] Discharge Date: [**2148-1-9**] Date of Birth: [**2084-2-12**] Sex: M Service: CARDIOTHORACIC Allergies: Hydrocodone Attending:[**First Name3 (LF) 165**] Chief Complaint: recurrent angina Major Surgical or Invasive Procedure: CABG x4 [**2148-1-5**] (LIMA to LAD, SVG to OM1, SVG to LPDA, SVG to RAMUS) cardiac cath [**2148-1-4**] History of Present Illness: 63 yo male with long history of CAD, s/p MI and LAD stent in [**2135**], with known occlusion of RCA. He developed sx again in [**10-29**] and has been taking SL NTGs for relief. He also underwent a recent MRI for back pain workup. Given his increase in sx, he was cathed and this revealed LM and severe 3 VD. Referred for urgent CABG. Past Medical History: coronary artery disease s/p CABG x 4 myocardial infarction [**2135**] with LAD stent peripheral vascular disease s/p left carotid endarterectomy hypertension hypercholesterolemia arthritis non-insulin dependent diabetes mellitus PSH: Knee arthroscopies bil. left carotid endarterectomy tonsillectomy right carpal tunnel surgery laminectomy Social History: quit smoking [**2135**] 2-3 beers per day lives with wife semi-retired well driller Family History: father with MI in his 50's Physical Exam: HR 77 RR 18 156/77 215 # 6'2" well-appearing, robust male, seen post cardiac cath skin unremarkable well-healed left neck scar neck supple with full ROM faint right carotid bruit, none on left RRR no murmur abd soft, NT, ND, + BS extrems warm,well-perfused, no edema right radial cyst right fem cath site with drsg. left 2+ fem 2+ bilat. DPs/PTs/ radials Pertinent Results: Conclusions PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. 5. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. 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. No 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. Preserved biventricular systolic function post CPB. Trivial MR, no AI. 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) **] [**2148-1-5**] 11:06 [**2148-1-8**] 06:30AM BLOOD WBC-9.1 RBC-2.85* Hgb-8.6* Hct-24.9* MCV-87 MCH-30.0 MCHC-34.4 RDW-15.0 Plt Ct-156 [**2148-1-4**] 03:30PM BLOOD WBC-8.3 RBC-3.81* Hgb-11.2* Hct-32.2* MCV-84 MCH-29.5 MCHC-34.9 RDW-14.4 Plt Ct-208 [**2148-1-6**] 03:09AM BLOOD PT-15.4* PTT-36.7* INR(PT)-1.4* [**2148-1-4**] 03:30PM BLOOD PT-13.6* PTT-26.8 INR(PT)-1.2* [**2148-1-8**] 06:30AM BLOOD Glucose-147* UreaN-20 Creat-0.8 Na-138 K-4.2 Cl-100 HCO3-31 AnGap-11 [**2148-1-4**] 03:30PM BLOOD Glucose-117* UreaN-21* Creat-0.7 Na-138 K-4.1 Cl-104 HCO3-25 AnGap-13 [**Known lastname 18009**],[**Known firstname **] [**Medical Record Number 18010**] M 63 [**2084-2-12**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2148-1-7**] 1:58 PM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2148-1-7**] 1:58 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 18011**] Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 63 year old man with s/p cabg, CTs d/c'd REASON FOR THIS EXAMINATION: r/o ptx Final Report CHEST, SINGLE VIEW ON [**1-7**]. HISTORY: Status post CABG, discontinuation of chest tubes. FINDINGS: The endotracheal tube, right IJ line, and NG tube have been removed. There is bilateral lower lobe volume loss, left greater than right, with small left effusion. Sternal wires are again visualized and underlying infiltrate in the left lower lobe cannot be excluded. DR. [**First Name (STitle) **] [**Doctor Last Name **] Approved: SUN [**2148-1-7**] 8:39 PM Imaging Lab Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] for a cardiac catheterization. This revealed a severe stenosis of his left main coronary artery. Given the findings, the cardiac surgical service was consulted and Mr. [**Known lastname **] was worked-up in the usual preoperative manner. On [**2148-1-5**], Mr.[**Known lastname **] was taken to the operating room where he underwent Coronary artery bypass grafting x 4(left internal mammary artery grafted to the left anterior descending artery/Saphenous vein grafted to the Obtuse Marginal/posterior descending artery/and Ramus). Please refer to Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] operative report for further details. He tolerated the procedure well and was transferred in stable condition to the CVICU. He awoke neurologically intact and was extubated that evening. All lines and drains were discontinued in a timely fashion. Beta-blockade, a statin and aspirin were started. On postoperative day one, Mr.[**Known lastname **] was transferred to the step down unit for further monitoring and progression. On postoperative day two, he was anemic and was transfused one unit packed red blood cells with an appropriate response. His glucose levels were elevated and he was treated with insulin as well as resuming his oral hypoglycemic at home medications. The remainder of his postoperative course was essentially uncomplicated. He continued to progress and on postoperative day four he was ready to be discharged to home with a visiting nurse. All follow up appointments were advised. Medications on Admission: celebrex 100 mg [**Hospital1 **] ASA 325 mg daily plavix 75 mg daily (300 mg [**1-3**]) diltiazem SR 180 mg daily glyburide 5 mg [**Hospital1 **] labetalol 200 mg [**Hospital1 **] metformin 100 mg [**Hospital1 **] metoprolol 12.5 mg [**Hospital1 **] moexipril 15 mg daily zocor 20 mg daily SL NTG Discharge Medications: 1. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Glyburide 2.5 mg Tablet Sig: as directed Tablet PO DAILY (Daily): 3 tabs in am and 1 tab in pm. Disp:*120 Tablet(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 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 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: coronary artery disease s/p CABG x 4(Lima->LAD/SVG->OM/PDA/Ramus) myocardial infarction [**2135**] with LAD stent peripheral vascular disease s/p left carotid endarterectomy hyypertension hypercholesterolemia arthritis non-insulin dependent diabetes mellitus Discharge Condition: good Discharge Instructions: no lotions ,creams or powders on any incision shower daily and pat incisions dry no drving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, drainage, of weight gain of 2 pounds in 2 days Followup Instructions: see Dr. [**Last Name (STitle) 18012**] in [**11-24**] weeks:#[**Telephone/Fax (1) 3183**] see Dr. [**Last Name (STitle) **] in [**12-26**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] please call for all appts. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2148-1-19**]

[ "412", "V58.66", "401.9", "414.01", "272.0", "443.9", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7993, 8064

4777, 6354

292, 401

8367, 8374

1667, 4135

8665, 9035

1247, 1275

6703, 7970

4175, 4216

8085, 8346

6380, 6680

8398, 8642

1290, 1648

236, 254

4248, 4754

429, 766

788, 1130

1146, 1231

3,969

135,568

3178

Discharge summary

report

Admission Date: [**2151-3-7**] Discharge Date: [**2151-3-11**] Date of Birth: [**2086-10-5**] Sex: F Service: MEDICINE Allergies: Imdur Attending:[**First Name3 (LF) 1973**] Chief Complaint: Diabetic Ketoacidosis Major Surgical or Invasive Procedure: None History of Present Illness: 64 yo F with pmh of HTN, CAD s/p CABG, hyperlipidemia, glucose intolerance, presented with N/V abd pain for 3 week, poor PO intake. On admission pts. blood sugar was found to be 1035 with an anion gap of 50 and pos. urine ketones. She was admitted to the MICU for diabetic ketoacidosis and new diagnosis of NIDDM. In the MICU pt. was given aggressive IV fluids, started on insulin drip until anion gap closed, ruled out for MI by enzymes. [**Last Name (un) **] was consulted and started on a insulin regimen. Pt. also presented in ARF which improved with IVF (2.6 to 1.2). Pt. still had residual abd pain after therapy. A CT abdomen showed possible small bowel ileitis and gallstones without obstruction. GI was consulted who recommended continuing treatment of DKA and small bowel follow through if pain persists. Surgery was also consulted, suggested pt. follow up as outpt. for cholecystectomy Past Medical History: CAD, s/p CABG [**1-/2143**] (LIMA-LAD, SVG-RCA, and SVG to RI to OM1) now occluded. Persantine MIBI showed EF 46% with severe reversible defects of inferolateral walls (worse than [**1-31**]) HTN Hypercholesterolemia DM recently diagosed in setting of DKA s/p hemithyroidectomy Social History: smoked 1 ppdX 20 years, quit 10 years ago; denies etoh/illicits, lives with husband Family History: NC Physical Exam: AVSS Gen - NAD, sitting up in chair. Able to answer questions, breathing normally. HEENT - adentulous, dry MM Neck - no JVD Chest - CTA bilat, no wheezes CV - RRR normal S1S2, no murmurs Abd - soft, NT/ND, BS + Extr - 1+ pitting edema bilaterally in LE Neuro - Alert and oriented x 3 Pertinent Results: [**2151-3-11**] 05:15AM BLOOD WBC-4.0 RBC-3.67* Hgb-11.3* Hct-31.4* MCV-86 MCH-30.7 MCHC-35.9* RDW-14.6 Plt Ct-101* [**2151-3-11**] 05:15AM BLOOD Glucose-141* UreaN-6 Creat-1.0 Na-138 K-3.6 Cl-106 HCO3-22 AnGap-14 [**2151-3-9**] 04:33AM BLOOD ALT-13 AST-21 LD(LDH)-174 AlkPhos-73 Amylase-40 TotBili-0.6 [**2151-3-9**] 04:33AM BLOOD Lipase-20 [**2151-3-7**] 11:14PM BLOOD CK-MB-5 cTropnT-<0.01 [**2151-3-7**] 05:12PM BLOOD CK-MB-6 cTropnT-<0.01 [**2151-3-7**] 10:20AM BLOOD CK-MB-5 cTropnT-<0.01 [**2151-3-11**] 05:15AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 [**2151-3-9**] 04:33AM BLOOD Hapto-283* [**2151-3-9**] 10:00AM BLOOD %HbA1c-16.5*# [Hgb]-DONE [A1c]-DONE [**2151-3-7**] 11:54AM BLOOD Type-ART Temp-36.1 pO2-103 pCO2-20* pH-7.24* calTCO2-9* Base XS--16 [**2151-3-7**] 01:30PM BLOOD Glucose-640* K-5.1 [**2151-3-7**] 11:43AM BLOOD Glucose-893* Na-135 K-5.6* [**2151-3-7**] 11:54AM BLOOD freeCa-1.28 CT ABD:IMPRESSION: 1) Diffuse low attenuation of the liver consistent with fatty infiltration. No focal liver lesion is identified. 2) Cholelithiasis without evidence of cholecystitis. 3) Hypodensities within bilateral kidneys, the largest in the right likely to represent a cyst, however, the remainder are too small to characterize. 4) Mild bowel wall thickening of a short segment of distal ileum which is nonspecific and may suggest ileitis. No evidence of obstruction. 5) 3.0 x 2.2 cm left adnexal cyst for which ultrasound is recommended for further evaluation in this post-menopausal female. ABD US:IMPRESSION: 1. Gallstones without additional signs of cholecystitis. 2. Fatty liver. Other forms of liver disease and more advanced liver disease, including hepatic fibrosis/cirrhosis cannot be excluded on this study. Brief Hospital Course: This is a 64 yo F with pmh of HTN, CAD s/p CABG, hyperlipidemia, glucose intolerance presented with DKA, s/p MICU stay now transferred to floor for further management of new diagnosis of diabetes. . 1 Type 1 vs. Type 2 Diabetes uncontrolled with complications: pt. does not have a hx. of diabetes, however, she presented with severe hyperglycemie, ketoacidiosis and AG which is unusual in setting of DMII. There is no sign of infection or cardiac event as a precipitant. During her MICU stay, her glucose improved as did her anion gap. She is currently stabalized on an insulin regimen as [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. - continue current insulin regimen - pt. will need teaching and follow up for new diagnosis of diabetes. . 2. Cholelithiasis: Gallstones seen on US and CT without Cholecystitis. Pain may be [**1-29**] to DKA. GI is following, recommend SBFTNo evidence of cholecystitis on u/s. ? biliary colic given lack of white count/fever. Sxs may also be [**1-29**] to DKA itself. Pancreatitis also on ddx, though only mildly elevated lipase, nml amylase. Will cont to follow symptoms as gap corrects. --anti-emetics --pain control . 3. Acute Renal Failure: Creatinine was elevated on admission [**1-29**] dehydration and ketosis. Now normalizing with IVF. --follow crt. --IVF as needed. . 4. CAD: Pt. was continued on home doses of bb/asa/lipitor, however, BPs have been low. - will titrate BB as appropriate - continue ASA lipitor . 5. benign hypertensions: cont home BB, but titrate down if pt. remains hypotensive hold amlodipine and ACE-I. . 6. hyperlipidemia: cont statin . 7. hypothyroidism: continue at home dose. . 8. gout: cont colchicine, renally dose allopurinol . # FEN: advance diet as tolerated. . # ppx: hep sc, bowel regimen . # Dispo: to home with follow up for new diagnosis of diabetes, gall stones, adnexal mass. . #Full code Medications on Admission: Per MICU H and P allopurinol 300 mg daily Norvasc 7.5 mg a day Lipitor 80 mg a day colchicine 0.6 mg daily hydrochlorothiazide 25 mg a day lisinopril 40 mg daily asa 325 mg daily levoxyl 100 mcg daily lopressor 100 mg [**Hospital1 **] zetia 10 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*1* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 8. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*1* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 10. Lancets & Blood Glucose Strips Combo Pack Sig: One (1) box Miscellaneous four times a day: Please supply lancets and test strips for the One Step Ultra 2 Glucometer. Disp:*QS 1 month* Refills:*2* 11. Syringe with Needle (Disp) [**12-29**] mL 28 X [**12-29**] Syringe Sig: One (1) syringe Miscellaneous QAC/HS: For insulin administration. Disp:*QS 1 month* Refills:*2* 12. Humalog 100 unit/mL Solution Sig: 0-16 units Subcutaneous QAC/HS: Per sliding scale. Disp:*QS 1 month* Refills:*2* 13. Lantus 100 unit/mL Solution Sig: Thirty Three (33) units Subcutaneous at bedtime. Disp:*QS 1 month* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Diabetes Mellitus Dehydration Abdominal Pain Hypertension Ovarian Cyst Discharge Condition: Her blood sugars were well controlled. She was afebrile and tolerating her meals. Discharge Instructions: You were admitted to the hospital because of extremely high glucose levels secondary to your new diagnosis of diabetes. You have now been started on insulin which you should continue to take at home as instructed. You also need to closely monitor your glucose levels on a regular basis. We have made several adjustments to your blood pressure medications and gout medications. - For you blood pressure we stopped your norvasc and hydrochlorothiazide. We decreased your metoprolol to 25mg twice a day and lisinopril to 10mg once a day. You need to have your blood pressure checked as an outpatient and those meds should be readjusted as needed. - For you gout you should only take the colchicine during an acute flare. Otherwise you should continue with allopurinol at 200mg once a day. We have set you up with follow up with several physicians: 1. Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] 2. GI for EGD and colonoscopy 3. OB/Gyn for evaluation of an ovarian cyst and ultrasound 4. [**Last Name (un) **] for your diabetes 5. General surgery for evaluation of your gallstones If you experience any nausea, vomiting, diarrhea, inability to keep fluids down, chest pain, high blood sugar levels, fevers, or chills or confusion please seek medical attention. Followup Instructions: You have multiple follow up appointments with various specialists. 1.) General Surgery for further evaluation of your gallstones. You are scheduled with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**2151-3-16**] at 1:00pm at [**Hospital Unit Name 14956**]. Please call ([**Telephone/Fax (1) 14957**] if you have any questions or cannot make the appointment. 2.) [**Last Name (un) **] follow up for your diabetes. You are scheduled for diabetic education starting on Wednesday [**3-17**] at 8:00 am on the [**Location (un) **] of [**Last Name (un) **]. You also have an appointment with Dr. [**First Name (STitle) 3636**] on [**3-30**] at 2:00pm on the second ([**Location (un) **] at [**Last Name (un) **]. Please call ([**Telephone/Fax (1) 4847**] if you have questions. 3.) You have follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-4-15**] 9:00 4.) OB/Gyn follow up for ovarian cyst. You will first have a pelvic ultrasound at 2:30pm on [**4-21**] on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Please arrive with a full bladder, it is recommended that you drink 32 ounces of fluid prior to the exam. If you have any questions please call ([**Telephone/Fax (1) 6713**]. You then have follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2151-4-21**] at 3:30pm on the [**Location (un) 858**] in the [**Hospital Ward Name 23**] Building. Please call [**Telephone/Fax (1) 2664**] if you have any questions or need to change the appointment. 5.) Gastroenterology- For EGD and colonoscopy. [**5-7**] at 11:30 AM on [**Hospital Ward Name 121**] 8. They will send you a letter with further instructions. If you have any questions please call ([**Telephone/Fax (1) 667**].

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icd9cm

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icd9pcs

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116,701

36309

Discharge summary

report

Admission Date: [**2168-5-28**] Discharge Date: [**2168-6-2**] Date of Birth: [**2117-8-31**] Sex: M Service: MEDICINE Allergies: Fish derived Attending:[**First Name3 (LF) 12174**] Chief Complaint: hematemasis Major Surgical or Invasive Procedure: 1. EGD [**2168-5-28**] History of Present Illness: 50 yo M with history of PSC cirrhosis, varices, encephalopathy in addition to portal hypertension, on the transplant list who presents with 1 day of hematemsis and abd pain. Of note, patient was admitted [**Date range (1) 62162**] for similar presentation. He had an EGD on [**5-4**] which showed varices but no stigmata of bleeding. His nadolol was stopped for bradycardia. He underwent PMIBI for CP which was negative. He represents now after noticing black stools yesterday. He had dinner last night around 6pm and then at midnight had three episodes of emesis after eating at Chilis last night. The first episode he had small specs of fresh blood but then more blood to clots with subseqent episodes. He originally presented to OSH ED where VSS. Labs notable for WBC to 14.5, hct 38.5, plt 162, no bands. Na 130, K 6.0, lipase 347. He had hypoglycemia to 69 and given amp of d50, treated with morphine 4mg x2, zofran 4mg iv, and 10 U regular insulin. . In the ED, 95.4 80 100/70 18 2L NC. Tender abd. Not encephalopathic. Had 2 20G IVs placed and started on protonix bolus and drip, octreotide bolus and drip. He was type and crossed for two units. Blood cx and lactate obtained. Liver wanted CTX. Abdominal u/s with Doppler, r/o portal vein thrombosis. No emesis in ED. Admit for EGD. Prior to transfer 97.1 87 120/77 18 95% on RA. . Upon arriving to ICU, patient reported ongoing abd pain but no more emesis. He endorsed that his abd pain was different as usually it is associated with abd distention which he denied currently. Located mostly in the right upper quadrant. Endorsed urinary retention on admission. Denied fever, chills, or confusion. Reports lower edema extremity swelling improved. Reports compliance with medications. . ROS: Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: # Primary sclerosing cholangitis # History of UGIB in [**10-12**] # Hepatic encephalopathy # HCV: by history, had positive HCV with HCV VL in [**2157**], but on follow up cleared HCV spontaneously # Horseshoe kidney # Heart murmur # Distant history of polysubstance abuse # History of dysphagia with normal barium swallow on [**2167-11-24**] # Typical Angina Social History: Last drink 20 years ago. Quit smoking 14 years ago. Not employeed. Lives alone. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. Grandfather with diabetes. Physical Exam: ADMISSION: VS: Temp: 97.1 BP: 105/79 HR:87 RR:23 O2sat 95% 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, icteric sclera, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Decreased BS at b/l bases, otherwise CV: RR, S1 and S2 wnl, no m/r/g ABD: mild distension, tender diffusely worse in RUQ, no rebound or guarding, +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c, 2+edema to midshins SKIN: no rashes/no splinters, slight jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis. DISCHARGE: VS: 98 97.1 109/68 99-118/68-82 60-71 18 98%RA 24H [**Telephone/Fax (1) 82265**]+, BMx2 GEN: pleasant, comfortable, NAD, appears slightly fatigued, A&Ox3 HEENT: EOMI, icteric sclera, MMM NECK: supple, no JVD RESP: no use access mm, CTAB without wheezes or crackles CV: RRR, S1 and S2 wnl, no appreciated murmurs ABD: +BS, moderate distension, tympanic to percussion, mildly tender to palpation RLQ, no rebound or guarding, soft, no masses or hepatosplenomegaly. No shifting dullness appreciated. EXT: warm, dry, 1+ pitting edema to just below the knee, mildly increased SKIN: no rashes, slight jaundice NEURO: AOx3. Cn II-XII grossing intact. Moving all extremities. Pertinent Results: ADMISSION LABS: [**2168-5-28**] 09:04PM SODIUM-132* POTASSIUM-4.7 CHLORIDE-103 [**2168-5-28**] 09:04PM HCT-33.3* [**2168-5-28**] 02:52PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2168-5-28**] 02:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-NEG [**2168-5-28**] 01:58PM GLUCOSE-122* UREA N-40* CREAT-1.3* SODIUM-130* POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 [**2168-5-28**] 01:58PM ALT(SGPT)-107* AST(SGOT)-170* LD(LDH)-212 ALK PHOS-340* TOT BILI-5.1* [**2168-5-28**] 01:58PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.1 [**2168-5-28**] 01:58PM VoidSpec-UNABLE TO [**2168-5-28**] 01:58PM HCT-39.2* [**2168-5-28**] 01:58PM PT-16.9* PTT-32.6 INR(PT)-1.5* [**2168-5-28**] 12:38PM LACTATE-1.7 [**2168-5-28**] 09:25AM GLUCOSE-112* UREA N-36* CREAT-1.1 SODIUM-130* POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-25 ANION GAP-14 [**2168-5-28**] 09:25AM estGFR-Using this [**2168-5-28**] 09:25AM WBC-17.3*# RBC-4.49* HGB-14.3 HCT-41.7 MCV-93 MCH-31.8 MCHC-34.2 RDW-17.3* [**2168-5-28**] 09:25AM NEUTS-85* BANDS-0 LYMPHS-4* MONOS-10 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2168-5-28**] 09:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-1+ TARGET-2+ SCHISTOCY-OCCASIONAL [**2168-5-28**] 09:25AM PLT SMR-NORMAL PLT COUNT-196 DISCHARGE LABS: [**2168-6-2**]: Na 131 K 4.5 Cl 100 HCO3 25 BUN 20 Cr 1.1 Gluc 104 Ca 8.2 Mg 2.2 P 2.8 ALT 86 AST 130 AP 260 Tbili 3.4 PT 18.4 PTT 34.9 INR 1.6 WBC 8.9 Hgb 11.5 Hgb 34.1 plt 153 Micro: BLOOD CX [**2168-5-28**]: PENDING URINE CX [**2168-5-28**]: NO GROWTH . CXR: [**5-28**] IMPRESSION: 1. Streaky bibasilar opacities, likely atelectasis, although early pneumonic infiltrates cannot be entirely excluded. 2. Prominence of the right superior mediastinum, to which attention should be paid with followup PA and lateral chest radiographs. [**5-28**] EGD: prelim: gastropathy with blood in the fundus, no major active bleeding, banded varices LIVER U/S [**5-28**]: IMPRESSION: 1. Patent hepatic vasculature. No evidence of portal vein thrombosis. 2. No acute process of the liver or gallbladder. 3. Liver cirrhosis, splenomegaly and mild-to-moderate amount of ascites. CXR [**2168-5-29**]: IMPRESSION: Streaky bibasilar atelectasis. Brief Hospital Course: Mr. [**Known lastname 26438**] is a 50 yo M with history of PSC cirrhosis, varices, encephalopathy in addition to portal hypertension, on the transplant list who presents with 1 day of hematemsis and abdominal pain. He was admitted to the ICU and had an EGD suggestive of portal hypertensive gastropathy with varices banded prophylactically. He was treated with 5 days of ceftriaxone for SBP ppx. He was transferred to the medicine floors and remained stable without further episodes of bleeding. He had a leukocytosis thought to be inflammatory response without fever or s/s of infection that downtrended. He was improved and discharged home. # Hematemesis: Patient s/p EGD in ICU. Showed portal hypertensive gastropathy as likely source of bleeding. He had esophageal varices that were not overtly bleeding but were banded prophylactically. Remained HD stable with active t+s. He was initially treated with octreotide and protonix gtt. Ceftriaxone was given for SBP prophylaxis. He was transferred to the medicine floors and had no further episodes of bleeding. He was transitioned to po protonix and carafate. Also restarted on Nadolol 10mg daily. He should have repeat EGD in [**4-6**] weeks with GI as an outpatient. # Abdominal pain: Seems to be chronic in nature per liver. Liver u/s showed patent vasculature. Lipase was normal. Pt had some mild discomfort on the floors, thought to be related to banding. Pt noted to have possible colopathy [**2-3**] cirrhosis vs. colitis on previous imaging. Pt was symptomatically improved and will follow-up with GI on discharge for further management. # Leukocytosis: Likely inflammatory response to GIB bleeding. WBC trended downward. Urine culture showed no growth. Blood cultures were negative. He remained afebrile during this admission and WBC was within normal limits on discharge. # ESLD: [**2-3**] PSC, MELD 17. Patient having GIB on admission, but not variceal (see above). He did not appear decompensated otherwise. His diuretics were initially held, and restarted on the floors. Restarted lasix 120mg daily (per recent dose change), and spironolactone at lowered dose 150mg daily. He was also restarted on Nadolol at a lowered dose. He was continued on home rifaximin, lactulose, and ursodiol. # Hyponatremia: Sodium lower than baseline, likely [**2-3**] hypervolemia and volume overload. Improved with fluid restriction and increased diuresis. Na was 131 on discharge. # Hyperkalemia: Slightly elevated on admission may be [**2-3**] spironolactone. Held spironolactone initially. Spironolactone was restarted slowly on the medicine floors with no more hyperkalemia. Discharged home on a lowered dose. TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT: [**Name (NI) **] [**Name (NI) 26438**] sister Phone: [**Telephone/Fax (1) 82266**] 3. FOLLOW-UP: - GI, REPEAT EGD IN [**4-6**] WEEKS - LIVER - PCP 4. MEDICAL MANAGEMENT: - STARTED Pantoprazole 40mg by mouth twice daily, Sucralfate 1gm by mouth four times daily - DECREASE the amount of Spironolactone from 200mg daily to 150mg by mouth daily - RESTARTED Nadolol at 10mg by mouth daily 5. OUTSTANDING TASKS: none Medications on Admission: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed [**2157**] mg daily as this can damage the liver. . 4. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 40mg mg Tablet Sig: 3 Tablet PO DAILY (Daily). 6. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day). 7. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual once a day as needed for chest pain for 1 doses: Use for chest pain. If chest pain persists after 3 doses, call 911 or report to the nearest emergency room. . 12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. tramadol 50 mg Tablet Sig: One 1.5 Tablet PO every 6-8 hours as needed for pain: Do not drive or operate machinery while using this medication. [**Month (only) 116**] cause confusion or somnolence. 14. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Do not exceed [**2157**] mg daily as this can damage the liver. . 4. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day). 5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO three times a day. 8. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once may repeat x1 as needed for chest pain: Use for chest pain. If chest pain persists after 3 doses, call 911 or report to the nearest emergency room. . 10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. tramadol 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours) as needed for abd pain: Do not drive or operate machinery while using this medication. [**Month (only) 116**] cause confusion or somnolence. . 12. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. 13. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 15. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 16. furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNAs of [**Location (un) 511**] Discharge Diagnosis: Primary Diagnoses: 1. Upper GI bleed 2. Portal hypertensive gastropathy 3. Abdominal pain 4. Hyperkalemia Secondary Diagnoses: 1. End-stage liver disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 26438**], It was a pleasure taking care of you during this admission. You were admitted with vomiting up blood. You had an endoscopy showing some blood probably from portal hypertension associated with you liver disease. You had several varices that were not bleeding but were banded to prevent bleeding. You will need to have a repeated endoscopy with the GI doctors [**Last Name (NamePattern4) **] [**4-6**] weeks when you leave here. We made a few medication changes, see below. You had some chest pain, which is due to the banding, and should improve over time. The following medications were changed during this admission: - DEACREASE the amount of Spironolactone from 200mg daily to 150mg by mouth daily **You will need to have your labs checked and this dose may be adjusted by your doctors based on the labs and your swelling. - START Pantoprazole 40mg by mouth twice daily - START Sucralfate 1gm by mouth four times daily - RESTART Nadolol at a lower dose that you have taken prior at 10mg by mouth daily Please continue the other medications you were on prior to this admission. Followup Instructions: Please follow-up with the following appointments: Department: TRANSPLANT When: WEDNESDAY [**2168-6-8**] at 2:20 PM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 82267**],MD Specialty: Primary Care Address: [**Street Address(2) 82262**], E. [**Hospital1 **],[**Numeric Identifier 82263**] Phone: [**Telephone/Fax (1) 82264**] When: Wednesday, [**6-15**] at 12:30pm Department: ENDO SUITES When: THURSDAY [**2168-6-16**] at 12:30 PM You will have to be accompanied by someone as they will need to take you home after receiving sedating medications. Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2168-6-16**] at 12:30 PM With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], 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 Completed by:[**2168-6-3**]

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icd9cm

[ [ [] ] ]

[ "42.33" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2108-8-29**] Discharge Date: [**2108-9-9**] Date of Birth: [**2042-6-25**] Sex: F Service: MEDICINE Allergies: Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin / Percocet / Quinine / Levofloxacin / Penicillins / Vicodin / latex gloves / Morphine / optiflux / Warfarin Attending:[**First Name3 (LF) 3705**] Chief Complaint: Vomiting/ ? Sepsis Major Surgical or Invasive Procedure: [**2108-9-4**]: Tunneled [**Month/Day/Year 2286**] line removal [**2108-9-5**]: Midline removal [**2108-9-7**]: Tunneled [**Month/Day/Year 2286**] line placement History of Present Illness: 66F with ESRD on HD complicated by calciphylaxis, atrial fibrillation on lovenox, DM2, OSA, hypothyroidism, HL, depression presenting with hypotension from [**Month/Day/Year 2286**], generalized weakness, fever/chills in setting of nausea/vomiting for one day. Of note, she was recently admitted from [**2108-7-31**] to [**2108-8-10**] for weakness and melena concerning for GIB in setting of INR > 19. She was admitted to the ICU s/p six units of pRBC. Endoscopy was within normal limits. Her hospital course was complicated by calciphylaxis. Pain management was also an issue with IV dilaudid, PCA, and fentanyl patch being utilized. She was discharged to rehab on lovenox for anticoagulation, sodium thiosulfate for calciphlaxis, PO dilaudid, fentanyl patch, and APAP for pain. Patient endorses a 3-day history of poor PO intake with weight loss over the past month. She has apparently been receiving extra sessions on Thursday for ultrafiltration per [**Hospital 100**] rehab notes. She received [**Hospital 2286**] on day of admission with HD stopped after approximately 3.7 L was removed secondary to shivering, RVR to 130s, and asymptomatic SBP drop to mid-80s. She was given 500 cc back. For her fever, she was cultured and started on vancomycin and imipenum. In the ED, initial vs were: 99.5 [**Telephone/Fax (1) 96398**] 18 99% 4L. Exam notable for systolic blood pressures ranging between 69 and 90. Afebrile throughout stay. Diffuse abdominal tenderness to palpation but no rebound or guarding. CT abdomen given diffuse abdominal ttp and vomiting in the setting of a febrile with no acute process. Given the concern for hypotension in the setting of a febrile illness with unknown source, she was started on vancomycin 1g IV and cefepime 2 gm IV. She received 2 L IVF. Admit Vitals 97.1 [**Telephone/Fax (1) 96399**] 17 97 2L On the floor, patient mentating well, primarily concerned about pain medication regimen. Past Medical History: Cardiac: 1. CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**7-31**] 2. CHF, EF 50-55% on echo in [**7-/2105**] Systolic and diastolic heart failure with mild mitral regurgitation and tricuspid regurgitation. 3. PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left) 4. Hypertension 5. Atrial fibrillation noted on admission in [**9-1**] 6. Dyslipidemia 7. Syncope/Presyncopal episodes - This was evaluated as an inpatient in [**9-1**] and as an opt with a KOH. No etiology has been found as of yet. One thought was that these episodes are her falling asleep since she has a h/o of OSA. She has had no tele changes in the past when she has had these episodes. Pulm: 1. Severe Pulmonary Disease 2. Asthma 3. Severe COPD on home O2 3L 4. OSA- CPAP at home 14 cm of water and 4 liters of oxygen 5. Restrictive lung disease Other: 1. Morbid obesity (BMI 54) 2. Type 2 DM on insulin 3. ESRD on HD since [**2107-2-28**] - 4x weekly [**Year (4 digits) 2286**] Monday/Wednesday/Thurs/Fri 9R 2 lumen tunnelled line 4. Crohn's disease - not currently treated, not active dx [**2093**] 5. Depression 6. Gout 7. Hypothyroidism 8. GERD 9. Chronic Anemia 10. Restless Leg Syndrome 11. Back pain/leg pain from degenerative disk disease of lower L spine, trochanteric bursitis, sciatica Social History: Lives on the [**Location (un) 448**] of a 3 family house with [**Age over 90 **] year old aunt and multiple cousins in Mission [**Doctor Last Name **]. Walks with walker. Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). Infrequent EtOH use (1drink/6 months), [**Year (4 digits) **] other drug use. Retired from electronics plant. Family History: Per discharge summary: Sister: CAD s/p cath with 4 stents MI, DM, Brother: CAD s/p CABG x 4, MI, DM, ther: died at age 79 of an MI, multiple prior, DM, Father: [**Name (NI) 96395**] MI at 60. She also has several family members with PVD. Physical Exam: On Admission: General Appearance: No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral [**Name (NI) **]: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: limited secondary to habitus Abdominal: Soft, Non-tender, Obese Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+, various calciphylaxis on LE Skin: Warm Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed On Discharge: T98 BP 109/64 P83 RR20 O2 97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated, no LAD Lungs:Good air movement, no adventitious sounds CV: Irreg irreg, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended with ventral hernias, multiple old scars, bowel sounds present, no rebound tenderness or guarding, no organomegaly detected Ext: warm, well perfused, 2+ pulses, Pitting 3+ edema and pt grossly anasarcic. Skin: Calciphylaxis with wounds on both legs Pertinent Results: [**2108-8-29**] 12:10PM WBC-11.2* RBC-3.45* HGB-9.9* HCT-30.2* MCV-88 MCH-28.8 MCHC-32.8 RDW-16.9* [**2108-8-29**] 12:10PM NEUTS-95.8* LYMPHS-2.6* MONOS-1.1* EOS-0.5 BASOS-0 [**2108-8-29**] 12:10PM PLT COUNT-361 [**2108-8-29**] 12:10PM PT-13.0 PTT-38.5* INR(PT)-1.1 [**2108-8-29**] 12:10PM ALT(SGPT)-9 AST(SGOT)-12 ALK PHOS-144* TOT BILI-0.2 [**2108-8-29**] 12:10PM LIPASE-9 [**2108-8-29**] 12:10PM GLUCOSE-127* UREA N-14 CREAT-2.8*# SODIUM-139 POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-21* [**2108-8-29**] 12:23PM LACTATE-1.4 [**2108-8-29**] 05:47PM LACTATE-0.9 Relevant Labs: [**2108-9-3**] 04:15PM BLOOD LMWH-0.62 (This is a peak factor Xa level, and is considered therapeutic) Discharge Labs: [**2108-9-9**] 09:25AM BLOOD WBC-8.1 RBC-3.31* Hgb-9.4* Hct-28.9* MCV-87 MCH-28.4 MCHC-32.6 RDW-18.1* Plt Ct-412 [**2108-9-8**] 09:25AM BLOOD Neuts-87.5* Lymphs-7.3* Monos-4.4 Eos-0.5 Baso-0.2 [**2108-9-9**] 09:25AM BLOOD Plt Ct-412 [**2108-9-9**] 09:25AM BLOOD Glucose-84 UreaN-13 Creat-2.9* Na-135 K-3.5 Cl-92* HCO3-28 AnGap-19 [**2108-9-9**] 09:25AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.7 Microbio: [**2108-8-29**] 12:10 pm BLOOD CULTURE #1. **FINAL REPORT [**2108-9-4**]** Blood Culture, Routine (Final [**2108-9-4**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2108-8-30**]): Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 394**] @ 8PM [**2108-8-30**]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. [**2108-8-31**] 3:06 pm SWAB Source: R thigh ulcer. **FINAL REPORT [**2108-9-6**]** GRAM STAIN (Final [**2108-8-31**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final [**2108-9-6**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S [**2108-9-3**] 6:45 am BLOOD CULTURE Source: Line-HD CATH SET 1. **FINAL REPORT [**2108-9-9**]** Blood Culture, Routine (Final [**2108-9-9**]): PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. PSEUDOMONAS AERUGINOSA. SECOND MORPHOLOGY. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 16 I 8 S CEFTAZIDIME----------- 4 S 2 S CIPROFLOXACIN--------- 1 S 2 I GENTAMICIN------------ 8 I <=1 S MEROPENEM------------- 1 S <=0.25 S PIPERACILLIN/TAZO----- S S TOBRAMYCIN------------ <=1 S <=1 S Aerobic Bottle Gram Stain (Final [**2108-9-4**]): GRAM NEGATIVE ROD(S). Reported to and read back by DR. [**Last Name (STitle) 73069**] [**2108-9-4**] 09:51AM. Blood cultures from rehab facility in early [**Month (only) 216**] before coming to hospital: Blood positive for Enterobacter: Sensitive to bactrim, cefotaxime, ceftriaxone (<8), cefepime,cipro, gent, penems, levo, zosyn. Imaging: CT Abdomen w and w/o [**8-29**] Final Report INDICATION: Fever, nausea, vomiting and periumbilical pain, assess for acute process. TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to pubic symphysis after administration of intravenous, but not oral contrast. Coronal and sagittal reformations were prepared. COMPARISONS: Multiple CTs of the abdomen and pelvis, most recently [**2107-9-16**]. CT OF THE ABDOMEN WITH CONTRAST: The imaged lung bases demonstrate bibasilar patchy consolidation, which could reflect atelectasis, although aspiration is an alternative consideration. Dense coronary calcification is noted. There is no pleural or pericardial effusion. Within the right lobe of the liver, a 2.3 x 2.5 cm hemangioma is again seen (2:32). The remainder of the liver is unremarkable without focal enhancing lesion, intra- or extra-hepatic biliary ductal dilatation. The gallbladder is surgically absent. Scattered calcifications in the liver compatible with prior granulomatous disease. The pancreas, spleen and bilateral adrenal glands are unremarkable with the exception of numerous splenic granulomas. The kidneys are shrunken and atrophic, compatible with known end-stage renal disease. They enhance but do not excrete contrast. Stomach, small and large bowel is unremarkable. There is no free air or free fluid in the abdomen. There is no mesenteric or retroperitoneal adenopathy. Numerous surgical clips are seen in the anterior abdominal wall with ventral hernia again noted. Aorta and major branches are patent with dense atherosclerotic calcification noted in the aorta and ostia of the major branches. CT OF THE PELVIS WITH CONTRAST: The bladder is shrunken. The rectum is unremarkable. Fluid is noted in the endometrial cavity, unexpected in the post-menopausal period. A 1.1 cm coarse calcification is again noted in the right adnexa. There is no free pelvic fluid. There is no pelvic or inguinal adenopathy. SOFT TISSUE AND OSSEOUS STRUCTURES: There is no lytic or sclerotic bony lesion concerning for osseous malignant process with extensive degenerative change noted in the thoracolumbar spine as well as bilateral SI joints. The patient status post ORIF of the left femoral fracture, which is not completely imaged on this study. Hyperdensities in the anterior abdominal wall soft tissues are likely from injection. IMPRESSION: 1. No acute abdominal process to explain the patient's symptoms. 2. Bibasilar atelectasis and/or aspiration. 3. Unchanged hepatic hemangioma and ovarian calcifications. 4. Fluid/hypodensity in the endometrial cavity is unexpected in the post-menopausal period. Further evaluation with pelvic ultrasound is recommended, nonemergently. Brief Hospital Course: 66F ESRD on HD complicated by calciphylaxis, atrial fibrillation on lovenox, DM2, OSA, hypothyroidism, HL, depression presenting with hypotension from [**Year (4 digits) 2286**] likely secondary to hypovolemia and sepsis. # Sepsis Pt was found to be bacteremic with multiple organisms including enterobacter, pseudomonas (grew through HD line), and coag negative staph though this latter organism may have been a contamination. Pt had fevers, an elevated white count, nausea and vomiting, hypotension and chills. This improved with antibiotics. Initially, broad spectrum was given with vancomycin and cefepime and narrowed to vancomycin and ceftazidime. Notably, pt has penicillin allergy but tolerates higher gen cephalosporins without issue. Pt was given a line holiday for two days as her TDC and midline were pulled. After 48 hours clear with no growth of cultures, pt had TDC replaced and returned to [**Year (4 digits) 2286**]. Tip cultures of TDC and midline were negative, but this is nontheless the suspected source of infection. No midline or PICC was placed for IV antibiotics as this will be done at the pt's LTAC. Pt became afebrile with return of baseline WBC count. Pt will complete two week course of antibiotic course from date of having all lines pulled ([**Date range (1) 96400**]) #. Calciphylaxis and [**Date range (1) 197**] Necrosis: Patient has breast lesions consistent with [**Date range (1) **] necrosis and calciphylaxis in other areas particularly in lower extremities. She finished her course of sodium thiosulfate without much resolution and was started on IV pamdironate 30 mg QOD with Dr [**First Name (STitle) 805**], renal attending, following. Currently unclear duration of pamidronate treatment. Derm has been very actively following, debriding the breast crusts from the [**First Name (STitle) **] skin necrosis, and injecting new calciphylaxis lesions with steroids. They recommened vinegar soaks for the calciphylaxis and the details of the rest of the skin care regimen is noted in their OMR consult note. # Pain [**2-29**] to calciphylaxis: Methadone was stopped as it seemed to coincide with her episodes of nausea. Pt titrated to a regimen of reasonable pain control with standing Oxycontin, hydromorphone for breakthrough, and standing gabapentin and acetaminophen. Chronic Diagnoses: # Atrial fibrillation Patient in NSR on admission but returned to atrial fibrillation. On MWF 100 mg Enoxaparin. Peak Factor Xa levels came back at 0.62 which is considered therapeutic. # Anemia Patient with recent hemoglobin drop with dark stools at rehab favored to be acute blood loss anemia from GI source with guiaic positive stools. Her hemoglobin was 7.9 on [**8-20**] (labs not available before this time from rehab) and up to 9.7 on [**2108-8-27**] without any interval transfusion and fluctuated since that time. # ESRD She is on a M,W,Th,F HD schedule and receiving her vanc and ceftazidime Stopped sevelamer since phosphates running low. # DM2 She was kept on her home insulin regimen. # OSA She was continued on home CPAP (14 cm and 4 L O2). # Hypothyroidism She was continued on synthroid. # Gout She was continued on allopurinol. # Rhinitis She was continued her nasal spray. # Hyperlipidemia She was continued on her statin. Transitional Issues: # Incidentalomas: -Needs outpatient follow up for endometrial fluid and right adnexal calcification. Will likely need ultrasound for better characterization of this. Code status: Full Health care proxy chosen: [**Name (NI) **] [**Doctor Last Name **] Relationship: sister Phone number: [**Telephone/Fax (1) 96401**] Cell phone: [**Telephone/Fax (1) 96402**] Proxy form in chart: No Comments: [**Telephone/Fax (1) **]'s number home [**Telephone/Fax (1) 96401**] and cell [**Telephone/Fax (1) 96402**] alternate [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] cell [**Telephone/Fax (1) 96403**] pt's states sister is still her [**2108-1-26**] Same HCP, currently staying at her house. Verified on date: [**2108-7-6**] Medications on Admission: - Acetaminophen 975 mg PO TID - Allopurnol 100 mg PO qD - ASA 81 mg PO qD - Calcitriol 0.25 mcg PO qD - Enoxaparin 100 mg M,W,F SC - Fexofenadine 60 mg PO BID - Fluticasone 1 spray NAS - Gabapentin 100 mg PO qD - Lantus 10 unit SC qHS - Insulin lispro SSI - sevelamer 800 mg PO TID with meals - Sodium thiosulfate [**Numeric Identifier 16351**] mg IV M,W,Fr - Vitamin B complex - lactulose 10 gm PO qD - levothyroxine 175 mcg PO qD - metadone 2.5 mg PO BID - metoprolol 12.5 mg PO q 6 hr - omeprazole 20 mg PO BID - paroxetine 40 mg PO qD - pravastatin 80 mg PO qHS - senna - Miralax - Hydromorphone 4 mg PO q 3 hr prn pain - Ondansetron 4 mg PO q 8 hr prn nausea - Capsaicin 0.075 % TOP [**Hospital1 **] - menthol/camphor 1 appl TOP [**Hospital1 **] Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO three times a day. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. enoxaparin 100 mg/mL Syringe Sig: One (1) injection Subcutaneous EVERY MONDAY, WEDNESDAY, [**Hospital1 **] (). 6. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 8. insulin lispro 100 unit/mL Solution Sig: Per sliding scale Subcutaneous qachs: Please refer to printed ISS. 9. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. lactulose 10 gram Packet Sig: One (1) PO once a day. 12. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 14. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 17. capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for skin pain . 18. sodium hypochlorite 0.5 % Solution Sig: One (1) Appl Miscellaneous ASDIR (AS DIRECTED). 19. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 20. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 21. collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 22. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 23. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 24. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). 25. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). 26. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO four times a day. 27. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). 28. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) Injection Q8H (every 8 hours) as needed for nausea . 29. ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection QHD (each hemodialysis). 30. pamidronate 30 mg/10 mL (3 mg/mL) Solution Sig: One (1) Intravenous EVERY OTHER DAY (Every Other Day): Renal will alert to how many treatments patient will need. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Sepsis Calciphylaxis Secondary: Atrial fibrillation End stage renal disease OSA Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 1968**], It was a pleasure taking care of you at [**Hospital1 827**]. You were brought to the hospital because you had low blood pressures while at [**Hospital1 2286**] and were feeling weak, nauseous, and with fever and chills. You received fluids to help increase your blood pressure and were started on the antibiotics vancomycin and cefepime for concern for blood stream infection. You had some elevated temperatures and fast heart rates which made us concerned that you did have an infection in your blood. Blood cultures that came back revealed that you had multiple different organisms that were growing in your blood, and we removed all your lines in order to help clear you of the source of infection. It'll be important for you to keep taking these IV antibiotics for your two week course from [**Date range (1) 96400**]. The calciphylaxis on your legs and skin necrosis on your breasts were also treated while you were in the hospital. Steroid injections were tried on the new lesion on your right buttock cheek. And the crusts on your breasts debrided. Medications STOPPED: Gabapentin 100 mg PO qD sevelamer 800 mg PO TID with meals Sodium thiosulfate [**Numeric Identifier 16351**] mg IV M,W,Fr Methadone 2.5 mg PO BID Hydromorphone 4 mg PO q 3 hr prn pain Ondansetron 4 mg PO q 8 hr prn nausea Medications STARTED: vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Injection QHD (each hemodialysis). sodium hypochlorite 0.5 % Solution Sig: One (1) Appl AS DIRECTED hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). collagenase clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QAM (once a day (in the morning)). oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO QPM (once a day (in the evening)). ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) Injection Q8H (every 8 hours) as needed for nausea. pamidronate 30 mg/10 mL (3 mg/mL) Solution Sig: One (1) Intravenous EVERY OTHER DAY (Every Other Day): Dr. [**First Name (STitle) 805**] of Renal will alert to how many treatments patient will need. Followup Instructions: Your following appointments are listed below: Name: [**Last Name (LF) **],[**First Name3 (LF) **] D. Location: [**Hospital3 249**]/[**Hospital1 **]/EAST Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 250**] Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge. Department: DERMATOLOGY When: MONDAY [**2108-9-17**] at 10:30 AM With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: [**Hospital Ward Name **] [**2108-9-14**] at 9:05 AM With: RADIOLOGY [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: [**Hospital Ward Name **] [**2108-9-14**] at 10:00 AM With: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2108-9-9**]

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Discharge summary

report+addendum+addendum

Admission Date: [**2175-2-23**] Discharge Date: [**2175-3-3**] Date of Birth: [**2128-11-22**] Sex: M Service: Intensive Care Unit NOTE: An Addendum will be dictated at a later time. CHIEF COMPLAINT: Pancreatitis. HISTORY OF PRESENT ILLNESS: This is a 46-year-old white male with a history of hypertension, and hepatitis C, and distant intravenous drug use who was in his usual state of good health until he developed upper abdominal pain on [**2-17**]. He had an acute episode of this upper abdominal pain which lasted for several hours and then passed. The abdominal pain returned on [**2-19**] with nausea, vomiting, and loose stools. The patient did experience chills, but he did not take his temperature. The patient presented to the Emergency Department at [**Hospital6 23694**] in [**Location (un) 5503**] on [**2-20**] where a right upper quadrant ultrasound revealed a dilated common bile duct and 10.5-mm thickened gallbladder. A computed tomography scan at this institution revealed a nonenhancing head of the pancreas consistent with necrosis, free fluid around the pancreas and gallbladder consistent with necrotizing pancreatitis. Notable laboratories from the outside hospital included an amylase of 801, lipase was 276, AST was 198, and ALT was 310. Hematocrit was 53, glucose was 162, and white blood cell count was 14.7. Creatinine was 1.4. The patient was admitted and treated with intravenous fluids, calcium repletion, and imipenem for his necrotizing pancreatitis. Gastrointestinal and General Surgery were consulted, and an endoscopic retrograde cholangiopancreatography was deferred at that institution because the patient's liver function tests were declining. The hospital course was complicated by low urine output, an increasing creatinine, declining calcium, and moderate-to-severe pain. The patient was given mannitol and dopamine for his low urine output and then transferred to [**Hospital1 69**] for further evaluation and management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hepatitis C. 3. History of intravenous drug and alcohol abuse (very distant); the patient denies any use in the past 10 years. MEDICATIONS ON TRANSFER: 1. Atenolol 50 mg p.o. q.d. 2. Imipenem 250 mg p.o. q.6h. 3. Morphine sulfate patient-controlled analgesia. 4. Ativan as needed. 5. Dopamine as needed ALLERGIES: The patient has an allergy to PENICILLIN. SOCIAL HISTORY: The patient is married with four children. He quit tobacco four years ago. He has a distant history of intravenous drug use and alcohol use, but he has not used these in 10 years. FAMILY HISTORY: Family history is notable for hypertension and cerebrovascular disease. PHYSICAL EXAMINATION ON PRESENTATION: Admission physical examination revealed temperature current of 100.9, heart rate was 104, blood pressure was 118/64, respiratory rate was 24 to 28 times, oxygen saturation was 95% on 4 liters nasal cannula. Generally, an obese white male in moderate distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light and accommodation. Extraocular muscles were intact. Mucous membranes were dry and without lesions. Carotid pulses were 2+ bilaterally. The neck was supple. Cardiovascular examination revealed tachycardic. Normal first heart sound and second heart sound. No murmurs, gallops, or rubs. Lungs revealed a few inspiratory wheezes and decreased lung volumes bilaterally. The abdomen was distended and tympanitic. Decreased bowel sounds. Moderate epigastric tenderness and increased in the right upper quadrant. Extremities revealed no cyanosis, clubbing, or edema. Distal pulses were 2+ in the upper extremities and lower extremities bilaterally. Neurologic examination revealed alert and oriented times four. Cranial nerves II through XII were tested and were grossly intact; nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed white blood cell count was 11.9, hematocrit was 38.2, and platelets were 228. Sodium was 138, potassium was 5.1, chloride was 107, bicarbonate was 16, blood urea nitrogen was 95, creatinine was 2.6, and blood glucose was 88. INR was 1.3, prothrombin time was 13.9, and partial thromboplastin time was 27.2. AST was 69, ALT was 56, total bilirubin was 0.8, alkaline phosphatase was 81, albumin was 3. Creatine kinase was 2103; although, MB and troponin I fractions were unremarkable. Amylase was 239 and lipase was 144. RADIOLOGY/IMAGING: A chest x-ray revealed a double lumen peripherally inserted central catheter in place and tube in good position. Low lung volumes. No acute process. An electrocardiogram revealed a normal sinus rhythm at 99, normal axis and normal intervals, a Q wave in lead III, early R wave progression. No acute ST-T wave changes. HOSPITAL COURSE BY ISSUE/SYSTEM: (Summary of the hospital course up to this time revealed) 1. PULMONARY SYSTEM: Several hours after admission, the patient's respiratory status decompensated because he was tachypneic and began to desaturate. The patient was intubated. The patient was alternatively managed throughout his stay on assist-controlled and pressure-controlled ventilation. Initially, during his hospitalization ventilation began difficult given his very high peak and plateau pressures. However, given the patient's large body habitus and marked abdominal distention, an esophageal balloon was performed to determine a potential contribution of his high ventilator pressures to his chest wall and abdomen versus his lungs. His transpulmonary pressure was calculated to be approximately 10 cm, and his intragastric pressures were found to be 30. This was felt to be most consistent with marked compression of his thoracic cavity by his abdominal distention and body habitus. The patient was felt to have significant room to move on his ventilatory status. At the time of this dictation, the patient is currently being gradually weaned off AC ventilator settings. Also with regard to pulmonary issues, the patient developed a large left pleural effusion early in his stay. This was felt most likely to be secondary to his acute pancreatitis. However, given his very high fevers, several attempts were made by the Interventional Pulmonology Service and Interventional Radiology Service to tap this effusion by ultrasound-guidance. However, because of the patient's body habitus, high positive pressure ventilation, and diffuse skin rash on his back this was not feasible and felt to be too high or a risk. 2. CARDIOVASCULAR SYSTEM: Throughout his stay in the Intensive Care Unit, the patient remained hemodynamically stable. Because of his markedly high fevers. His heart rate and his blood pressure were actually elevated. Given his massive fluid resuscitation, an echocardiogram was performed. He was found to have to have hyperdynamic ventricle with an ejection fraction of greater than 70%. At the time of this dictation, the patient has remained hemodynamically stable. A Swan-Ganz catheter was placed on [**2-28**] and revealed low systemic vascular resistance and high cardiac output; most likely consistent with septic shock. The patient's wedge pressures were markedly elevated to the 30s and 40s. Given the fact that there was no problems oxygenating, and the patient had normal left ventricular function, this was felt likely to be falsely elevated secondary to his abdominal compartment syndrome compressing his thoracic cavity. 3. GASTROINTESTINAL/BILIARY ISSUES: Following transfer with aggressive intravenous fluids resuscitation, the patient's pancreatic enzymes and liver function tests normalized. An ultrasound performed on the day following admission (on [**2-24**]) revealed a continually dilated common bile duct of 8 mm to 9 mm, but no evidence of stones or cholecystitis. The patient was evaluated by the Endoscopic Retrograde Cholangiopancreatography Service and felt not to require endoscopic retrograde cholangiopancreatography because the patient's pancreatitis was clinically improving. The patient was felt to need a cholecystectomy and endoscopic retrograde cholangiopancreatography with papillotomy eventually, but this was not emergent. A few days into his stay, the patient began to spike very high fevers to 103 to 104 degrees Fahrenheit. Given concerns for potentially infected pancreatic tissue, serial abdominal computed tomography scans were performed on [**2-24**] and [**2-27**]. These were notable for severe pancreatitis, nonenhancement of the head; consistent with necrosis, but no evidence of focal fluid collection or abscess were noted. The patient's small-bowel loops appeared normal. The patient was very closely followed by the Hepatobiliary Service and the General Surgery Service. Consideration was given for a percutaneous pancreatic sampling; however, after extensive discussions with Interventional Radiology and General Surgery, there was not felt to be a focal fluid collection that would be potentially drainable. On the day following his admission, a nasojejunal tube was placed by the Biliary Service for trophic tube feedings which the patient is currently receiving at this time. The patient's gastrointestinal course was also complicated by an marked ileus causing massive abdominal distention. This ileus, combined with his severe pancreatitis, resulted in marked abdominal distention which was believed to have caused an abdominal compartment syndrome, which compressed the patient's thoracic cavity. Throughout his stay, bladder pressures were closely monitored. General Surgery felt that there was no operative intervention at this time. 4. INFECTIOUS DISEASE ISSUES: In the couple of days following his arrival to [**Hospital1 188**], the patient began to spike very high fevers to 103 to 104. However, he remained hemodynamically stable. All blood cultures including fungal and myolytic isolators remained negative to this date. The patient was transferred on imipenem which was continued for a few days of his admission. However, given a rash on his abdomen, this was later changed to vancomycin, Levaquin, and fluconazole. The patient was very closely followed by the Infectious Disease Service. At the time of this dictation, the fluconazole was discontinued on [**3-2**] and consideration was being given to discontinuing the patient's remaining antibiotics given the evolution of the rash on his back and the fact that he has remained hemodynamically stable with very high fevers and negative blood cultures. 5. DERMATOLOGIC ISSUES: On approximately [**2-28**], the patient began to develop a diffuse erythematous macular rash on his back which appeared to worsen over the course of a few days. Given its appearance, and the fact that the patient was on fluconazole, it was not felt to be fungal in nature. A Dermatology consultation was obtained on [**3-1**], and they that this rash was most likely consistent with a drug eruption, with imipenem being the most likely culprit, but that any of his medications could potentially cause this. Given the fact that the patient remained critically, was febrile, and did not appear to be suffering in terms of mucosal or [**Doctor Last Name **]-[**Location (un) **] syndrome with his current antibiotics, these were recommended to be continued. However, at the time of this dictation, consideration is being given to discontinuing antibiotics. 5. RENAL SYSTEM: The patient's blood urea nitrogen and creatinine declined over the first few days of admission with aggressive fluid resuscitation. However, there was a minor increase in his creatinine to 2.1 which was felt most likely to be compression of the renal vasculature with his abdominal compartment syndrome. A fractional secretion of sodium was checked, and this was found to be less than 1. This resolved with aggressive fluid resuscitation. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient's ionized calcium was closely followed and repleted, as were all of his other electrolytes. The patient was continued on total parenteral nutrition, and is currently receiving jejunal feeds. 7. LINES: The patient currently has a right internal jugular Quad-Lumen catheter which was placed on [**2-28**] and a left radial arterial line was placed on [**2-23**]. 8. COMMUNICATION ISSUES: Extensive discussions were held with the patient's family members including his wife and children. They were informed of the critical nature of the patient's illness and the potential for mortality and morbidity with a prolonged Intensive Care Unit stay. All questions were answered. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10037**], M.D. [**MD Number(1) 10038**] Dictated By:[**Last Name (NamePattern1) 9280**] MEDQUIST36 D: [**2175-3-3**] 16:09 T: [**2175-3-6**] 07:43 JOB#: [**Job Number 45834**] Name: [**Known lastname 8432**], [**Known firstname **] Unit No: [**Numeric Identifier 8433**] Admission Date: [**2175-2-22**] Discharge Date: [**2175-4-3**] Date of Birth: [**2128-11-22**] Sex: M Service: Discharge date has yet to be determined. This dictation will cover the hospital course from the period of [**2175-3-4**] to the date of [**2175-3-26**]. The remainder of the dictation will be added once his disposition is determined. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory failure: Patient through most of this time period has remained ventilator dependent. The patient's original respiratory failure was presumed to be a combination of both hypoxia as well as hypoventilation secondary to both ARDS/pneumonia as well as a component of abdominal compartment syndrome. Patient initially during this time period was transitioned from assist-controlled ventilation to pressure support, and was initially doing well. However, patient acutely worsened with rising abdominal pressures as by bladder pressures, and the patient was transitioned over to pressure control ventilation. He remained on this ventilatory setting for a period of approximately one week after which he was transitioned back to pressure support ventilation. Patient was gradually weaning on his pressor support parameters until overall course was complicated by ventilator-associated pneumonia secondary to her MRSA. During this time period, the patient's lung compliance worsened significantly, and required increasing levels of pressure support ventilation. During this time period, the patient was diuresed fairly aggressively with intravenous Lasix, and the MRSA pneumonia was treated with both Vancomycin and subsequently linazolid once Mr. [**Known lastname **] developed a rash with the Vancomycin. Over the next approximately 5-6 days, the patient's lung compliance measurements improved gradually, and at the time of dictation, the patient was able to be transitioned over to trache mask ventilation. He is currently on a trache mask with very good oxygenation. The patient currently appears to be retaining CO2 which it remains unclear whether or not this is his baseline, although this does appear unlikely from patient's past medical records. At this time, we are currently lowering patient's PAO2 in attempt to increase his respiratory drive, and hopefully improve his hypercarbia. He is otherwise oxygenating very well and is able to remain off the ventilator for possibly permanently. 2. Pancreatitis: Pancreatitis had largely resolved by enzymes as of the beginning at this time on [**2175-3-4**]. Initially, patient was started on trophic tube feeds with a postjejunal nasogastric tube. He otherwise received most of the nutrition through TPN at this time. The patient underwent CT scans to assess his volumes, progression of his pancreatitis, as well as excessive fluid collection during this time course most notably on [**3-7**] and [**3-20**]. Both of these abdominal CT scans showed increased persistent necrosis of the pancreas, but no evidence of infection. There were large peripancreatic fluid collections that appear to become more progressively more organizing, but nothing necessitating immediate drainage. Throughout this time period, the patient's abdominal pressures as transduced by bladder pressures as well as his clinical examination improved dramatically. As to the end of this time period, the patient was having bowel movements, active bowel sounds, and was able to tolerate gastric feeds after an OG tube. The patient will continue to have occasional chest PTs to assess the progression of his fluid collections and possible pseudocyst formation. Otherwise is believed to have no active surgical issues. His pancreatitis remains largely resolved by his enzymes. 3. Infectious Disease: [**Hospital **] hospital course has been complicated by multiple nosocomial infections. Initially, [**Hospital 1325**] hospital course was complicated by a coag-negative Staph bacteremia, which was believed secondary to due to one of his many lines. Blood cultures from [**3-11**] and 23rd all came back positive for coag-negative Staph. The patient was treated initially with Vancomycin and the lines were removed and changed. Shortly after the surveillance cultures from the 25th, 26th, and [**3-19**], were negative while being treated. During this time period, the patient also developed a MRSA ventilator associated pneumonia. While there were no infiltrates on chest x-ray, the pneumonia was diagnosed by change in quantity and quality of sputum as well as concomitant worsened lung compliances by ventilator. The patient also was treated with Vancomycin with this as well. During this time, the patient appears to have developed a drug reaction to Vancomycin, and was changed to IV linazolid. The MRSA subsequently showed sensitivity to this [**Doctor Last Name 932**]. Patient's course was also complicated by severe sinusitis as diagnosed by a CT scan on [**3-20**]. The patient was evaluated by ENT, who recommended removal of the nasogastric tube as well as conservative management with nasal steroids. Afrin spray and nasal saline flushes to the nares. Patient clinically appears to be improving in terms of his nasal drainage at this time. Hospital course was again complicated by a second episode of coag negative Staph bacteremia on [**3-21**]. The quad lumen catheter tip subsequently also grew back coag negative Staph suggested this also was a second line infection. The patient is currently in the midst of a 14 day course of linazolid to complete treatment of this line sepsis. He is currently being evaluated for possible seeding with a transthoracic echocardiogram. Transesophageal echocardiogram will be considered if bacteria persists. 4. Volume overload: The patient outside of this time period was grossly volume overloaded with over 32 liters positive for the hospitalization. Patient got even further volume overloaded as his hospital course was complicated by hypernatremia requiring large amounts of free water. It was believed that he was becoming intervascularly depleted secondary to his active pancreatitis. However, gradually over the next week, the hypernatremia resolved, and patient was able to be diuresed aggressively with IV Lasix. Over the next two weeks, the patient was diuresed nearly 17-18 liters negative. He is currently diuresing well and gently. He has become mildly contracted by bicarbonate, but his BUN and creatinine had remained excellent, and we are continuing gentle diuresis at this time. 5. Renal: As stated above, renal function has remained excellent throughout this hospitalization. 6. Hematology: The patient has required occasional transfusions to maintain a hematocrit above 25. There is no active source of blood loss, although stools were faintly guaiac positive. He has remained on gastrointestinal prophylaxis, but there is no clear gross single GI episode of bleeding. It is believed that the anemia is most likely due to overall marrow suppression from his overall illness as well as daily phlebotomy. We will continue to transfuse as necessary at this time. 7. Endocrine: The patient initially had a very difficult to control blood sugar given his pancreatitis as well as persistent D5 infusions along with TPN. During his first episode of coag-negative Staph bacteremia, the patient was started on insulin drip to keep blood sugars less than 120 in general. Over the last one week, patient has been transitioned off TPN and onto NPH insulin which has been maintaining his blood sugars under good control at this time. Patient also had a Cortrosyn test during a hypertensive episode in late [**Month (only) 1860**]. This subsequently resolved no frank adrenal insufficiency, although the patient did not have a maximal response to the Cortrosyn stimulation. He was transiently on steroids while this was rapidly tapered off after the largely negative Cortrosyn stimulation test. 8. Electrolytes: The patient's electrolytes were overall complicated mainly by hypernatremia, which resolved with increasing free water. 9. Nutrition: The patient initially was on TPN at the beginning of his hospital course. This was gradually tapered off over the past week, and the patient is currently on a goal rate of tube feeds through orogastric tube. We are currently evaluating whether or not patient will improve significantly enough for a swallowing evaluation or whether he will need a permanent feeding tube such as a PEG. 10. Disposition: The patient is currently improving and mental status improved daily. Sedation has generally has been weaned gradually, and the patient is interactive at this time. We are currently evaluating whether he is able to feed him orally, at which point, he could possibly be discharged both off the ventilator as well as on oral feedings. As he is currently doing well off the ventilator, he may not require hospitalization at a chronic ventilator facility. [**Name6 (MD) 593**] [**Name8 (MD) 304**], M.D. [**MD Number(1) 594**] Dictated By:[**Name8 (MD) 3732**] MEDQUIST36 D: [**2175-3-27**] 13:30 T: [**2175-3-28**] 08:36 JOB#: [**Job Number 8434**] Name: [**Known lastname 8432**], [**Known firstname **] Unit No: [**Numeric Identifier 8433**] Admission Date: [**2175-2-22**] Discharge Date: [**2175-4-3**] Date of Birth: [**2128-11-22**] Sex: M Service: ICU HOSPITAL COURSE: 1. Respiratory - Secretions improved. Diuresis of one to 1.5 liters per day. Continue with decreasing phase of pleural effusion by chest x-ray and by examination initially requiring Lasix but as status improved, he was able to diurese on his own. His respiratory rate gradually declined. He continued on tracheostomy mask not requiring any more ventilator support. For the last ten days of his hospital course, his oxygen saturation remained good and his pCO2 trending downward, last at 50. He was transitioned to a smaller trach. After initially failing a swallow study, transitioned to a #4 LPC Shiley and was also able to tolerate a PMV and was speaking well by the time of discharge. 2. Gastrointestinal - Pancreatitis clinically resolved. He has multiple fluid collections that will be reimaged in one to two weeks by CT scan and will eventually need surgical follow-up for consideration of cholecystectomy. His follow-up should be with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1099**] in four to six weeks. 3. Infectious disease - Last blood cultures were positive on [**2175-3-23**], for coagulase negative Staphylococcus and Enterococcus. His lines were changed. Linezolid was continued and transthoracic echocardiogram was performed to rule out vegetation. His transthoracic echocardiogram was negative with a normal ejection fraction. The same blood cultures later grew out several other species including alpha Streptococcus and a second Enterococcus. Given the multiple species with no clinical change, these were suspected a contaminant He remains on the Linezolid and should complete his course on [**2175-4-5**], for a total fourteen days for his Staphylococcal pneumonia. His sinus drainage which also grew out Staphylococcus and was followed by ENT resolved with antibiotics, saline nasal spray and steroid nasal spray which is discontinued on discharge. 4. Renal - Fluid overload diuresis above. He also had a metabolic alkalosis likely secondary to his diuresis which slowly resolved. 5. Fluids, electrolytes and nutrition - He passed a swallowing study on [**2175-3-31**], and will tolerate thin liquids and solid food. 6. Hematology - Hematocrit remains stable at 28.0 to 30.0 without further need for transfusions in the last ten days of his hospitalization. 7. Endocrine - Blood sugar became progressively easier to control on his insulin which was initially 15 and 15 of NPH with four times a day regular coverage able to be decreased and by the date of discharge, he did not require insulin though fingerstick should continue to be followed. 8. Neuro/psychiatric - His mental status gradually improved after discontinuing the ventilator and allowing him to speak. He was noted to be somewhat confused especially at night though mostly clear during the day. Given the clinical course, this is thought most likely secondary to psychosis. He had been on Ativan as part of a very slow taper and remained on some p.r.n. Ativan which was later discontinued as it was revealed that he had a history of addiction to substance. He had received some Haldol with minimal effect and plans were to try q.h.s. Seroquel at the time of this dictation. DISCHARGE DIAGNOSES: 1. Necrotizing gallstone pancreatitis. 2. Adult respiratory distress syndrome. 3. Methicillin resistant Staphylococcus aureus pneumonia. 4. Sinusitis. 5. Diabetes mellitus secondary to pancreatitis. 6. Hypotension. 7. Coagulase negative Staphylococcal bacteremia. 8. Anemia. 9. Volume overload. 10. Drug rash times two to Imipenem and Vancomycin. 11. Delirium. MEDICATIONS ON DISCHARGE: 1. Linezolid 600 mg p.o. twice a day until [**2175-4-5**]. 2. Metoprolol 100 mg p.o. three times a day. 3. Lisinopril 40 mg p.o. once daily. 4. Albuterol and Atrovent MDI. 5. Heparin subcutaneous 5,000 units three times a day. 6. Stool softeners as needed. FOLLOW-UP: Primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8435**], of [**Hospital1 1947**]. CT scan and surgical follow-up as above. DR.[**Last Name (STitle) 639**],[**First Name3 (LF) 77**] 12-948 Dictated By:[**Name8 (MD) 8436**] MEDQUIST36 D: [**2175-4-3**] 14:29 T: [**2175-4-3**] 17:27 JOB#: [**Job Number 8437**] 1 1 1 R

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41449

Discharge summary

report

Admission Date: [**2137-1-17**] Discharge Date: [**2137-1-30**] Date of Birth: [**2052-12-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: asymptomatic new Atrial Fibrillation Major Surgical or Invasive Procedure: [**2137-1-24**] 1. Redo sternotomy. 2. Aortic valve replacement with a size 25-mm St. [**Male First Name (un) 923**] Epic tissue valve. History of Present Illness: 84 yo Polish speaking man with known coronary disease-status post coronary artery bypass grafting x 4 [**2128**], diastolic heart failure requiring a recent admission to OSH ([**Date range (1) 90165**]) reported doing well since his discharge. He showed up to Dr[**Last Name (STitle) 90166**] office for a two week follow up and newly diagnosed, rate controlled, atrial fibrillation was documented on ECG. Mr.[**Known lastname **] was asymptomatic however was readmitted to OSH for further workup. Cardiac cath performed and transfer to [**Hospital1 18**] for evaluation of aortic valve replacement. Past Medical History: Past Medical History: newly diagnosed atrial fibrillation Coronary Artery disease s/p Coronary Artery Bypass Grafting [**2128**] Diastolic HF (EF=60%) severe Aortic Stenosis Hypertension Hyperlipidemia Diabetes Mellitus II Arthritis Cerebral Vascular accident Hypothyroidism Past Surgical History: Coronary Artery Bypass Grafting [**2128**] Social History: Race: Caucasian Last Dental Exam: Several years ago Lives with: Alone, wife died 2 years ago Occupation: Retired Tobacco:denies ETOH:denies Family History: significant for pulmonary hypertension Physical Exam: Pulse:57 Resp:20 O2 sat: 96% RA B/P Right:129/55 Left: Height:68" Weight: 191# General:AAO x 3 in NAD Skin: Dry [] intact [] Left LE erythema with punctate eschar HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [], well-perfused [] Edema LLE 1+ edema with LE erythema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit: transmitted murmur bilaterally Pertinent Results: Admission Labs [**2137-1-17**] 05:25PM PT-15.5* PTT-42.9* INR(PT)-1.4* [**2137-1-17**] 05:25PM PLT COUNT-145* [**2137-1-17**] 05:25PM WBC-8.4 RBC-3.54* HGB-10.6* HCT-31.6* MCV-90 MCH-30.0 MCHC-33.5 RDW-14.7 [**2137-1-17**] 05:25PM %HbA1c-6.8* eAG-148* [**2137-1-17**] 05:25PM ALBUMIN-3.6 MAGNESIUM-2.5 [**2137-1-17**] 05:25PM LIPASE-30 [**2137-1-17**] 05:25PM ALT(SGPT)-12 AST(SGOT)-29 LD(LDH)-189 ALK PHOS-104 AMYLASE-23 TOT BILI-0.5 [**2137-1-17**] 05:25PM GLUCOSE-55* UREA N-17 CREAT-1.3* SODIUM-139 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-30 ANION GAP-11 Discharge Labs: [**2137-1-29**] 04:30AM BLOOD WBC-7.3 RBC-3.21* Hgb-10.0* Hct-29.4* MCV-92 MCH-31.1 MCHC-33.9 RDW-15.5 Plt Ct-306 [**2137-1-30**] 04:30AM BLOOD PT-29.0* INR(PT)-2.8* [**2137-1-29**] 04:30AM BLOOD PT-19.6* INR(PT)-1.8* [**2137-1-30**] 04:30AM BLOOD Glucose-88 UreaN-28* Creat-1.3* Na-139 K-3.9 Cl-103 HCO3-29 AnGap-11 Radiology Report CHEST (PA & LAT) Study Date of [**2137-1-30**] 8:57 AM FINDINGS: In comparison with the study of [**1-26**], the IJ catheter has been removed. There is still substantial enlargement of the cardiac silhouette in this patient who has undergone prior CABG procedure. The superior mediastinal contents appear to be within normal limits. There may be minimal residual indistinctness of pulmonary markings consistent with mild elevation of pulmonary venous pressure. Basilar atelectasis has substantially improved, and there are several streaks of atelectasis in the left mid zone. Mild blunting of the costophrenic angles are again noted. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.9 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.30 >= 0.29 Left Ventricle - Ejection Fraction: >= 65% >= 55% Left Ventricle - Stroke Volume: 91 ml/beat Left Ventricle - Cardiac Output: 5.47 L/min Left Ventricle - Cardiac Index: 2.90 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 13 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Peak Velocity: *4.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *80 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 48 mm Hg Aortic Valve - LVOT pk vel: 0.90 m/sec Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2 Aortic Valve - Pressure Half Time: 479 ms Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 2.50 Mitral Valve - E Wave deceleration time: 221 ms 140-250 ms Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Moderate symmetric LVH. Top normal/borderline dilated 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. Mildly dilated ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. 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 valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area ~0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: 84year old man found to have new onset atrial fibrillation on routine exam. Admitted to [**Hospital6 3105**] for workup, echocardiogram revealed severe aortic stenosis. He was transferred to [**Hospital1 18**] to evaluate surgical candidacy. After the ussual surgical workup including dental and carotid evaluation as well as treatment for LE cellulitis the patient was brought to the operating room for redo sternotomy and aortic valve replacement. Please see operative report for details. He tolerated the operation well and was transferred from the operating room to the cardiac surgery intensive care unit in stable condition. He was hemodynamically stable in the early post-op period. He woke from anesthesia neurologically intact was weaned from the ventilator and extubated on the day of surgery. All tubes lines and drains were removed per cardiac surgery protocol. He remained hemodynamically stable but was noted to have some delerium and remained in the ICU for that reason. By POD4 he had cleared and was trnasferred to the cardiac stepdown floor for continued care and recovery. Physical therapy was consulted to assist with activities of daily living, strength and endurance. He continued to make progress and on POD6 was discharged to rehabilitation at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 51865**] Health care in [**Location (un) **]. He is to follow up with Dr [**First Name (STitle) **] in 3 weeks. Medications on Admission: Proventil nebs prn, Aspirin 325 mg once daily, Citalopram 20 mg once daily, Colace 100 mg twice daily, Lasix 40 mg once daily, Magnesium Oxide 400 mg twice daily, Metformin 500 mg twice daily, Metoprolol 6.25 three times daily, Nifedipine XL 30 mg once daily, Potassium Chloride 40mEQ twice daily, Simvastatin 40 mg once daily, Losartan-HCTZ 100/12.5 mg once daily, Glyburide 5 mg twice daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily x1 week then 200mg daily. 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing/SOB. 9. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed for sleep/confusion. 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): goal INR 2-2.5 [**1-30**] dose 1mg. 16. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day. 17. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Redo sternotomy/AVR(25mm tissue) PMHx: atrial fibrillation, coronary artery disease s/p Coronary Bypass Grafting [**2128**], Diastolic Heart Failure(EF=60%), severe Aortic Stenosis, Hypertension, hyperlipidemia, Diabetes Mellitus II, arthritis, cerebral vascular accident, hypothyroidism, Appendectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Edema-2+ bilat. Leg leg eccymotoic from pre-op fall 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) 7772**] on [**2137-2-25**] @1:45P Primary Care Dr..SKORUPKA,MIROSLAWA [**Telephone/Fax (1) 34574**] on [**3-14**] @10:45 Please call to schedule appointments with your Cardiologist: Dr [**Last Name (STitle) 90167**], [**First Name3 (LF) **] in [**12-27**] 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 ?????? for Atrial Fibrillation Goal INR 2-2.5 First draw [**1-31**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2137-1-30**]

[ "780.09", "428.0", "V45.81", "427.31", "414.00", "424.1", "428.30", "285.1", "401.9", "682.6", "244.9", "459.81", "250.00", "272.4" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

10466, 10604

6992, 8435

348, 486

10950, 11163

2434, 3006

12004, 12730

1658, 1699

8879, 10443

10625, 10929

8461, 8856

11187, 11981

3022, 6969

1438, 1483

1714, 2415

271, 310

514, 1118

1162, 1415

1499, 1641

70,937

139,748

41542

Discharge summary

report

Admission Date: [**2150-4-1**] Discharge Date: [**2150-4-13**] Date of Birth: [**2078-12-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: Anemia. Major Surgical or Invasive Procedure: None. History of Present Illness: 71 year old [**First Name3 (LF) 8230**] speaking gentleman with past medical history of hypertension, right sided MCA CVA with left sided residual hemiparesis and speech deficit, s/p resection of colocutaneous fistula, transverse [**First Name3 (LF) 499**] resection and resection of gastrocolic fistula at [**Hospital1 3278**] who was recently admitted to [**Hospital1 18**] from [**2150-2-9**] to [**2150-3-6**] for AAA repair and readmitted shortly thereafter with hypernatremia from [**3-10**] to [**3-12**]. He presented with a low HCT. . SUMMARY OF HIS RECENT COURSE: The patient was admitted to [**Hospital1 3278**] in [**1-/2150**] and found to have his G-J tube eroded into his transverse [**Year (4 digits) 499**] through gastrocolic fistula. This was repaired, as well as a colocutaneous fistula. He was sent home but then presented to [**Hospital1 18**] several days later in late [**1-/2150**], was unstable so intubated and taken emergently for AAA repair. He stayed here for a month post op ([**Date range (1) 90361**]) with a complicated course afterwards including a MRSA PNA treated with 14 days of IV vanco, [**Last Name (un) **], acute blood loss anemia requiring PRBC's, hypernatremia, diarrhea with three negative Cdiff's, and new afib. He was readmitted from [**Date range (1) 90362**] for atrial fibrillation. He was noted at a point in between to have a Hct drop, so he was sent in for blood transfusion on [**3-21**] then sent back to rehab. On [**3-25**] he had a G-J tube exchange. He then came to ED in mid [**4-4**] with Hct drop from 30's to 17 and found on CT to have a very large pelvic hematoma. Of note, he may have been abandoned by his family. There are several SW notes to this effect. . He was sent to our ED referred to ED from HCT fall from 29->17. In our ED, he got 2u pRBC, last one at 10:30. Large bore access with 14g and 16g. His only complaint was pain in left leg. EKG: old RBBB, rate 100. Guaic + brown, gellatinous stool. Vascular saw him and recommended CTA that revealed a "14 x 7 cm hetereogeneous hyperdense collection concerning for acute hematoma." Surgery saw him and recommended medicine admission. Past Medical History: Right MCA CVA with residual left hemiplegia in [**2147**] negative Hypertension History of hypernatremia AAA s/p retroperitoneal repair in [**1-/2150**] Large pelvic hematoma in intramural right sigmoid [**Year (4 digits) 499**] with endoluminal extension and bleeding per rectum in [**3-/2150**] . PAST SURGICAL HISTORY: Ex lap for fecal drainage around PEG site: resection of colocutaneous and gastrocolic fistulas ([**Hospital 3278**] Medical Center [**1-30**] - [**2-6**]). Social History: Mandarin speaking only. Sister [**Name (NI) 17470**] and nephew [**Name (NI) **] are HCP. [**Name (NI) **] has been living at [**Hospital3 2558**]. His family has not been guardianship as they were very difficult to get in touch with, concerns of abandonment. Family History: Noncontributory. Physical Exam: Upon admission: General: Cachetic male in no acute distress. Sleeping but easily awoken. HEENT: NC/NT/Anicteric. Temporal wasting. Dry mucous membranes. Very poor dentition. Neck: Supple, JVP @ 8 cm. No thyromegaly, Firm submandibular left sided 1x1cm lesion. Lungs: Rhonchorous at the bases, upper airway sounds. CV: Tachy rate and rhythm. No murmurs or gallops appreciated. Abdomen: Soft, nontender and nondistended. Hyperactive bowel sounds. G-tube in place without erythema around it. Suture intact with no drainage or erythema around the site of AAA repair. GU: Foley in place Rectal Tube in place. Ext: No edema. No rash. wwp, DP 2+ bilaterally. Left arm and leg contractures. Neuro: CN 2-12 intact (PERRLA. EOMI. No facial droop. Midline tongue protusion). Language intact. L arm internally rotate and forearm externally rotated similar to left leg which is internally rotated which is consistent with prior CVA. Increase tone on left UE and LE. [**3-17**] motor strength on right UE and LE. . At discharge: V/S: 97.2 149/90 83 24 97% on RA I/O: [**Telephone/Fax (1) 90363**]/1000+50 maroon tinged stool gen: thin cachetic male awake and alert in NAD HEENT: temporal wasting, sclera anicteric, MMM without lesions Neck: supple, submandibular firm nodule CV: RRR, no m/r/g Resp: bibasilar rhochi to mid lung fields Abd: +BS, soft, nondistended, nontender, soft non pulsatile RLQ mass Ext: wwp, no LE edema, DP 2+ bilaterally, left arm and leg contractures Pertinent Results: Labs upon admission: [**2150-4-1**] 02:35PM BLOOD WBC-9.3 RBC-1.91*# Hgb-6.5*# Hct-18.5*# MCV-97 MCH-33.8* MCHC-34.9 RDW-19.1* Plt Ct-219 [**2150-4-1**] 02:35PM BLOOD Neuts-75.3* Lymphs-15.6* Monos-6.7 Eos-2.1 Baso-0.3 [**2150-4-1**] 04:37PM BLOOD PT-13.2 PTT-34.9 INR(PT)-1.1 [**2150-4-1**] 02:35PM BLOOD Glucose-113* UreaN-28* Creat-0.7 Na-138 K-4.0 Cl-100 HCO3-27 AnGap-15 [**2150-4-3**] 06:10AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3 [**2150-4-1**] 07:59PM BLOOD Hgb-7.1* calcHCT-21 [**2150-4-2**] 01:38PM BLOOD Lactate-1.1 Labs prior to discharge: [**2150-4-2**] 03:05AM BLOOD Hct-21.2* [**2150-4-2**] 06:30AM BLOOD Hct-22.1* [**2150-4-2**] 01:10PM BLOOD Hct-27.0* [**2150-4-3**] 06:10AM BLOOD WBC-9.1 RBC-3.27*# Hgb-10.1*# Hct-29.1* MCV-89# MCH-30.9 MCHC-34.7 RDW-19.9* Plt Ct-204 [**2150-4-4**] 07:00AM BLOOD WBC-10.7 RBC-3.45* Hgb-10.7* Hct-31.7* MCV-92 MCH-30.9 MCHC-33.6 RDW-19.3* Plt Ct-255 [**2150-4-10**] 05:58AM BLOOD WBC-5.5 RBC-3.23* Hgb-10.0* Hct-29.5* MCV-91 MCH-31.0 MCHC-33.9 RDW-17.5* Plt Ct-325 [**2150-4-11**] 05:53AM BLOOD WBC-9.8# RBC-3.25* Hgb-10.0* Hct-29.4* MCV-91 MCH-30.7 MCHC-33.9 RDW-17.7* Plt Ct-307 [**2150-4-12**] 04:10AM BLOOD WBC-6.3 RBC-3.18* Hgb-10.0* Hct-29.5* MCV-93 MCH-31.6 MCHC-34.1 RDW-17.6* Plt Ct-310 [**2150-4-10**] 05:58AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-138 K-4.2 Cl-103 HCO3-26 AnGap-13 [**2150-4-10**] 05:58AM BLOOD Albumin-3.0* Calcium-8.9 Phos-3.8 Mg-2.3 [**2150-4-9**] 06:10AM BLOOD Triglyc-134 [**2150-4-8**] 11:30PM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND Imaging: [**2150-4-9**] left femur xray: A single frontal projection is provided. Distal femur is not completely included in the field of view. No gross osseous destructive lesion is seen. Mild degenerative changes at the left hip joint are seen. A catheter extends towards the upper abdomen and the [**Known firstname **] is not included in the field of view, small area of calcification is demonstrated within the soft tissues adjacent to the ischial tuberosity that likely reflects calcification in the proximal hamstrings due to an enthesopathy. Correlation with prior CT torso from [**2-9**], [**2149**] demonstrates this was also present on prior exam and is not new findings. No fracture is seen within the limits of single projection. IMPRESSION: No acute abnormality or aggressive appearing bone lesion is seen. [**2150-4-9**] CXR: 1. Left PICC ends in the low SVC. 2. Improved pulmonary vascular congestion. 3. Minimal bibasilar atelectasis. [**2150-4-6**] angiography: 1. Superior mesenteric angiogram demonstrating normal branching pattern with no evidence of extravasation or abnormal-appearing vessels in the distribution of the SMA. 2. Large renal artery angiogram demonstrating no abnormal contrast extravasation or vascular malformations noted. IMPRESSION: Superior mesenteric arteriogram and its marginal branch angiogram demonstrating no abnormal extravasation, vascular malformations or pseudoaneurysms. No intervention was performed. [**2150-4-4**] CTA abdomen/pelvis: 1. Large right pelvic hematoma, which appears to be intramural within the sigmoid [**Month/Day/Year 499**] with endoluminal extension. There is also high-density fluid identified in the rectum, consistent with a history of bright red blood per rectum. Also, there is a punctate focus of arterial enhancement seen along the medial aspect of this hematoma, suggestive of a pseudoaneurysm. This was not evident on the prior exam. 2. Extensive atherosclerosis, including changes from previous AAA repair. There is a residual infrarenal aneurysm which is stable in appearance and measures up to 4.1 cm. 3. Calcified gallstones along the probable 8 mm gallbladder polyp. 4. Bilateral renal cortical microcysts, findings which suggest a history of previous long-term lithium therapy. [**2150-4-2**] abdominal ultrasound: A large heterogeneous collection measures approximately 11 x 8 x 5 cm, compared to the prior CT measurement of 14 x 8 x 10 cm, without evidence of interval enlargement allowing for the difference of technique. The collection is very heterogeneous in echogenicity but without any significant fluid component, compatible with an organized hematoma. Small vessels are noted in the periphery of this collection, but there is no vascular flow through the collection. IMPRESSION: Large organized hematoma in the right lower quadrant, without internal vascular flow. No evidence of interval increase in size. . [**2150-4-1**] abdominal CTA: 1. Large pelvic hematoma of unclear source. 2. Post-repair of an abdominal aortic aneurysm without evidence of endoleak or other complication. 3. Moderate thickening of the sigmoid [**Last Name (LF) 499**], [**First Name3 (LF) **] represent colitis, possibly infectious, inflammatory, or ischemic. 4. PEG tube and catheter extending into the proximal jejunum appears unremarkable. 5. Bibasilar dependent consolidations likely atelectasis and aspiration. 6. Bilateral renal cortical microcysts could reflect lithium-induced changes. 7. Cholelithiasis. 8. Stable aneurysmal dilation of the abdominal aorta at the level of the hiatus as well as the right internal iliac artery. 9. Possible early skin changes in the region of the gluteal cleft, which may indicate early decubitus ulcer formation. Clinical correlation is advised. Brief Hospital Course: 71 yo [**First Name3 (LF) 8230**] speaking male, with history of right MCA CVA in [**2147**], dysphagia s/p GJ tube placement, s/p retroperitoneal AAA repair in [**1-/2150**], with recent G-J tube exchange admitted with acute hematocrit drop found to have a large pelvic hematoma. # Pelvic hematoma: Large mesenteric abdominal/pelvis hematoma found on CTA of abdomen/pelvis upon admission. Vascular surgery was consulted who felt this was not a complication of his AAA repair. Guaiac positive brown stool was noted upon admission which the patient has not previously had. He received four units of packed RBC's during admission at which point his blood levels stabilized at 28 to 30. He had large puddles of BRBPR on [**4-4**] necessitating MICU transfer. His hematocrit was stable throughout the MICU stay. Repeat CTA done during his bleeding episodes revealed extension of the hematoma into the sigmoid [**Month/Year (2) 499**]. This was likely a result of tracking of the hematoma. He went to IR were angiogram did not show extravasation or pseudoaneurysm and therefore embolization was not able to be done. GI was consulted but was unable to perform a flex [**Month/Year (2) 65**] given the high risk or perforation or disruption of the hematoma. Surgery was consult and noted that the patient was not a surgical candidate for colectomy and recommended percutaneous IR guided drainage. However, his Hct was stable for over a week, with continued BRBPR and diarrhea, so the hematoma was draining itself through the sigmoid [**Month/Year (2) 499**] and rectum. Plan for now is conservative management. He will be d/c to LTAC for close monitoring and TPN via PICC for 1-2 weeks. He will need to have repeat CTA to reevaulate the size of the hematoma and whether it is reabsorbing. He will need drainage if abdominal hematoma is not reabsorbing on its own. He currently has a Flexiseal in place given dark, liquid stool; however this should be reassessed and removed once liquid stool has abated. # Strongyloides: Chronic diarrhea of unknown etiology. Stool studies sent in light of BRBPR with chronic diarrhea. Strongyloides found in stool in two of three cultures so far. Completed treatment with ivermectin 200mcg/kg for two doses. Stool afb is also pending at the time of discharge. # History of CVA with afib: CHADS2 = 4. Previously on aspirin as secondary prophylaxis for CVA. Aspirin was held indefinitely given risk of bleed is large, and GI did not feel the benefit of ASA to outweigh the risk of bleeding. # Malnutrition: Previously feed with tube feeds via G-J tube. Cannot use enteral feeding in light of hematoma and sigmoid communication. He will be fed with TPN via a PICC line until hematoma has reabsorbed. Decubitus ulcers on testicles and sacrum. Condom catheter was placed and Foley removed. # Hyponatremia: Likely hypovolemic initially. Sodium normal at 136 today. This responded to normal saline boluses and TPN. # Left leg pain: Chronic pain thought to be secondary to contractures s/p CVA in [**2147**]. Requiring more opiates, concern for bony lesion, however plain films are negative. Pain more controlled with lidoderm patch, standing tylenol, and pt started on MS Contin 15mg [**Hospital1 **]. Pain should be assessed (able to understand English word "pain") and pain regimen adjusted prn. # Code Status: DNR/DNI confirmed with patient, HCP, and nephew via [**Name (NI) 8230**] interpreter. Medications on Admission: Aspirin 325 Lansoprazole 30 Metop 12.5 [**Hospital1 **] Ipratropium q6 Lidoderm patch fibersource tubefeeds which he tolerates well at goal rate of 65 cc/hr with 1-2 loose BM a day Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Thirty (30) ml PO TID (3 times a day). 3. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) application Mucous membrane [**Hospital1 **] (2 times a day). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to left thigh. 5. oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) ml PO every four (4) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Abdominal Hematoma communicating to the Sigmoid [**Hospital1 **] Secondary Diagnosis: s/p CVA, HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were admitted for blood loss. You developed a hematoma in your abdomen that eroded into your sigmoid [**Hospital1 499**]. Your blood levels have been stable. This hematoma has been draining on its own, as evidence by your bloody diarrhea. Because of the connection between the hematoma and the bowel, you need to be fed through your IV. You will have a repeat CT scan of your abdomen in 2 weeks to re-evaluate the hematoma. In addition, you were found to have an infection in your stool called strongyloides. This was treated with two doses of Ivermectin. The following changes were made to your medication list: STOP aspirin STOP Metoprolol 12.5 [**Hospital1 **]. The doctors at the rehab should reassess whether to continue this or not based on your blood pressures. STOP Ipratropium nebs q6 hrs START Clorhexedine gluconate mouthwashes Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 7841**] [**Name (STitle) 7842**] at the [**Hospital3 2558**] after discharge, you can call her office at: Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 608**] Fax: [**Telephone/Fax (1) 23926**]

[ "707.03", "707.22", "276.1", "127.2", "401.9", "459.0", "261", "285.1", "438.20", "438.10", "276.8" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.6", "38.93", "88.47" ]

icd9pcs

[ [ [] ] ]

14495, 14556

10134, 13582

311, 319

14720, 14720

4821, 4828

15815, 16244

3305, 3323

13813, 14472

14577, 14577

13608, 13790

14855, 15792

2854, 3011

3338, 3340

4354, 4802

264, 273

347, 2510

14684, 14699

14597, 14662

4842, 10111

14735, 14831

2532, 2831

3027, 3289

6,432

161,911

18966+19012

Discharge summary

report+report

Admission Date: [**2140-8-4**] Discharge Date: [**2140-8-9**] Date of Birth: [**2079-8-1**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with a history of catatonic schizophrenia, questionable history of cardiomyopathy who was doing well at baseline until the night prior to admission when noted to be tachypneic and febrile to 102.7 degrees. Chest x-ray showed a lower lobe infiltrate. The patient was started on levofloxacin. Over the next day the patient was noted to have increased lethargy with onset in the morning of oxygen saturations of 84-87% on room air and 96% on three liters. He was also found to be tachypneic with a heart rate up into the 130's. He was transferred over to the Emergency Department. When the EMS staff saw him his vital signs were noted to be heart rate of 105, respirations 46, blood pressure in the 90's over 50's and he was breathing 100% on nonrebreather. He received three liters of intravenous fluids..... [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Last Name (NamePattern1) 3809**] MEDQUIST36 D: [**2140-8-8**] 14:42 T: [**2140-8-8**] 15:08 JOB#: [**Job Number 51839**] Admission Date: [**2140-8-4**] Discharge Date: [**2140-8-9**] Date of Birth: [**2079-8-1**] Sex: M Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with a history of catatonic schizophrenia and a questionable history of cardiomyopathy who was doing well until the night prior to admission when he was noted to be tachypneic and febrile to 102.7 degrees. Of note, the patient lives at a nursing home. At the nursing home his white count was found to be 18 in addition to the high temperature and he had a left lower lobe infiltrate upon chest x-ray. He was started on levofloxacin at the nursing home. Overnight at the nursing home to the day of admission the patient was found to have increasing lethargy. He was hypoxic satting 84 to 87% on room air. He was subsequently transferred to the Emergency Department for further care. In the Emergency Department his systolic blood pressures were found to be in the 70's. He was given three liters of normal saline and started on Neo-Synephrine for pressure support. From the Emergency Department he was transferred to the Medical Intensive Care Unit where he remained on Neo-Synephrine for one day and was subsequently called out to the floor after that. PERTINENT LABS FROM ADMISSION: His creatinine was found to be 2.6. His liver enzymes were elevated. His ALT was 67, his AST was 89. His albumin was low at 3.1. He had an INR of 1.6. PHYSICAL EXAMINATION: His temperature was 99. His blood pressure was 90/50, heart rate of 120. His respirations were 26. He was breathing 100% on a nonrebreather. In general, he was lying in bed in no acute distress, somewhat diaphoretic. His pupils were pinpoint. He would not follow commands. His conjunctivae were clear. He was tachypneic but a regular breathing rate. There were no murmurs, rubs or gallops. His neck was supple. There were a few crackles in the lungs and no rhonchi sounds. His abdomen was soft, non-tender. Bowel sounds were present. His extremities were warm with no edema. He had 2+ pulses bilaterally. On neuro examination, he responded only to pain. He was very non-verbal. Unable to test most of the rest of the examination. HOSPITAL COURSE: The patient was weaned off Neo-Synephrine and his blood pressure remained stable for the duration of his admission. He was started on Flagyl in addition to levofloxacin for presumed aspiration pneumonia. His hematocrit dropped on hospital day two to the high 20's and remained at that point for the duration of his admission up until [**8-8**] when the patient received two units of packed red blood cells. The patient remained intermittently febrile running low grade temperatures to the 100.2, 100.4 range. A speech and swallow evaluation was obtained on hospital day four and was noted to state that the patient was able to eat soft solids, drink thin liquids and required that his pills be crushed. His mental status continued to be nonresponsive to verbal commands, only responding to pain. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: Pneumonia. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg q. day day four of 14. 2. Flagyl 500 mg t.i.d. He is currently on day four of 14. 3. Heparin 5000 units subcu t.i.d. 4. Senna. 5. Calcium carbonate. 6. Colace. 7. Docusate. 8. Multivitamin. FOLLOW-UP PLANS: The patient should follow up with primary care physician, [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) 5762**], within one week. [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Last Name (NamePattern1) 3809**] MEDQUIST36 D: [**2140-8-8**] 14:56 T: [**2140-8-8**] 15:13 JOB#: [**Job Number 51931**]

[ "285.29", "425.4", "038.9", "507.0", "584.9", "295.20", "593.9", "599.0", "785.59" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4390, 4402

4425, 4648

3532, 4344

2765, 3514

4359, 4368

4666, 5095

1458, 2742

2,002

144,217

693

Discharge summary

report

Admission Date: [**2120-11-23**] [**Month/Day/Year **] Date: [**2120-11-26**] Date of Birth: [**2067-8-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: 53 M with CAD, ischemic CM with depressed systolic EF (20%), diabetes and h/o PE on anticoagulation who presented to ED with LE weakness and feeling unwell where he was found to be in ARF complicated by hyperkalemia. States that he started to feel unwell a few days ago. Has been suffering with frequent loose bowel movements a day during the past 4 days; no associated N/V, change in appetite, abd pain or fevers. No melena or BPR. No sick contacts or recent travel. No change in dietary habits. No Abx exposure since [**2120-8-25**]. Today he felt particulary week and clumsy. Because of which he was unable to arise from his W/C and fell. Pt recently seen in heart failure clinic and was placed on a larger dose of lisinopril. He denies any chest pain, for which he never suffers from. He has no SOB or marked orthopnea. He LE edema is much improved since his admission in [**Month (only) **]. He does not know his current and/or dry weight. Pt reports good UOP without change in quality or quantity. No recent illnesses or sore throat. Changes in medications include increased ACEi dose. Pt with leg pain consistent with his neruopathy but difficult to separate from Sx's secondary to claudication. Pt transferred to ICU for management of ARF and hyperkalemia. Upon arrival to the ICU he feels fatigued with back and leg discomfort after his long stay in the ED. . ED Course: Afeb, 107/97, 79 32 98% RA. Given Insulin/D50, CaGluc, Kayexelate, lasix, 3 amps NaHCO3, attempt at dialysis catheter unsuccessful. Past Medical History: 1. Type 2 diabetes (insulin dependent x26 years) with associated neuropathy and Charcot foot deformities. 2. History of pulmonary embolism, on Coumadin. 3. Chronic renal insufficiency (1.1-1.3) 4. Coronary artery disease, myocardial infarctions in the past, with prior stenting. Cardiac catheterization in [**2116**] showed 50% LAD, 50% left circumflex. Catheterization in [**2-/2119**], 99% LAD, 70% OM1, RCA not imaged and thought to be occluded, patient had two drug-eluting stents placed to the LAD. The patient underwent another catheterization in [**3-/2119**] with 70% stenosis of the OM1 and a CYPHER stent was placed at that time. 5. Ischemic cardiomyopathy with congestive heart failure and LVEF of 20%. Most recent echocardiogram from [**6-/2120**] reveals left ventricular dilatation with LVDD at 6.4 cm, ejection fraction 20%, severe global LV hypokinesis, and no significant valvular disease, with moderate pulmonary hypertension. 6. h/o osteomyelitis and nonhealing foot ulcers 7. recent mycobacterial skin infection (completed ABx course 2 mo ago) 8. AFib Social History: The patient lives alone in senior housing. Social alcohol about twice per week. Denies tobacco but has a 45-pack-year history, quit 20 years ago. No illicit drug use. Currently on disability and mostly w/c bound given his Charcot feet/Neuropathy. The patient is driving, has a handicap ramp, and hand controls for his car. Family History: Father died from a bad heart. Mother is still alive in her 80s. Siblings, without significant cardiac history. No renal disease. Physical Exam: VS: 95.6, 102, 113/69, 23 100% RA . PE: gen- sitting comfortably in bed, NAD, tachypneic but no increased WOB or distress heent- perrl, eomi, anicteric, op wnl, mmm neck- supple, no JVD appreciated at 60 deg cvs- distant but tachycardic and regular, unable to appreciate any murmurs or abnl heart sounds lungs- CTAB abd- obese, soft, NT/D, +BS ext- trace LE edema L>R, associated erythema (chronic per pt). Right foot dressed, unable to appreciate good DP on left. Feet cool but remaining skin exam WWP. Right groin with 1+ Fem pulse no bruit or hematoma neuro- AO3, cns intact, strngth [**3-29**], sensation to pin decreased in LE bilaterally, appropriate and follows commands Pertinent Results: [**2120-11-23**] WBC-7.5# RBC-6.16# Hgb-15.4# Hct-46.8# MCV-76* MCH-25.0* MCHC-32.9 RDW-17.6* Plt Ct-257 Neuts-86.6* Lymphs-5.8* Monos-6.0 Eos-1.1 Baso-0.7 [**2120-11-24**] WBC-8.7 RBC-6.05 Hgb-15.2 Hct-44.7 MCV-74* MCH-25.1* MCHC-34.0 RDW-17.8* Plt Ct-248 [**2120-11-25**] WBC-5.5 RBC-5.36 Hgb-13.2* Hct-40.7 MCV-76* MCH-24.7* MCHC-32.5 RDW-17.8* Plt Ct-208 [**2120-11-26**] WBC-4.5 RBC-5.04 Hgb-12.7* Hct-38.6* MCV-77* MCH-25.3* MCHC-33.0 RDW-17.6* Plt Ct-180 . [**2120-11-23**] PT-20.7* PTT-34.9 INR(PT)-2.0* [**2120-11-26**] PT-20.0* PTT-34.3 INR(PT)-1.9* . [**2120-11-23**] Glucose-379* UreaN-114* Creat-2.8*# Na-118* K-8.5* Cl-90* HCO3-14* AnGap-23* [**2120-11-24**] Glucose-320* UreaN-112* Creat-2.4* Na-125* K-6.5* Cl-93* HCO3-18* AnGap-21* [**2120-11-24**] Glucose-119* UreaN-106* Creat-2.5* Na-132* K-4.8 Cl-97 HCO3-21* AnGap-19 [**2120-11-25**] Glucose-144* UreaN-95* Creat-1.9* Na-132* K-4.7 Cl-101 HCO3-22 AnGap-14 [**2120-11-26**] Glucose-118* UreaN-78* Creat-1.6* Na-135 K-4.2 Cl-100 HCO3-24 AnGap-15 Calcium-8.5 Phos-4.0# Mg-3.0* . [**11-23**] CXR: 1. Mild CHF and small bilateral pleural effusions. . [**11-23**] Non contrast Head CT: 1. No hemorrhage or mass effect. Brief Hospital Course: 53yo male with CAD, DM, CHF, and chronic renal insufficiency transferred from the MICU after being initially admitted for acute renal failure with hyperkalemia both of which are now improved. . PLAN: 1. Acute Renal Failure: Patient was initially admitted with hyperkalemia secondary to acute renal failure with creatinine elevated to 2.8 from baseline of [**11-25**].2 thought most likely secondary to increased ACEI dose in the setting of hypovolemia from diarrhea and continued diuretics. Creatinine has improved to 1.9 from 2.8 on admission with roughly 700cc positive for LOS. Pt. did not receive dialysis during stay. Continued lisinopril at 1/2 dose for now. Holding lasix and spironolactone. Patient will follow-up with PCP within the next 1-2 days after [**Date Range **] to decide whether to restart lasix and spironolactone. Renally dosed medications. Continued telemetry. Renal followed patient during hospitalization. Followed Creatinine and urine output. . 2. CHF: Patient with known ischemic cardiomyopathy with EF 20% and followed by Dr. [**Last Name (STitle) 911**] in cardiology. Continue to hold lasix (home dose is lasix 160mg PO daily) until renal function and BP stabilize, will need to be restarted as outpatient. Continue low-dose ACEI with lisinopril at 5mg (1/2 dose), beta blocker with low-dose carvedilol 3.125mg PO daily. Continued daily weights and low sodium diet. Patient has outpatient follow-up for consideration of ICD placement with Dr. [**Last Name (STitle) **] on [**2120-11-29**]. . 3. Tachypnea: Upon admission, patient with tachypnea, though most likely a compensatory response [**12-27**] metabolic acidosis from renal failure. Now improved with improving renal function. . 4. Asymptomatic Hyponatremia: Na 118 upon admission thought most likely secondary to ARF and volume depletion and diuretics use. Has been improving steadily since admission with Na 135 on day of [**Month/Day (2) **]. . 5. Coronary Artery Disease: No evidence of active ischemia. Continued beta-blocker, high dose statin, ASA. Gave 1/2 dose ACEI given ARF. . 6. Diabetes Mellitus: Continued patient's home insulin regimen of lantus 72 units at bedtime with insulin sliding scale. Monitored finger sticks. . 7. Depression: continued home dose of prozac. . # FEN: Diabetic, heart-healthy, low Na, renal diet. Continued MVI, iron daily, folate 1mg daily. . # Proph: Continued H2 blocker, anticoagulated on coumadin. Maintained contact precautions. [**Name2 (NI) **] bowel regimen given recent diarrhea. . # CODE: FULL CODE Medications on Admission: Aspirin 325 mg daily; multivitamin daily; iron daily; Prozac 40 mg daily; folic acid 1 mg daily; Cozaar 25 mg daily; calcitriol 0.25 mcg daily; Zantac 150 mg twice a day; Lasix 160 mg daily; Lipitor 80 mg daily; lisinopril increased to 10 mg daily; Coumadin spironolactone 25 mg daily; Coreg 3.125 mg twice a day; potassium 20 mEq twice a day; Ambien as needed to sleep; Lantus insulin 72 units at bedtime with Humalog insulin per sliding scale Combivent inhalers four times a day; vitamin C daily. [**Name2 (NI) **] Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Carvedilol 6.25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO qSunTuWFSat. 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours. 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 13. Lantus 100 unit/mL Solution Sig: Seventy Five (75) units Subcutaneous at bedtime. 14. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous as directed: please take as your prior sliding scale. 15. Outpatient Lab Work CBC, Chem-10, BUN, creatinine lab check in 2 days [**Name2 (NI) **] Disposition: Home [**Name2 (NI) **] Diagnosis: Primary: 1. hyperkalemia 2. acute renal failure 3. chronic renal failure 4. type II diabetes 5. coronary artery disease. 6. atrial fibrillation Secondary: 1. peripheral neuropathy 2. history of pulmonary embolism 3. history of osteomyelitis and nonhealing foot ulcers 4. history of mycobacterial skin infections [**Name2 (NI) **] Condition: stable. ambulates with wheelchair (at baseline). Acute renal failure resolving. [**Name2 (NI) **] Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . 1. Your medications have been changed due to your acute episode of renal failure and high potassium. Please take your medications as below and review your medications with your primary care physician. [**Name10 (NameIs) **], DO NOT continue to take potassium, lasix, aldactone, cozaar until speaking with your physician. . 2. If you experience any fevers, chills, weakness, nausea, vomiting, chest pain, shortness of breath or other worrisome symptoms please seek medical attention. Followup Instructions: 1. please call your primary care physician for [**Name Initial (PRE) **] follow up appointment and to review your medication changes. [**Last Name (LF) **],[**First Name3 (LF) **] Y [**Telephone/Fax (1) 5194**] . 2. Please call the [**Hospital **] clinic to make an appointment with Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**] in 2 weeks. ([**Telephone/Fax (1) 817**]. . 3. You are already set up for the following appointment: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2120-11-29**] 1:00 Completed by:[**2120-11-26**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5423, 7980

337, 344

4201, 5356

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3355, 3487

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Discharge summary

report

Admission Date: [**2188-6-18**] Discharge Date: [**2188-6-24**] Date of Birth: [**2138-9-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: right lower lobe squamous cell cancer Major Surgical or Invasive Procedure: right thoracotomy right pneumonectomy History of Present Illness: Mr. [**Known lastname 13670**] is a 49-year-old gentleman with a biopsy-proven right lower lobe squamous cell carcinoma, metastatic to the N1 modes but with negative mediastinoscopy. Past Medical History: PSYCHIATRIC HISTORY: -Patient has never been in psychiatric tx. He does not have a Psychiatrist or therapist, has never been hospitalized, denies suicidal attempt, and homicidal/assaultive behavior. . PAST MEDICAL HISTORY -HTN -Hypercholesteremia -Eosinophilia - per PCP, w/up for Strongyloides - prescribed tx, unsure of compliance . SUBSTANCE ABUSE HISTORY -Smoking cigarrettes - quit smoking 6 years ago -Etoh - some weekends; 4-5 beers; denies blackouts, w/d sx, and detox -Denies IV and illicit drug use Family History: non- contributory Physical Exam: general: well appearing male in NAD. HEENT: unremarkable Chest: right thoracotomy incision well approx. mild erythema, no drainage. COR: RRR S1, S2 abd: soft, round, NT, ND, +BS extrem: no C/C/E neuro: intact Pertinent Results: TWO-VIEW CHEST [**2188-6-22**] COMPARISON: [**2188-6-21**]. INDICATION: Status post pneumonectomy. Patient is fully upright on current study and was likely semi-upright on the most recent study, limiting comparison. The right pneumonectomy space is mostly fluid filled, with a prominent air-fluid level demonstrated at the level of the aortic arch, corresponding to the sixth posterior right rib level. Multiple pockets of gas are again demonstrated below this level. Allowing for positional differences, there has probably not been a substantial change in the amount of fluid within the pneumonectomy space. Within the left lung, minor atelectasis is present. Subcutaneous emphysema is again demonstrated in the right chest wall and supraclavicular region. IMPRESSION: Right pneumonectomy space is mostly fluid filled, with air-fluid level at right sixth posterior rib level. Brief Hospital Course: pt was admitted an dtaken tot he OR for right thoracotomy , right pneumonectomy. OR course was uneventful. A chest tube wa splaced in the right chest to prevent mediastinal shift and was removed on POD#1. An epidural was placed for pain control. pt was admitted to the ICU for for pulmonary and hemodynamic monitoring. On POD#1 pt was transferred form the ICU to the general surgical floor for ongoing post op care and PT. The epidural was split and a dilaudid PCA was added for more complete pain control. On POD#3 pt had episode of orthostatic hypotension. HCT Epidural was d/c'd on POD#3 and started on po pain med w/ good relief. Pt progessed well w/ PT and oxygen sats were 98% on 2 liters and 92% on roomair. Pt failed voiding trial x1 and was straight cath'd- subsequently, pt was able to void. Mild incisional erythema was noted on POD#5 and 7 day course of keflex was started. d/c'd to home w/ supportive services. Medications on Admission: Lisinopril 10mg, diazepam, Celexa 40mg, and Tylenol Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* 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:*1* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*80 Tablet(s)* Refills:*0* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: right pneumonectomy Depression, HTN, hypercholesterolemia Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest pain, shortness of breath , fever, chills, reness or drainage from your incision site or any symptoms that concern you. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] on the [**Hospital Ward Name **] clinical center [**Location (un) **] on [**7-3**] at 3:30. Please arrive 45 minutes prior to your appointment and report to the [**Location (un) **] radiology for a chest XRAY. Completed by:[**2188-6-25**]

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icd9cm

[ [ [] ] ]

[ "03.90", "33.23", "32.49", "40.3" ]

icd9pcs

[ [ [] ] ]

4241, 4298

2332, 3259

359, 399

4400, 4407

1425, 2309

4661, 4971

1162, 1181

3361, 4218

4319, 4379

3285, 3338

4431, 4638

1196, 1406

282, 321

427, 612

634, 1146

31,005

120,863

9663

Discharge summary

report

Admission Date: [**2106-1-25**] Discharge Date: [**2106-2-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: lightheadedness Major Surgical or Invasive Procedure: Ablation of ventricular tachycardia via epicardial approach History of Present Illness: 85 M h/o MI '[**82**] (no PTCA/CABG), VT (~[**2098**]), s/p ablation x 2 ([**2099**] as part of study, [**2101**] [**2-27**] syncope), HTN, hyperlipid, in USOH until ~9AM [**1-25**], when he developed "indigestion" (central chest burning) a/w upper jaw discomfort, no SOB, n/v, diaphoresis, palpitations, but also noted LH, so checked his BP, which revealed HR 130s, SBP 102/60s, so he activated EMS and was taken to OSH. . Initial EKG @ 4PM showed VT, HR=120s, CK 103, CKMB 3.2, Trop 0.05, BUN/Cre 27/2.0, initially some concern for STEMI, however seen by cardiology, and not felt to be the case. Pt continued to have +SOB and [**5-6**] CP @ OSH, however LH had resolved. He was given amio iv x 1, the started on amio gtt, and given lidocaine x 1, with persistent VT. . Admitted to ICU, with persistent VT, underwent DCCV for sustained VT wiith SBP 90s at ~8PM [**1-25**], with breif reversion to an av-paced rythym for ~1hr per pt and OSH EKG, however rythym back to VT. Pt subsequently ([**1-26**] early AM) received lidocaine 100mg bolus x 1, then lidocaine 90mg x 1 with HR down to 115s. Neo gtt started [**2-27**] hypotension. Pt then given 5mg IV lopressor ~6AM for unclear HR, BP without benefit, and received 500cc IVF bolus. . . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence chest pain prior to episode yesterday, no episodes of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, . pt notes stable DOE with climbing 1 flight of stairs, and 4 episodes of "total body fatigue" lasting 3-4hrs over past 6 weeks. He denies other any syncopal episodes since last VT ablation ~3 yrs ago. Past Medical History: - MI - [**2082**] - no ptca/cabg. EF=20% 4/02. - VT - [**2098**] - s/p ICD placement, BiV upgrade, see below. - VT ablation [**2099**], [**2101**] - HTN - hyperlipidemia - CKD (baseline 1.9-2.0 [**2-27**] vit d intoxication?) - peripheral neuropathy - awaiting neurology appt next week for w/u. - h/o gout - AAA (4.4 cm, dx [**7-3**], stable on repeat imaging 12/07 per pt) - GERD - h/o appedectomy - h/o inguinal hernia repair bilaterally Social History: Social history is significant for the absence of current tobacco use. Pt smoked 1ppd x 25 yrs, quit 40yr ago. There is no history of alcohol abuse. Currently drink 1beer/day. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: 97.5 130 100/80 17 98%RA on neo gtt @ 0.17, amio gtt 1/hr. Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of [**7-4**] cm at 45 degrees CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, split s2, ?s3. No S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. ICD/PM in place in RUQ of chest. c/d/i. Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c. trace B LE edema. L UE hand edema at site of IV placement. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2106-1-25**] 12:59PM PLT COUNT-130* [**2106-1-25**] 12:59PM WBC-7.9 RBC-4.67 HGB-15.5 HCT-44.2 MCV-95 MCH-33.3* MCHC-35.1* RDW-13.4 [**2106-1-25**] 12:59PM CALCIUM-8.4 MAGNESIUM-2.3 [**2106-1-25**] 12:59PM ALT(SGPT)-14 AST(SGOT)-21 CK(CPK)-77 ALK PHOS-49 [**2106-1-25**] 12:59PM GLUCOSE-140* UREA N-24* CREAT-1.9* SODIUM-141 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15 [**2106-1-25**] 04:54PM URINE MUCOUS-RARE [**2106-1-25**] 09:02PM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-2.1 [**2106-1-25**] 09:02PM CK(CPK)-73 [**2106-1-25**] 09:02PM UREA N-25* CREAT-1.9* SODIUM-142 POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15 Ablation A total of 2 LV epicardial ablations were performed for a total of 81 seconds. Conclusions 1) Ablation of late potentials on LV epicardial surface performed via epicardial approach. 2) Unable to induce clinical VT. Brief Hospital Course: 84 M h/o CAD, VT s/p ICD, ablation x 2 ([**2098**],[**2101**]), admitted to OSH with CP and VT s/p DCCV x 1 with persistent VT. . # Ventricular tachycardia - h/o VT s/p ablation x 2, transferred from OSH after amiodarone load and lidocaine x 1 with persistent slow VT, hemodynamically stable. s/p RAMP pacing by EP fellow and attg on [**1-26**], with subsequent resolution of VT. S/p ablation- underwent minimal epicardial ablation but could not induce VT to undergo endocardial ablation. Had some hemopericardium post procedure. Therefore drain left in place and remained intubated overnight. The following day drain was removed and patient was successfully extubated without difficulty. He remained [**Hospital1 **] V paced for the duration of his stay with no further episodes of ventricular tachycardia. Discharged on amiodarone. . # CAD/Ischemia: no evidence of ischemia. No EKG changes suggestive of ischemia. - continued on aspirin and coreg. . # Pump: pt euvolemic on clinical exam; not in decompensated heart failure. Repeat ECHO showed moderately depressed (LVEF= 30 %) secondary to akinesis of the inferior and posterior walls. - continued home regimen of digoxin 0.1875. - continue home regimen of lasix 40mg po bid . # Valves: 1+ aortic regurgitation per most recent ECHO done on this admission; trivial MR/TR. . # Right femoral hematoma: patient completed Right groin ultrasound notable for AV fistula. Evaluated by vascular surgery who felt as no active issues at this time and patient should be followed up in the outpatient setting. . # HTN: normotensive currently, continued home regimen of coreg. . # hyperlipidemia - continued home regimen of lipitor 10mg po qdaily, and gemfibrozol. . . # CKD - baseline 1.9-2.0 etiology unclear, pt currently at reported baseline. Creatinine remained stable at baseline . # h/o gout - continued home dose allopurinol . # AAA (4.4 cm, dx [**7-3**], stable on repeat imaging 12/07 per pt) - continue antihypertensives (coreg only). - outpt f/u per PCP. . # GERD - continued omeprazole. . # thrombocytopenia - baseline 100-240s, currently low 100s, - wnl . # Code: DNR/DNI. discussed extensively with pt and daughter, pt does not want CPR or intubation. however external defibrillator shocks are okay, epinephrine and pressors are ok. . Medications on Admission: coreg 25mg po bid lipitor 10mg po daily allopurinol 100mg po qdaily gemfibrozol 600 mg po bid lasix 40mg po bid omeprazole 20mg po bid digoxin 0.1875 po qdaily k-lor 10meq po bid lyrica - self d/c'd few months ago. asa 81mg po qdaily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: 0.1875 mg PO DAILY (Daily). 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. K-Lor 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular tachycardia Secondary: Coronary artery disease Discharge Condition: Good, vital signs stable Discharge Instructions: You were admitted to the hospital with an arrhythmia (abnormal heart rhythm). You underwent ablation with some improvement in your heart rhythm. You were started on a new medication called amiodarone. You should continue to take this medication as prescribed unless otherwise directed by your physician . Please follow up with your regularly scheduled appointments. . Please contact your doctor or return to the emergency room if you develop worrisome symptoms such as shortness of breath, chest pain, palpitations, passing out, etc. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2106-3-3**] 1:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2106-4-2**] 10:00

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icd9cm

[ [ [] ] ]

[ "37.34", "37.27" ]

icd9pcs

[ [ [] ] ]

8204, 8210

4970, 7266

278, 339

8322, 8349

4070, 4947

8932, 9195

3005, 3087

7554, 8181

8231, 8301

7295, 7531

8373, 8909

3102, 4051

223, 240

367, 2333

2355, 2797

2813, 2989

28,814

118,264

33804

Discharge summary

report

Admission Date: [**2146-4-18**] Discharge Date: [**2146-5-9**] Date of Birth: [**2064-8-29**] Sex: M Service: SURGERY Allergies: Aspirin / Lisinopril / Morphine / Percocet / Amoxicillin Attending:[**First Name3 (LF) 695**] Chief Complaint: New area of drainage right abdomen Major Surgical or Invasive Procedure: [**2146-4-22**] cholangiogram [**2146-5-4**] PTC: gistula tract embolized with gelfoam. internal/external stent exchanged for a covered stent History of Present Illness: 81 y/o male well known to hepatobiliary service. 1 year post Left hepatic lobectomy for intrahepatic cholangiocarcinoma complicated post op by persistent bile leak since the time of surgery. Has had multiple drains, attempted stents, attempted tract embolizations. Most recently he underwent [**Month/Day/Year **] on [**3-31**] showing a metal stent in place which appeared to go into the right main hepatic duct with extravasation of contrast noted at the proximal end of the metal stent. Two 6cm by 10FR Cotton [**Doctor Last Name **] biliary stents were successfully placed into the common hepatic duct and coming out of the major papilla. The following day he had tract embolization with silver nitrite and gelfoam pledgets. He was using an ostomy appliance over the remaining hole post embolization with approximately 20-30 cc daily of bilious appearing fluid. The patient reports he felt "like himself" and had gotten back his appetite and some energy until last Friday around noontime when he started feeling fatigued and without appetite. He noted last week that there was a "ridge" on his abdomen, but did not think much about it. At about 4AM today the patient awoke with wetness on his nightclothes and noted a new hole in his abdomen, more lateral than the previously known tract. The drainage appeared slightly bloody to him, he called his VNA who came out early to see him and had him transported to [**Hospital1 18**] via ambulance. He reports no episodes of fever. The abdomen has been somewhat more painful in the general area of this new opening. He denies nausea or vomiting and has been having regular formed bowel movements. No chest pain or shortness of breath are reported. . Past Medical History: diverticulitis, hyperlipidemia, cardiac murmur,, CAD s/p MI in his 50s. PSH: CABG [**2123**], knee surgery [**2136**],partial colectomy [**2141**] with temporary colostomy with subsequent reversal. States this was not for a malignancy [**2146-3-31**] [**Month/Day/Year **] with cbd stent placed [**2146-4-1**] drain tract embolization Social History: He is a widower and retired carpenter. He has six children. 57 y.o. dtr with h/o polio died [**2145-10-24**], one has had an MI, and the third has type I DM, and the other three children are healthy Family History: Mother died of a stroke at age 83, father died of heart failure at age 89. Strong family history of cardiac disease. Physical Exam: VS: 98.2, 65, 155/93. 20, 98%RA, weight 71.6 kg General: Alert and oriented, NAD, appears "down" with quiet affect, sadness over this most recent admission. "I have a few good days and then I get knocked down again". Three pound weight loss noted since last admission. [**Month/Day/Year 4459**]: skin appears dry, and sl dry mucous membranes. Of note, patient is HOH and does not have his hearing aid with him. Card: RRR, III/VI murmur noted Lungs: Right base with diffuse crackles, otherwise CTA bilaterally. Abd: Soft, tender at area around new skin opening. Dry Dressing in place with purulent/bloody/greenish tinged fluid on dressing and oozing from hole. Old site more midline with greenish, thick drainage noted. More volume coming from new opening. Skin around new opening is erythematous, slightly raised and very tender to the touch. slightly red towards flank on right side. Extr: + pedal pulses, no edema noted, warm and well perfused Neuro: no focal deficit noted, alert and oriented x3, affect depressed. Skin: warm and dry. eryhtematous around opening as described above. GI: no N/V/D . Brief Hospital Course: IV unasyn was started on admission. CT of the abdomen on [**4-18**] demonstrated interval removal of right upper quadrant drainage catheter with persistent tract to the skin. Small hypodense focus in the right abdominal wall and mild edema of the distal stomach and proximal duodenum was noted. Stable enhancing focus in segment VIII of the liver and stable appearance of multiple air locules adjacent to the surgical clips and biliary catheter in the right upper quadrant without associated fluid collection. Blood cultures were sent and were negative. The abdomenal fistula tract was cultured showing 1+ pmn, no organisms and no growth. On [**4-19**], the draining area was I&D'd and [**Hospital1 **] dry dressing changes were continued. The wound continued to drain serosanguinous fluid. He remained afebrile. WBC decreased from admission wbc of 13.5 to 6.7. On [**4-22**], a cholangiogram was performed with placement of internal/external percutaneous biliary drain via the anterior ducts. Uncomplicated placement of [**Location (un) 2617**]-[**Doctor Last Name 2418**] at the level of the patient's bile leak. PTC demonstrated biliary leak adjacent to proximal end of the right hepatic duct stent. Post procedure, he developed rigors, hypotension and spiked a temperature to 103. Blood cultures were sent and he was treated with zosyn. He was transferred to the SICU for management which included pressor support for sepsis. Once stabilized, he was transferred back to the med-[**Doctor First Name **] unit on [**4-24**]. Blood cultures grew out VRE. Unasyn and zosyn were switched to Daptomycin on [**4-25**]. A picc line was inserted as iv access became difficult. Repeat daily surveillance blood cultures were drawn and remained negative. A TTE was negative for vegetations. EF was 55%, dilated left atria, trace AR and minimal aortic valve stenosis was noted. On [**5-4**], a pullback cholangiogram demonstrated no definite biliary leak. A covered balloon expandable stent was placed in the biliary system extending the peripheral end of the previously placed stent for 2 mm. The tract in the perihepatic space was embolized with Gelfoam and Betadine. Prior to this procedure, he was started on Zosyn in addition to the Daptomycin. Both the internal/external biliary drain and the drain in the perihepatic space were exchanged over a wire. He tolerated this procedure well, but did have some rigors and a temperature of 101.6 post procedure. Zosyn was continued in addition to the Daptomycin.The Zosyn was stopped after 48 of remaining afebrile and with negative blood cultures. On [**5-6**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] removed the previous endoscopically placed stents. These stents were sent to pathology. This procedure was well tolerated. Of note, the drain in the perihepatic space had some tan, thick drainage at the insertion site. The drain was uncapped with only ~ 20cc/day of thick brown drainage. A small amount of drainage appeared at the insertion site. On [**5-9**], Daptomycin was stopped after completing 14 days of treatment for VRE. He was ambulating independently, tolerating a regular diet(with supplements) and vitals remained stable. He was seen by Nutrition and given supplements as his appetite and intake had diminished mid hospitalization due to nausea which was likely due to antibiotics and pain medication (vicodin). Vicodin was stopped and Ultram was started. Ultram was stopped as he did have some hallucinations with the Ultram. Tylenol was then used for comfort. LFTs were notable for alkaline phosphatase that remained in the mid 300's to 400 range. [**Company 1519**] ([**Telephone/Fax (1) 12065**]was arranged for nursing and PT at home. He was discharged home in stable condition. Medications on Admission: Atenolol 25 mg PO daily, Pantoprazole 40 mg PO daily, MVI daily, Lasix 40 mg daily PRN, last dose about 1 week ago Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take as needed for leg swelling. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: bile leak s/p left hepatic lobectomy [**4-10**] septicemia, vre Discharge Condition: good Discharge Instructions: Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills, worsening abdominal pain, drainade from wound or redness of edge of wound, recurrent drainage from old drain tract Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2146-5-20**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2146-5-18**] 9:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2146-5-9**]

[ "995.91", "V09.80", "V45.81", "576.4", "412", "E878.1", "272.4", "553.3", "998.59", "V45.79", "V10.07", "038.0", "562.10", "V45.72", "038.19", "997.4", "458.29" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13", "87.51", "97.55", "00.14", "99.29", "86.04", "87.54" ]

icd9pcs

[ [ [] ] ]

8508, 8557

4073, 7856

349, 493

8665, 8672

8924, 9397

2813, 2931

8022, 8485

8578, 8644

7882, 7999

8696, 8901

2946, 4050

275, 311

521, 2222

2244, 2580

2596, 2797

59,630

121,268

47114

Discharge summary

report

Admission Date: [**2166-6-23**] Discharge Date: [**2166-6-27**] Date of Birth: [**2096-1-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 70 y/o F with history of restrictive/obstructive lung diseases, asthma, pulm hypertension, dCHF, hypoventilation, OSA who presents with shortness of breath over the past week, worsening. She did not want to come in, and today her daughter forced her to. The patient reports decreased exercise tolerance over the past week. already minimally active, but now even less active. She denies change in her diet or weight, but is weighing in higher than baseline (b/; ~93lbs, here 97). denies increased salt in her diet. She denies fevers, chills, cough, abdominal pain, dysurea. She is on 3L NC at home. She reports that she has been wearing her Bipap every night since her last visit with Dr. [**Last Name (STitle) 4507**]. No sputum production, no cough. slight runny nose consistent with allergies. She reports no change in her routine, has been compliant with her medications. Per OMR notes, her Lasix PO was decreased from 80mg daily to 40mg because of high creatinine. Patient also reports that she has had intermittent headache since starting the bipap. In the ER, her intial vitals were, T 98.6, BP 151/60, RR 28, 69% on 2NC. She was started on a nitro gtt, given Lasix 80mg IV x2, having put out about 800cc. On the floor, The patient was interactive and breathing fast. She reports shortness of breath, no chest pain, cough, fever, see above. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies , sinus tenderness, or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Severe kyphoscoliosis s/p operative repair in [**2140**]. Last spirometry [**8-/2165**] FVC 30% pred (490cc), FEV1 27% pred (300cc), ratio 0.62, DLCO 17% pred - Severe sleep disordered breathing - Hypoventilation syndrome due to severe restrictive lung disease - Asthma - Chronic hypercapneic, hypoxic respiratory failure- resting ABG pH of 7.40 and PCO2 of 85 on continuous home oxygen - Chronic diastolic heart failure - Pulmonary hypertension - TTE [**1-/2166**] with TR gradient 60-70, RVH and mild RV dilation in setting of elevated PCWP. - Large hiatal hernia - GERD - Hypertension - h/o severe skin burns as child - Osteoporosis - h/o hip and back pain Social History: Prior smoke (X 11 years) but quit in [**2138**]. No alcohol. Lives with daughter and performs own ADLs (bathing, dressing, cooking). Previously worked as a home health aide. Widowed. Family History: Father died of liver cancer. Daughter with breast cancer at 45. Also history of colon cancer. No history of pulmonary disease. Physical Exam: Vitals: T: 99.2 BP: 144/66 P: 75 R: 22 O2: 95%/2L General: Alert, oriented, mildly labored breathing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: JVP elevated. Lungs: severe kyphosis and scoliosis. rales diffusely, also some wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: misshapen secondary to childhood burn injury. nontender GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CBC [**2166-6-23**] 08:50AM BLOOD WBC-5.6 RBC-3.26* Hgb-9.6* Hct-31.8* MCV-98 MCH-29.5 MCHC-30.2* RDW-16.6* Plt Ct-212 [**2166-6-24**] 04:22AM BLOOD WBC-2.9* RBC-3.02* Hgb-8.9* Hct-29.5* MCV-98 MCH-29.4 MCHC-30.1* RDW-15.6* Plt Ct-179 [**2166-6-25**] 04:31AM BLOOD WBC-4.2 RBC-3.04* Hgb-8.9* Hct-29.2* MCV-96 MCH-29.3 MCHC-30.5* RDW-16.0* Plt Ct-209 Diff [**2166-6-23**] 08:50AM BLOOD Neuts-65.6 Lymphs-24.4 Monos-6.8 Eos-2.7 Baso-0.4 Chem 7 [**2166-6-23**] 08:50AM BLOOD Glucose-111* UreaN-22* Creat-1.6* Na-148* K-3.5 Cl-96 HCO3-47* AnGap-9 [**2166-6-23**] 07:08PM BLOOD Glucose-124* UreaN-19 Creat-1.3* Na-150* K-3.7 Cl-97 HCO3-45* AnGap-12 [**2166-6-24**] 04:22AM BLOOD Glucose-148* UreaN-17 Creat-1.3* Na-145 K-3.5 Cl-94* HCO3-46* AnGap-9 [**2166-6-24**] 03:18PM BLOOD Glucose-153* UreaN-18 Creat-1.6* Na-138 K-3.8 Cl-89* HCO3-43* AnGap-10 [**2166-6-25**] 04:31AM BLOOD Glucose-84 UreaN-21* Creat-1.6* Na-139 K-4.4 Cl-92* HCO3-40* AnGap-11 Other chemistry [**2166-6-24**] 04:22AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.7 [**2166-6-25**] 04:31AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.6 ABG [**2166-6-23**] 03:34PM BLOOD Type-ART Temp-36.1 pO2-81* pCO2-113* pH-7.28* [**2166-6-23**] 05:37PM BLOOD Type-ART pO2-80* pCO2-128* pH-7.25* calTCO2-59* [**2166-6-25**] 08:20AM BLOOD ART Temp-38.0 O2 Flow-3 pO2-75* pCO2-94* pH-7.34* CHEST (PORTABLE AP) Study Date of [**2166-6-23**] There are bilateral fluffy perihilar opacities. Lung volumes are low. There is chronic elevation of the bilateral diaphragms; however, bilateral pleural effusions are likely present. There is scoliosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 931**] rod in place. Significant deviation of the trachea is present; however, similar in appearance to prior examinations. IMPRESSION: Findings consistent with volume overload. Brief Hospital Course: Ms. [**Known lastname 80571**] is a 70 year old woman with a history of hypercarbic respiratory, failure, hypoventilation secondary to kyphosis, and sleep disordered breathing. She presented to the ICU with SOB and hypercarbic respiratory failure. # Hypercarbic respiratory failure: She has a history of hypercarbia, sleep disordered breathing, restriction from kyphosis. Baseline pCO2 is 85. Upon admisison, pCO2 in 90??????s. Respiratory failure likely multifactorial- infection/allergy, diastolic CHF, bronchospasm. She was treated with BiPAP and did not require intubation. She was started on antibiotics with Vanc, Zosyn, and Levofloxacin to cover hospital acquired and atypical pneumonia. She was also started on methylprednisolone and then changed to oral steroids with prednisone 60 mg Q day, and she was on standing nebulizers. Her goal oxygenation is 88-92%. She was also given diuretics with good response. She was transferred to the Medicine floor on [**6-25**], where she continued to improve and was at her baseline oxygen requirement of 2L. Antibiotics were narrowed to levofloxacin, as there was no radiographic evidence of pneumonia. . # Obstructive Sleep Apnea: She was continued on BiPAP. Her outpatient sleep physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], made arrangements for her to receive a new BIPAP SV AUTO machine with increased supplemental O2. He coordinated this with her homecare company. He arranged to have [**Hospital 6549**] Medical deliver the machine to [**Hospital1 **], where it will be in Ms. [**Known lastname 80572**] possession. She will need to take it home with her. . # Acute on chronic diastolic heart failure: EF 75%. JVP elevated on admission with BNP at high of [**Numeric Identifier **]. She was treated with furosemide IV as noted above, and on the medical floor she was switched back to her prior dose of 80mg po once daily. . # Acute on Chronic renal failure: Baseline 1.1, then 1.6 on admission, prerenal in etiology. This improved with treatment of her CHF. Ace-Inhibitor was held in MICU and restarted on the day of discharge. . # Hypertension: Elevated BP first day of admission, later improved. . # Anemia: Chronic normocytic, attributed to chronic disease, stable. . Medications on Admission: Albuterol nebs as needed Albuterol inhaler as needed Fosamax 70mg weekly [**Doctor First Name **] 180mg daily during allergy season Fluocinonide 0.05% daily Fluticasone 220mcg twice daily Lasix 80mg daily Lisinopril 40mg nightly Metoclopramide 10mg TId with with meals Pantoprazole 40mg daily Salmeterol 50mch inhaled 1 puff at bedtime Calcium Coenzyme Q10 Colace Vitamin D Multivitamin with iron Omega 3 fatty acid O2 3L NC at all times Medications on Transfer Heparin 5000 UNIT SC TID Albuterol 0.083% Neb Soln 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezes Fexofenadine 60 mg PO BID Pantoprazole 40 mg IV Q24H Vancomycin 1000 mg IV Q48H Levofloxacin 750 mg IV Q48H Piperacillin-Tazobactam 2.25 g IV Q6H Ipratropium Bromide Neb 1 NEB IH Q6H PredniSONE 60 mg PO/NG DAILY Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezes. 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 weeks: decrease dose by 10mg per week until you are down to 20mg daily, then see your lung doctor. 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 13. Docusate [**Hospital1 **] 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 16. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 5 doses: next dose is due tonight ([**6-27**]). Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: # hypercarbic and hypoxic respiratory failure # COPD exacerbation # acute on chronic diastolic CHF # acute renal failure # chronic kidney disease stage II # obstructive sleep apnea # hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with respiratory failure due to exacerbation of your chronic obstructive lung disease (COPD) as well as exacerbation of heart failure. In the intensive care unit, you were managed with BiPAP, steroids, bronchodilators, antibiotics, and diuretics (lasix). You improved markedly and were transferred to the medicine floor. You were assessed by Physical Therapy, who recommended rehab. When you get home, please weigh yourself every morning, and [**Name8 (MD) 138**] MD if your weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2166-7-11**] at 4:15 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4131**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: WEDNESDAY [**2166-7-30**] at 2:30 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2166-6-27**]

[ "V46.2", "416.8", "518.84", "276.0", "737.10", "584.9", "V15.82", "428.0", "327.26", "564.09", "V58.65", "553.3", "285.29", "403.90", "327.42", "428.33", "327.23", "530.81", "585.2", "493.22", "733.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10296, 10367

5477, 7731

334, 340

10607, 10607

3636, 5454

11339, 12064

3013, 3142

8571, 10273

10388, 10586

7757, 8548

10790, 11316

3157, 3617

275, 296

1749, 2109

368, 1731

10622, 10766

2131, 2796

2812, 2997

854

175,684

21807

Discharge summary

report

Admission Date: [**2146-10-3**] Discharge Date: [**2146-10-7**] Date of Birth: [**2079-6-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2042**] Chief Complaint: melena, hypotension Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) [**10-4**] History of Present Illness: Mr. [**Known lastname 57230**] is a 67 yo M with history of multiple myeloma, paroxysmal atrial fibrillation, and prior known duodenal ulcer who presented to an outside hospital with one day history of melena and hypotension to SBP in the 80s at home. He had chemotherapy with valcade and dexamethasone at [**Hospital3 328**] three days prior to admission. At OSH, he was guaiac positive, and his hct was found to be 22 down from a baseline in the mid 30s per his wife. [**Name (NI) **] was transfused two units of packed red cells and a Cordis was placed. Patient also complained of chest pain on presentation and had dynamic ST depressions in the lateral leads. He was given nitro and blood with resolution of his symptoms. Patient was transferred to [**Hospital1 18**] for further management. In the [**Hospital1 18**] ED, initial vs were: 97.0, 99, 128/89, 20, 100% 10L NRB. Patient was given a IV bolus and started on a PPI drip. He had a negative NG lavage but was again guaiac positive. Repeat labs here showed hematocrit of 24.8 (he did not bump his hematocrit after the two units given at the OSH). EKG here showed atrial fibrillation without any ST changes. GI was consulted, and he was admitted to the ICU for further management. On transfer, vitals were 107, 122/76, 14, 99% 2L NC. In the MICU, the patient received a total of 4 units which he tolerated well without complaints. His chest pain completely went away when he received blood products. Patient had 18 hours of diarrhea after taking his chemo on Friday but did not notice any blood at that time. He did have three hours of melena on Saturday night but has had no further BMs since. No abdominal pain, nausea, vomiting, constipation. No change in PO intake, difficulty breathing or dyspnea on exertion. Past Medical History: Multiple myeloma on chemo Paroxysmal Afib CAD s/p PTCA in [**2115**] HTN h/o gastric ulcer TIAs Hypercholesterolemia PFO with ASD on echo with right to left & left to right shunts Presumed diagnosis of amyloid angiopathy h/o ICH while on warfarin (no longer anticoagulated) Social History: He is married and his wife is his HCP. [**Name (NI) **] denies smoking, EtOH or drugs. Family History: Uncle: Died of MI in 70's Father: Leukemia, MI at age 65 also AML Uncle: Died of MI in 40's Physical Exam: On transfer in the [**Hospital1 18**] ER Temp:97.0 HR:99 BP:128/89 Resp:20 O(2)Sat:100 normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic; pale conjunctiva Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: tachy Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended Pertinent Results: ADMISSION LABS: [**2146-10-3**] 06:25AM BLOOD WBC-15.0*# RBC-2.87*# Hgb-8.8*# Hct-24.8*# MCV-87 MCH-30.8 MCHC-35.5* RDW-16.5* Plt Ct-214 [**2146-10-3**] 06:25AM BLOOD Neuts-85.7* Lymphs-10.0* Monos-4.0 Eos-0.1 Baso-0.1 [**2146-10-4**] 04:09AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+ Schisto-OCCASIONAL [**2146-10-3**] 06:25AM BLOOD PT-12.3 PTT-19.4* INR(PT)-1.0 [**2146-10-3**] 06:25AM BLOOD Glucose-128* UreaN-72* Creat-1.6* Na-139 K-3.9 Cl-105 HCO3-25 AnGap-13 [**2146-10-3**] 01:46PM BLOOD Calcium-7.9* Phos-2.8 Mg-2.5 [**2146-10-3**] 01:46PM BLOOD ALT-19 AST-15 CK(CPK)-63 AlkPhos-66 TotBili-1.3 [**2146-10-3**] 06:25AM BLOOD cTropnT-0.02* [**2146-10-3**] 01:46PM BLOOD CK-MB-4 cTropnT-0.05* [**2146-10-3**] 03:20PM BLOOD CK-MB-4 cTropnT-0.05* [**2146-10-3**] 08:42PM BLOOD CK-MB-3 cTropnT-0.06* [**2146-10-4**] 04:09AM BLOOD CK-MB-3 cTropnT-0.05* [**2146-10-4**] 08:08PM BLOOD CK-MB-3 cTropnT-0.04* . ECG Study Date of [**2146-10-3**] 6:22:00 AM Atrial fibrillation with rapid ventricular response. Diffuse non-specific ST-T wave flattening. Compared to the previous tracing of [**2142-9-29**] the lateral ischemic appearing T wave abnormalities are no longer recorded. However, pseudonormalization cannot be excluded, given the rapid rate. Atrial fibrillation has appeared. Followup and clinical correlation are suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 105 0 84 362/440 0 -3 134 . EGD [**2146-10-4**] Normal esophagus. Edematous, erythematous antral fold noted consistent with inflammation and possibly underlying ulcer. A single non-bleeding 2 mm ulcer was found in the stomach body. Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Mr. [**Known lastname 57230**] is a 67 yo male with history of paroxysmal atrial fibrillation, coronary artery disease, hypertension and multiple myeloma s/p recent chemo. He has a known duodenal ulcer and presented with melena and hypotension (SBP 80's) to an outside hospital. There he was found to have a hematocrit of 22 down from his baseline in the mid 30's. He also complained of chest pain with lateral ST depressions noted on EKG that resolved when he received nitroglycerin and 2 units PRBCs. . ICU COURSE: He was transferred to [**Hospital1 18**]. On initial evaluation in the emergency room he had a hematocrit of 24 despite the 2 units PRBCs from the outside hospital and was noted to be in atrial fibrillation with a ventricular rate greater than 100. He was started on a PPI drip and admitted to the ICU for further management. While in the ICU, his atrial fibrillation was controlled with metoprolol IV and reinstitution of his sotalol. The patient had one further episode of chest tightness that resolved with nitrates as he received an additional 4 units of PRBC's with his hematocrit stabalizing in the low 30's. He was ruled out for an MI and remained stable from a cardiac standpoint after that single episode. He had no further melena or guaiac positive stools in the ICU and underwent EGD on [**2146-10-4**] with the results as noted above. On [**Hospital 57232**] transfer to the hospital floor on [**2146-10-5**], he had a transient episode of hypotension with a pressure of 85/58 when he was transferring from the stretcher to the bed, which was attributed to the patient having restarted his home dose of labetalol on the evening of transfer. His labetalol was subsequently held (until the day of discharge) and his blood pressure stabalized. . # GI bleed: EGD: edematous, erythematous antral fold noted c/w inflammation and possibly underlying ulcer; single non-bleeding 2 mm ulcer was found in the stomach body. The patient was treated with a total of 6 units of PRBCs with stabalization of his hematocrit. His intravenous pantoprozole was changed to po and the patient's diet was advanced. On the 4th and 5th hospital days following transfer from the ICU, the patient had an episode of black tarry stool on each day. In consultation with the GI service, these episodes were felt to be due to old blood from his initital upper GI bleed. His hematocrit and blood pressure remained stable over the course of these two days with no further evidence of new bleeding. . # Chest pain: The patient's episode of chest tightness was felt to be demand ischemia related to GI bleed superimposed on atrial fibrillation and rapid ventricular response. Pain improved with SL nitroglycerin and blood transfusions. His troponins remained flat and he ruled out for an MI. He has been continued on his statin. The [**Hospital 228**] hospital course was reviewed with the patient's primary cardiologist and the patient will follow up with him on [**10-12**]. . # Atrial fibrillation: The patient has paroxysmal atrial fibrillation treated with sotalol and labetalol. His rapid ventricular response at the outside hospital appeared related to hypovolemia and ischemia from his GI bleed. His rate has been controlled with single doses of metoprolol IV when in the ICU and reinstitution of his sotalol. He converted to NSR by hospital day 4. On the last hospital day, he has been restarted on a lower dose of his labetalol (in addition to sotalol) to prevent further rapid ventricular response, but his dose is limited by his earlier hypotensive episodes. The patient is anticoagulated with low dose aspirin and aggrenox, but these were held during his GI bleed. He received a single dose of each on the 4th hospital day just prior to having two further guaiac positive, melenic stools. Although, the stools are thought to be from old blood and the patient's hematocrit has remained stable, his anticoagulation was discontinued. This has been discussed with his primary cardiologist by phone, and the patient will see him in follow up on [**10-11**] to address restarting low dose aspirin and aggrenox. . # Multiple myeloma: Last chemo [**9-30**] with velcade and decadron at [**Hospital3 328**]. The patient was continued on bactrim and acyclovir prophylaxis and he will follow up with Dr. [**Last Name (STitle) 57233**] at the [**Company 2860**] on [**10-10**] where he will be evaluated and the decision whether or not to proceed with chemotherapy will be made. . # Hypertension: He takes numerous antihypertensives at home including amlodipine, tekturna, labetalol, clondine and losartan. These had been held in the setting of his hypotension and GI bleeding and only clonidine and labetalol have been reinstituted at the time of discharge. He will follow up with his cardiologist on [**10-12**] and his PCP on [**10-13**] to reinstitute these medications as tolerated. Medications on Admission: Aggrenox 200 mg-25 mg [**Hospital1 **] amlodipine-atorvastatin 10 mg-80 mg daily aliskiren 300 mg daily Sotalol AF 120 mg daily labetalol 400 mg [**Hospital1 **] clonidine 0.1 mg [**Hospital1 **] furosemide 80/40 mg daily Aspirin Low-Strength 81 mg Chewable daily (takes [**12-27**]) losartan 100 mg daily folic acid 1 mg daily Vitamin D 50,000 unit qweek nitroglycerin 0.4 mg Sublingual PRN multivitamin 1 daily amlodipine besylate 5mg daily dexamethasone -- Unknown Strength Revlimid -- Unknown Strength Valcade Unknown sig Bactrim -- Unknown Strength qMonday Wednesday Friday acyclovir unknown daily Discharge Medications: 1. sotalol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Omeprazole 40 mg Tablet, Sig: One (1) Tablet, PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): do not take if your pulse is less than 50 beats per minute. Disp:*60 Tablet(s)* Refills:*2* 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Vitamin D 50,000 unit Capsule Oral 10. multivitamin Oral 11. take your chemotherapy medicines as directed by your oncologist these include revlimid, dexamethasone, and velcade Discharge Disposition: Home Discharge Diagnosis: Upper Gastrointestinal Bleed from Gastric Ulcers Atrial Fibrillation Coronary artery disease Hypercholesterolemia Multiple myeloma TIAs S/P intracranial hemorrhage on warfarin for afib presumed amyloid angiopathy patent foranen ovale with ASD on echo with righ to left and left to right shunts Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a bleeding ulcer that required intensive care because your blood pressure was low. You were treated with blood transfusions and a new medicine to decrease your stomach acid production. Your anemia and low blood pressure caused you to have chest pain from your heart disease and caused your heart to beat fast from your atrial fibrillation (afib). The blood transfusions and heart medicine helped to stop the chest pain. There are no signs that you had a heart attack. In the setting of your bleeding, your blood thinners for your afib and heart disease were stopped. You will work with your cardiologist to decide the right time to restart your blood thinners. Because your blood pressure has been low, we have stopped most of your high blood pressure medicines. Do NOT take your losarten, amlodipine, tekturna (also called aliskiren), or lasix until advised to restart these medications by your doctors. Do NOT take your aggrenox or low dose aspirin. You should avoid taking any aspirin, ibuprofen or drugs containing aspirin or NSAIDs (motrin or aleve)unless you have asked one of your doctors. You were taking caduet - a combination blood pressure and statin, but you will take only atorvastatin now. Followup Instructions: Hematology Oncology Name: Dr. [**Last Name (STitle) 57233**] When: Monday [**2146-10-10**] at 1pm Cardiology Name: Dr. [**Last Name (STitle) 57206**] When: Wednesday [**2146-10-12**] at 1PM Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Thursday [**2146-10-13**] at 12 PM Address: 199 ROUTE 101 [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 57234**] Phone: [**Telephone/Fax (1) 57235**] Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2146-10-19**] at 3:30 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], 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

[ "427.31", "V45.82", "414.01", "403.90", "585.3", "277.30", "745.5", "203.00", "531.40", "285.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

11348, 11354

4848, 9739

335, 380

11692, 11692

3109, 3109

13094, 13994

2618, 2713

10392, 11325

11375, 11671

9765, 10369

11843, 13071

2728, 3090

276, 297

408, 2201

3126, 4825

11707, 11819

2223, 2498

2514, 2602

27,601

192,059

34581

Discharge summary

report

Admission Date: [**2191-8-30**] Discharge Date: [**2191-9-8**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2191-8-30**] Chest tube placment on right [**2191-9-1**] ORIF, right intertrochanteric hip fracture with IM nail [**2191-9-6**] Pleurodesis on right [**2191-9-6**] Bedside swallow evaluation History of Present Illness: 88 year-old who presents after a fall from standing. Per report she was standing and fell, hitting her head and right hip. The patient has an unknown complete medical history but is known to be on plavix and to have a pace maker. She was taken to [**Hospital **] Hospital and transferred to [**Hospital1 18**] after a subarachnoid hemorrhage was noted in the right frontal lobe and a right femoral neck fracture was identified. Of note, between the outside hospital and admission, the hematocrit dropped from 41-29. she received 2 units of FFP. PTT was elevated for unclear reasons to over 100. Past Medical History: Asthma/emphysema, CAD s/p multiple MI's & PCI's, Dementia, COPD, AF, pacemaker, L-spine compression fx, pelvic fx (7-8yrs ago) Family History: Noncontributory Physical Exam: Upon admission: O: T: 96.9 BP: 95/48 HR: 84 R 12 O2Sats 100% Gen: In pain from hip fracture HEENT: Pupils: 2-1 mm, equal EOMs grossly intact Extrem: Warm and well-perfused. Neuro: Mental status: arosuable, deaf, difficult to examine Cranial Nerves: II: Pupils equally round and reactive to light, 2 to mm 1 bilaterally. . III, IV, VI: Extraocular movements intact bilaterally V, VII: face symmetric. VIII: patient is deaf, without hearing aides. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moves all 4 extremities spontaneously. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Right 2+ 2+ Left 2+ 2+ Toes upgoing bilaterally Pertinent Results: [**2191-8-30**] 11:23PM HCT-26.8* [**2191-8-30**] 09:03PM UREA N-14 CREAT-0.9 [**2191-8-30**] 09:03PM AMYLASE-74 [**2191-8-30**] 09:03PM cTropnT-<0.01 [**2191-8-30**] 09:03PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2191-8-30**] 09:03PM WBC-13.9* RBC-3.13* HGB-10.0* HCT-29.9* MCV-96 MCH-32.1* MCHC-33.5 RDW-14.3 [**2191-8-30**] 09:03PM PLT COUNT-256 [**2191-8-30**] 09:03PM PT-13.9* PTT-25.7 INR(PT)-1.2* [**2191-9-1**] NON-CONTRAST CT HEAD: The right frontal lobe demonstrates a focus of hyperintensity that is stable since [**01**] hours ago measuring 3.8 x 2.5 cm. There is stable appearance of subarachnoid hemorrhage into the interhemispheric fissure with associated mild 7-mm left-to-right midline shift. There are areas of hyperdensity scattered within the right occipital lobe consistent with subarachnoid hemorrhage, unchanged. Moderate bifrontal edema, right greater than left is unchanged. An area of hypodensity along the right temporal/occipital lobe likely represents a late subacute infarct, unchanged. IMPRESSION: 1. Stable appearance of right-sided frontal intraparenchymal hemorrhage as well as foci of subarachnoid hemorrhage. 2. No evidence of increased mass effect or hydrocephalus. 3. Hypodense area along the right temporooccipital lobe likely represents a late subacute infarct and appears unchanged since [**01**] hours ago. [**2191-8-30**] CT CHEST: The right lung demonstrates a large pleural effusion. There are scattered foci of increased density in the lung with a 1.2 x 1.3 cm lesion with spiculated margins in the right upper lobe (2:33). There is extensive paraseptal and centrilobular emphysema in both lungs. The left lung is otherwise grossly unremarkable without evidence of effusion, except to note several sub-4-mm nodules which should be followed in the left lower lobe (2:23, 24). The aorta is of normal course and caliber throughout, with extensive calcifications noted. There is moderate-to- severe coronary atherosclerosis, most severe in the left anterior descending artery. A right subclavian catheter terminates in the right atrium. A dual- lead intraventricular pacemaker is noted with its leads overlying the right ventricle and right atrium. There is no evidence of pericardial effusion. CT ABDOMEN WITH IV CONTRAST: The liver demonstrates marked intra- and extra- hepatic biliary dilatation, with the CBD measuring up to 12mm. The pancreatic duct is also dilated diffusely, measuring up to 5-6 mm. The remainder of the pancreas and adrenals appear unremarkable. The kidneys demonstrate scattered sub-6-mm hypodensities that likely represent simple cysts, although are too small to be characterized. The spleen demonstrates a sub-3-cm fluid collection (approximately 46 Hounsfield units) that may represent a perisplenic hematoma or adjacent focal fluid. No splenic laceration noted. The intra- abdominal loops of large and small bowel are grossly unremarkable without evidence of free fluid, free air, or pneumatosis. CT PELVIS: The rectum, uterus and adnexa are grossly unremarkable except to note calcifications in the uterus which may represent calcified fibroids. There is extensive sigmoid diverticulosis without evidence of diverticulitis. The lower ureters are grossly unremarkable. There is ectasia and focal aneurysm at the bifurcation of the common iliac arteries (2:81). Bone windows demonstrate a right intertrochanteric fracture with valgus angulation. There is a compression fracture with near-complete height loss at L1 of unknown chronicity. There are no suspicious lytic or blastic lesions, although there are moderate-to-severe degenerative changes noted throughout the thoracolumbar spine. No rib fractures noted. IMPRESSION: 1. Large right pleural effusion. 2. Extensive emphysematous changes with a 1.3-cm spiculated lesion within the right lung which is suspicious for a neoplasm. Dedicated chest CT when the patient is clinically stable is recommended for further evaluation. 3. Marked dilation of the intra- and extra-hepatic biliary ducts and common bile duct as well as pancreatic duct. No pancreatic head mass identified. Comparison with outside previous studies is recommended. If these studies are not available, then MRCP is recommended when the patient is clinically stable. 4. Right comminuted intertrochanteric fracture with valgus angulation. 5. L1 compression fracture of unknown chronicity. 6. Ectasia of the bilateral common iliac arteries. 7. Extensive emphysema. 8. Small perisplenic, mildly complex fluid collection. ECHO Report [**2191-8-31**] Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - E Wave deceleration time: 168 ms 140-250 ms Mitral Valve - [**Last Name (un) **]: 0.20 cm2 Mitral Valve - Regurgitation Volume: 30 ml TR Gradient (+ RA = PASP): *42 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by TEE). RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. Normal IVC diameter (<2.1cm) with >55% decrease during respiration (estimated RA pressure (0-5mmHg). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV systolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Calcified tips of papillary muscles. Eccentric MR jet. Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. No PS. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mid to apical inferior and mid inferolateral hypokinesis. The remaining segments contract normally (LVEF = 45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction consistent with coronary artery disease. Moderate pulmonary arterial hypertension. Moderate mitral regurgitation. Moderate tricuspid regurgitation. Mild aortic regurgitation CLINICAL IMPLICATIONS: Based on [**2190**] 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. Brief Hospital Course: She was admitted to the Trauma Service. Neurosurgery, Orthopedics and Thoracic were consulted. She was taken to the operating room on ORIF, right intertrochanteric hip fracture with intramedullary nail. Her intraparenchymal hemorrhage and subarachnoid hemorrhage were managed non operatively; she was loaded with Dilantin and will need to remain on this until follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery. There have been no seizure activity noted. Thoracic surgery was consulted for RUL nodule and right transudative pleural effusion. A chest tube had already been placed at the time of presentation, with 800 cc of serosanguinous fluid immediately returned. This fluid was sent for analysis, revealing a transudative effusion. Cytology was negative for malignant cells. Doxycycline pleurodesis was performed on [**9-6**] and was successful; her CT was pulled on [**9-8**]. Cardiology was consulted for episodes of atrial fibrillation; she was started on IV Lopressor and was later changed to oral with adequate rate control. her Lasix was restarted. Geriatrics was consulted given her age, co morbidities and mechanism of injury. Several recommendations were made pertaining to her medications. A Speech and Swallow evaluation was done at bedside; her diet was advanced to ground solids with thin liquids; aspiration precautions should be observed. She was evaluated by Physical therapy and it was recommended that she go to rehab following her acute hospital stay. Medications on Admission: plavix 75', protonix 40', lipitor 40', lisinopril 5', lasix 20', ASA, combivent, nasacort Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [**Hospital1 **] (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q12H (every 12 hours) for 4 weeks. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Ultram 50 mg Tablet Sig: [**1-19**] Tablet PO every 6-8 hours as needed for pain. 12. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Discharge Disposition: Extended Care Facility: Ledgewood Discharge Diagnosis: s/p Fall Right subarachnoid hemorrhage Right pulmonary contusion/right pleural effusion Right hip fracture Discharge Condition: Hemodynamically stable; pain adequately controlled; tolerating an oral diet Discharge Instructions: Continue with the Dilantin until follow up with Dr. [**First Name (STitle) **], Neurosurgery in 4 weeks. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in 2 weeks with Thoracic surgery, call [**Telephone/Fax (1) 170**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call [**Telephone/Fax (1) 600**] for an appointment. Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery, call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Completed by:[**2191-9-9**]

[ "285.9", "E849.0", "518.89", "564.00", "511.9", "416.8", "852.01", "427.31", "424.0", "414.01", "820.8", "V58.63", "V45.82", "412", "427.89", "397.0", "294.8", "E888.8", "348.8", "493.20", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "79.35", "99.07", "34.92", "34.04" ]

icd9pcs

[ [ [] ] ]

13189, 13225

10465, 11965

269, 465

13376, 13454

2047, 2534

13607, 14194

1258, 1275

12107, 13166

13246, 13355

11991, 12082

13478, 13584

8947, 10177

1290, 1292

10200, 10442

221, 231

493, 1090

1554, 2028

2543, 8898

1306, 1484

1499, 1538

1112, 1242

20,289

112,491

29791

Discharge summary

report

Admission Date: [**2127-1-9**] Discharge Date: [**2127-1-29**] Date of Birth: [**2082-8-14**] Sex: M Service: MEDICINE Allergies: Nafcillin / Ciprofloxacin Attending:[**First Name3 (LF) 5755**] Chief Complaint: Cough Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 44 yo male with hx of asthma, EtOH and tobacco who presented with SOB and fever to OSH found to have RML PNA requiring intubation now complicated by pancreatitis, drug rash and acure renal failure. Pt was admitted [**12-29**] for cough, anorexia, fever and hemoptysis. CXR on admission showed RML PNA and was started empirically on azithromycin and ceftriaxone. He was also noted to be in ARF and was hydrated with improvement to creatinine 1.1. He became more hypoxic and tachycardic on [**12-30**] and was intubated. He was started on solumedrol due to severe wheeze. Over the past 5-6 days his creatinine has continued to climb and then stabilized at 4.2. During this period his hematocrit has also dropped to 25.2 from 39.7. He was started on tube feeds but these were discontinued after an episode of high residuals and emesis on [**1-3**]. Amylase and lipase were found to be elevated at 212 and 310 with RUQ U/S revealing gallbladder wall thickening with sludge and and hypoechoic areas of the pancreas concerning for pancreatitis. On [**1-8**] sputum cx revealed MSSA with influenza negative so antibiotics were changed to nafcillin which resulted in diffuse rash so this was changed again to vancomycin. Due to continued clinical decline pt was transferred for further management. Of note pt did receive Zosyn per ID consulation at OSH but not noted on DC summary. Past Medical History: Asthma EtOH Smoking amputation of left 5th distal phalanx hemmorhoidectomy Social History: Lives with brother. Used to work dispatching oil truck but currently unemployed. Drinks 1 sick pack/day of beer with no hx of withdrawal seizures or DT's. 15 pack year smoking history. Family History: Unable to obtain Physical Exam: Vent AC at 700/18 Fio2 50% PEEP 5 satting 98% with PIPS 42 Gen-diaphoretic HEENT-PERRL, MMM, no elev JVP Hrt-tachy RR, nS1S2 no MRG Lungs-diffuse rhonchi with poor air movement throughout Abd-soft, NT, mod distended, liver 3cm below costal margin, hypoactive BS Extrem-2+ rad and dp pulsed, 2+ edema to knees bilat Neuro-sedated, hyperreflexic biceps and patellae bilat, legs flaccid Skin-diffuse maculopapular rash Pertinent Results: [**2127-1-9**] 10:12PM TYPE-ART TEMP-36.9 RATES-20/6 TIDAL VOL-500 PEEP-10 O2-50 PO2-78* PCO2-60* PH-7.30* TOTAL CO2-31* BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED [**2127-1-9**] 10:06PM URINE HOURS-RANDOM UREA N-759 CREAT-50 SODIUM-35 [**2127-1-9**] 10:06PM URINE OSMOLAL-397 [**2127-1-9**] 10:06PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2127-1-9**] 10:06PM URINE RBC-226* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2127-1-9**] 10:06PM URINE EOS-NEGATIVE [**2127-1-9**] 08:25PM TYPE-ART TEMP-36.9 RATES-14/2 TIDAL VOL-500 PEEP-10 O2-60 PO2-123* PCO2-71* PH-7.25* TOTAL CO2-33* BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED [**2127-1-9**] 08:25PM O2 SAT-98 [**2127-1-9**] 06:19PM estGFR-Using this [**2127-1-9**] 06:19PM ALT(SGPT)-25 AST(SGOT)-20 LD(LDH)-342* ALK PHOS-53 AMYLASE-79 TOT BILI-0.3 [**2127-1-9**] 06:19PM LIPASE-97* [**2127-1-9**] 06:19PM CALCIUM-8.4 PHOSPHATE-5.1* MAGNESIUM-2.4 [**2127-1-9**] 06:19PM TRIGLYCER-168* [**2127-1-9**] 06:19PM VANCO-17.9 [**2127-1-9**] 06:19PM WBC-12.6* RBC-2.78* HGB-8.4* HCT-25.4* MCV-92 MCH-30.4 MCHC-33.2 RDW-14.4 [**2127-1-9**] 06:19PM PLT COUNT-479* [**2127-1-9**] 06:19PM PT-13.5* PTT-36.4* INR(PT)-1.2* . C DIFF NEGATIVE X 3 . SPUTUM GRAM STAIN (Final [**2127-1-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2127-1-25**]): HEAVY GROWTH OROPHARYNGEAL FLORA. . BLOOD CX: NO GROWTH . PLEURAL FLUID CULTURE: GRAM STAIN (Final [**2127-1-11**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2127-1-14**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2127-1-17**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2127-1-13**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): . BAL: GRAM STAIN (Final [**2127-1-9**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2127-1-12**]): OROPHARYNGEAL FLORA ABSENT. ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S TOBRAMYCIN------------ <=1 S LEGIONELLA CULTURE (Final [**2127-1-16**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2127-1-10**]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2127-1-10**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Final [**2127-1-23**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2127-1-10**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE (Preliminary): No Virus isolated so far. . INFLUENZA, [**Last Name (un) **] LEGIONELLA: NEGATIVE Admission CXR Severe cavitary pneumonia of the right middle and upper lobes. . Renal Ultrasound The right kidney measures 12.6 cm. The left kidney measures 12.2 cm. There is no evidence of hydronephrosis, nephrolithiasis, or renal mass. Cortical medullary differentiation is well preserved. The bladder is decompressed secondary to a Foley catheter. . CT CHEST W/O CONTRAST [**2127-1-21**]: FINDINGS: The conglomerate of large cavities in the right upper lobe is smaller, 12.7 x 6.6 cm today, previously 13.7 x 8.2 cm, and contains less debris/soft tissue. Adjacent loculated pneumothorax has decreased in size. Peripheral consolidation located anterior to the right major fissure measures 20 x 13 mm, was 35 x 31 mm. Cavitary lesion in the left apex measuring 18 x 13 mm was 23 x 16 mm, now fluid filled. Peribronchial inflammation throughout remaining of both lobes is new, for instance in the left lower lobe (3, 50). Impaction and/or narrowing of the right upper lobe, bronchus intermedius, right middle lobe, and right lower lobe bronchus has resolved. There are no endobronchial lesions. Small right pleural effusion has decreased in size. There is no left pleural effusion. Trace of pericardial effusion is stable. Paratracheal, subcarinal, and carinal lymph nodes have decreased in size, for instance a 14- mm carinal lymph node was 16 mm. Cardiac size is normal. Moderate atherosclerotic calcification is present in the LAD. There are no bone findings of malignancy. The upper abdomen is unremarkable. IMPRESSION: Clearing necrotizing right upper lung pneumonia, resolved right bronchial obstruction, decreasing small, loculated right pneumothorax and small to moderate right pleural effusion, . New or increased mild peribronchial infiltration in both lungs may be due aspiration of purulent material. . MRI EXAM OF THE BRAIN AND MRA OF THE CIRCLE OF [**Location (un) **] (for flaccid paralysis): IMPRESSION: Partly degraded MRI exam due to repeated motion artifact and also partly related to the patient's intubated status. No acute territorial infarcts could be demonstrated on diffusion images. Scattered T2 hyperintense foci along the cerebral white matter seen only on FLAIR images. Bilateral mastoiditis of uncertain chronicity. Followup is suggested based on clinical grounds. MRA OF THE CIRCLE OF [**Location (un) **]: IMPRESSION: Unremarkable MRA exam of the circle of [**Location (un) 431**]. . MR C SPINE (for flaccid paralysis): IMPRESSION: Moderately degraded exam due to motion artifact and the patient's intubated status. Left paracentral herniation seen at C6-C7 level encroaching over the left exiting C7 nerve root. Mild-to-moderate foraminal stenosis at C5-C6 level. Right-sided facet effusion at C3-C4 level. Questionable T2 hyperintense signal involving the cervical cord at C4-C5 level, possibly artifactual in nature. Repeat T2-weighted sagittal images would be helpful for further evaluation of cord signal. . RIGHT UPPER EXTREMITY ULTRASOUND (for right UE swelling): IMPRESSION: 1. No son[**Name (NI) 493**] evidence of DVT in the right upper extremity. The most distal aspect of the right subclavian vein as it enters into the brachiocephalic vein was not visualized. 2. Small-caliber, but patent right internal jugular vein. . CT TORSO W/O CONTRAST [**2127-1-10**]: CT OF THE CHEST: There is a large multiloculated relatively thin walled cavitary lesion involving the right upper lobe measuring roughly 13.7 x 8.2 cm. There are what appears to be air- fluid levels within it. It is difficult to determine whether there is pleural invasion. An adjacent region of consolidative in the right upper lobe (3:27) measures 3.5 x 3.1 cm. Debris is seen within the right main stem bronchus. The trachea and left segmental bronchi are clear. A smaller cavitary lesion is seen in the left upper lobe, measuring 2.3 x 1.6 cm. Multiple small ground- glass opacities are also seen, particularly in the left upper lobe in a tree-in-[**Male First Name (un) 239**] pattern. There are additional consolidative nodular opacities, for example, in the left lower lobe (3:38) measuring 16 x 12 mm and in the right upper lobe measuring 8 mm in diameter. Multiple small paratracheal lymph nodes are seen, which do not meet criteria for pathologic enlargement. No axillary lymphadenopathy is appreciated. There is no cardiomegaly. There is a trace amount of pericardial fluid. There is a left-sided moderate pleural effusion of simple fluid attenuation. A left-sided central venous catheter tip terminates in the central brachiocephalic vein. A nasogastric tube tip is in the antrum of the stomach. An endotracheal tube tip is in the region of the thoracic inlet. CT OF THE ABDOMEN: On this non-contrast study, the liver, gallbladder, adrenal glands, spleen, pancreas, kidneys, and loops of bowel appear unremarkable. Multiple small retroperitoneal lymph nodes do not meet criteria for pathologic enlargement. There is no ascites. Nonspecific perinephric stranding is seen bilaterally. CT OF THE PELVIS: A Foley catheter is within the bladder lumen. The prostate, seminal vesicles, rectum, and pelvic loops of bowel appear unremarkable. There is no pathologic pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. There is dependent superficial subcutaneous edema consistent with anasarca. OSSEOUS STRUCTURES: No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Large cavitary right upper lobe lesion and smaller left upper lobe cavitary lesion with additional foci of ground glass as well as consolidative opacities in both lungs consistent with multifocal pneumonia. Moderate right- sided pleural effusion. Debris in the right-sided bronchi. 2. No drainable fluid collections or areas concerning for inflammation in the abdomen or pelvis. Brief Hospital Course: # Leukocytosis: Patient's initial leukocytosis resolved with treatment of his pneumonia. He then developed diarrhea and abdominal cramping with a rising wbc, concerning for c diff versus viral gastroenteritis. C diff negative x 3 and his symptoms are improving. He is tolerating po without precipitating pain/cramps. He will follow-up with his PCP [**Last Name (NamePattern4) **] 2 days to reassess his symptoms and recheck his wbc. If still symptomatic, would treat empirically with flagyl +/- send c diff toxin B. Of note, urinalysis negative and no other new signs/symptoms of infection. White blood cell count prior to discharge ranged from 12 to 13. . #. Cavitating MSSA pneumonia with also enterobacter in sputum: Patient was initially intubated at an outside hospital on [**12-30**]. He was successfully extubated on [**1-14**]. On BAL, while intubated, he was found to have pan-sensitive enterobacter cloacae and had MSSA in sputums from the outside hospital. ID was consulted and followed throughout his hospital stay. He was treated with 10 days of gram negative coverage (cefepime, then FQ) for the enterobacter and will complete 4 weeks of IV vancomycin, followed by an yet-to-be-determined course of po clindamycin for the MSSA. He is scheduled for a follow-up chest CT and ID follow-up to determine the course of his clindamycin. He was weaned off the steroids started at the outside hospital. He received nebs and will continue inhalers at home. Of note, interval CT during his hospital stay showed some improvement. His blood cultures remained negative. He underwent a thoracentesis which appeared exudative but was not consistent with an empyema. Additional work-up included, urine legionella antigen, influenze DFA, PPD, and AFB smear, all of which were negative. He also had a negative HIV antibody test in house. Please note, patient is due for a trough on [**2127-1-30**] and vancomycin dose will be adjusted prn based on this level. . # Anasarca: Patient developed swelling in his feet, ankles, hands, and sacral area in the setting of a urine protein/creatinine ratio of 0.4 and likely protein wasting enteropathy in the setting of his GI symptoms. His albumin was 2.3 on the day of discharge. He is on ensure supplements to aid. Will need PCP [**Name9 (PRE) 702**] to confirm proteinuria resolves. . # Drug Rash: Patient was transferred with history of drug rash to nafcillin. He then developed a rash at [**Hospital1 18**] to ciprofloxacin. Dermatology was consulted. The rash resolved without mucousal involvement with discontinuation of the cipro. . #. Acute renal failure: On admission, patient had creatinine of 4. Urine sediment suggested acute tubular necrosis. He was also noted to have positive urine eos and likely had a component of acute interstitial nephritis related to his drug reactions. His creatinine on the day of discharge was down to 1.6. He is making good urine and his lytes have been stable. . # Delerium: Suspect multifactorial: steroids, icu psychosis, resolving prolonged infection, benzo withdrawal. This resolved after steroids were weaned and patient began to improve. MRI head showed no evidence of stroke. At discharge he is back to baseline mental status. . # Flaccid weakness: The patient had flaccid paralysis noted bilaterally upper and lower extremitites on [**2127-1-13**]. Head and C-spine MRI were unremarkable. This resolved off steroids and with weaning of sedatives. He is now ambulatory again and was cleared by PT for discharge to home with continued PT to improve his strength. . #. Hypertension: Antihypertensives adjusted for improved blood pressure control (see discharge medications). . #. Pancreatitis: Resolved soon after admission. Suspect possibly due to high doses of propofol. Triglycerides were 168. Right upper quadrant ultrasound [**2127-1-17**] was unremarkable. CT abdomen did not show any evidence of fluid collections. . # Anemia: Suspect due to chronic disease. Ferritin 1149. Folate/B12/hapto were normal. Patient received 3 units of blood while in house. Patient did have one guaic positive stool in the setting of his diarrhea. Per patient he is due for his follow-up c-scope and will discuss this with his PCP. . # Access: PICC in place . # Code: Full . # Dispo: Patient discharged to home (staying with his parents) with services. Medications on Admission: Albuterol Flovent Norvasc Benazepril/HCTZ 20/12.5 Discharge Medications: 1. Outpatient Lab Work Please draw CBC with differential, potassium, BUN, creatinine, and magnesium on [**2127-1-31**] and call results to Dr. [**First Name (STitle) **],[**First Name3 (LF) **] L., phone: [**Telephone/Fax (1) 71298**] 2. Outpatient Lab Work Please draw vancomycin trough on [**2127-1-30**] and call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], phone: ([**Telephone/Fax (1) 4170**] 3. VANCOMYCIN 750 mg IV q24h Dispense: 9000 mg Refills: none 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). Disp:*360 Tablet(s)* Refills:*2* 9. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4-6H (every 4 to 6 hours) as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 12. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. Disp:*1 inhaler* Refills:*0* 13. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 1 months: START THIS AFTER YOU HAVE COMPLETED THE COURSE OF VANCOMYCIN. Disp:*120 Capsule(s)* Refills:*0* 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 1 months. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation twice a day. Disp:*1 inhaler* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapy Discharge Diagnosis: primary: MSSA cavitating pneumonia viral gastroenteritis drug rash acute renal failure acute pancreatitis secondary: history of hypertension Discharge Condition: good: afebrile, tolerating po Discharge Instructions: Please call your doctor or go to the emergency room if you experience temperature > 101, worsening shortness of breath or cough, vomiting or worsening diarrhea, or other concerning symptoms. Please take an ensure supplement two to three times per day for the next 2 weeks. You are allergic to penicillins and fluoroquinolones (levofloxacin, ciprofloxacin). Please avoid ibuprofen as this can affect your kidneys. Followup Instructions: Please call to schedule a follow-up chest CT on [**2127-2-21**]. Phone: [**Telephone/Fax (1) 327**] Please follow-up with the infectious disease doctor below: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2127-2-25**] 11:30 Location: [**Hospital1 18**], [**Hospital Unit Name **] ([**Last Name (NamePattern1) 71299**] Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5395**] (works with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) on Friday, [**2127-1-31**] at 10:45 AM to have your infection cell count checked, to have your kidney function checked, to discuss scheduling a colonoscopy, and for a routine follow-up. Phone: [**Telephone/Fax (1) 71298**].

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25455

Discharge summary

report

Admission Date: [**2165-5-2**] Discharge Date: [**2165-5-6**] Service: MEDICINE Allergies: Penicillins / Meropenem Attending:[**First Name3 (LF) 3326**] Chief Complaint: Fever and MS changes with mild hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 81M with MMP including CRI, HTN, PVD, CABG, a left-sided above the knee amputation and a previous fem fem bypass and a right fem peroneal bypass, recently admitted for UTI/ pyelonephritis and ARF sent to nursing home, was found to have fever, decreased urine output, started with avelox and gent yesterday, still febrile today, sent to ED. In ED, found to be hypotensive 80/41, received levo and flagyl, and 3L NS, and BP improved, sent to [**Hospital Unit Name 153**]. In [**Hospital Unit Name 153**], BP around 80's/50's, pt found to be unresponsive to sternal rub, pin point pupil, fs 129, O2sat upper 90's, pt responded to 1.8mg Narcan, became awake and interactive. . In the [**Hospital Unit Name 153**], the patient required several more liters of fluid but never required pressors. His Ucx grew proteus and his antibiotics were changed from meropenem -> vanco/aztreonam -> aztreonam. He continued to have intermittant fever spikes but subsequent cultures have not grown anything to date. F/U ultrasound of his L kidney showed resolution of his previously noted hydronephrosis. His mental status improved after administration of narcan and he has remained lucid. Past Medical History: 1. Hypertension 2. Peripheral [**Hospital Unit Name 1106**] disease. 3. ? h/o cardiomyopathy with a history of alcohol abuse. 4. Left above knee amputation in [**2161**] at Veterans Administration Hospital. Left phantom limb and stump pain 5. Ischemic right foot/leg, s/p intraoperative arteriogram with Right femoral thrombectomy and femoral-femoral bypass([**2164-7-23**]). 6. S/p right femoral to peroneal bypass with non-reverse saphenous vein graft on ([**2164-8-2**]). 7. CKD with baseline creat 1.8 Social History: The patient lives with his wife. Uses a walker/wheelchair. He has a 70 pack-year history of smoking. He had heavy alcohol use up until 3 years ago. Family History: Non-contributory Physical Exam: GEN: not arousable by voice or painful stimuli, breathing comfortably, not using accessory mm. HEENT: pinpoint pupil minimally reactive to light, dry mucous membrane. CV: reg rate, s1 s2 Lung: CTAB ABD: soft, NT/ND, +bs EXT: BKA on left, moving all extremities. . Pertinent Results: ADMISSION LABS: [**2165-5-2**] 10:10AM BLOOD WBC-22.1*# RBC-4.99 Hgb-12.4* Hct-38.4* MCV-77* MCH-25.0* MCHC-32.4 RDW-17.0* Plt Ct-240 [**2165-5-2**] 10:10AM BLOOD Neuts-93.4* Bands-0 Lymphs-3.0* Monos-2.9 Eos-0.6 Baso-0.1 [**2165-5-2**] 10:10AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2165-5-2**] 10:10AM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2* [**2165-5-2**] 10:10AM BLOOD Plt Smr-NORMAL Plt Ct-240 [**2165-5-2**] 02:35PM BLOOD Ret Aut-1.4 [**2165-5-2**] 10:10AM BLOOD Glucose-135* UreaN-54* Creat-3.4*# Na-136 K-4.3 Cl-106 HCO3-16* AnGap-18 [**2165-5-2**] 10:10AM BLOOD ALT-15 AST-45* AlkPhos-81 Amylase-130* TotBili-0.5 [**2165-5-2**] 10:10AM BLOOD Lipase-13 [**2165-5-2**] 02:35PM BLOOD Calcium-6.9* Phos-2.6* Mg-1.4* [**2165-5-4**] 03:53AM BLOOD calTIBC-122* Ferritn-361 TRF-94* [**2165-5-2**] 08:31PM BLOOD Ethanol-NEG Bnzodzp-NEG [**2165-5-2**] 02:23PM BLOOD Type-ART pO2-50* pCO2-30* pH-7.30* calHCO3-15* Base XS--9 Comment-QNS TO REP [**2165-5-2**] 10:16AM BLOOD Lactate-2.2* . IMAGING: CT abd [**2165-3-7**]: IMPRESSION: 1. New obstruction of the left kidney with hydronephrosis, hydroureter and perinephric stranding. Left ureter dilated to level of aortic bifurcation. The cause of obstruction is not identified and may be due to a ureteral stricture or mass. There is no obstructing stone 2. Multiple small stones in the gallbladder without evidence of acute cholecystitis. 3. Atherosclerotic disease with aneurysmal dilatation of the abdominal aorta, not significantly changed from prior. 4. Rounded structure arising from left mediastinum, possibly representing duplication cyst, not significantly changed from prior. . [**5-3**]: Renal U/S: Resolution of the previously seen left-sided hydronephrosis. Small simple-appearing cysts in both kidneys. . [**5-3**]: CXR: Left skin fold should not be mistaken for pneumothorax; there is none, nor any significant pleural effusion. Tip of a right internal jugular line projects over the upper third of the superior vena cava. Thoracic aorta is chronically enlarged and tortuous. The saccular aneurysm of the descending portion is obscured by the cardiac silhouette and mild left lower lobe atelectasis. . Brief Hospital Course: BRIEF OVERVIEW: 81M with MMP including CRI, HTN, PVD, CABG, presented with recurrent UTI, delta ms, and acute on chronic renal failure. He was resuscitated with IVF and treated with narcan for MS changes. Somnolence resolved, Utox was negative. BP normalized with fluids. Urine grew proteus [**Last Name (un) 36**] to cephalosporins, but pt has hx of anaphylaxis to PCN, therefore was treated with aztreonam. Foley was discontinued and Pt was transfered to the floor. . Course by Problem: . # ID/fevers- His Ucx grew proteus and the patient was treated with aztreonam for this microbe. His fever curve trended down on this medication and he was afebrile for >24hrs prior to d/c. He will be d/c to complete a 10d course of [**Hospital1 **] aztreonam at his nursing home. . # delta MS: Was somnolent on admission - resolved with narcan. He was interactive throughout the rest of his admission but . #H/o Hydronephrosis: seen by urologist on [**2165-4-24**] for history of left-sided hydronephrosis and was thought most likely secondary to fibrosis from his peripheral [**Date Range 1106**] disease and graft placements. To ensure that there is no malignancy in the area of the mid ureter, pt was advised to have a cystoscopy and retrograde pyelogram on the left side with balloon dilatation and ureteral stent placement and was told to f/u with urology for this. . # acute on chronic renal failure- The patient's baseline creatinine appears to be 1.8, and was 3.1 on admission. It was assumed that this was [**1-31**] a pre-renal picture given his septic presentation and he trended to normal w/ hydration. U/S r/o obstruction and the patient w/ f/u with his outpatient urologist in 1mo. . # anemia: baseline 35-38 and iron studies c/w a mixed anemia of chronic dz and iron deficiency picture. He was started on iron supplementation and his Hct trended upwards throughout his admission. . # HTN: Outpt HTN meds were held on his admission given his hypotension. Once he was afebrile for a 24hr period his HCTZ was added back and his imdur and BBlocker should be readded as necessary at his rehab facility Medications on Admission: 1. Gabapentin 300 mg qd 2. Acetaminophen 325-650 mg PRN 3. Pantoprazole 40 mg qd 4. Aztreonam 1000 mg Q12H 5. Senna prn 6. Docusate Sodium 100 mg [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Urosepsis, AMS, acute on chronic renal failure . Secondary: HTN, PVD, left AKA, Discharge Condition: Stable; tolerating PO and afebrile Discharge Instructions: Please take your medications as directed by your facility Return to the ER or call your PCP [**Name Initial (PRE) **]: 1. fever to 101 2. chest pain 3. shortness of breath 4. other concerning symptoms Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2165-8-1**] 3:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2165-5-8**] 2:15 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2165-5-8**] 1:00 . Please make an appointment to be seen by your PCP ([**Last Name (LF) 63604**],[**First Name3 (LF) **] [**Telephone/Fax (1) 14943**] EXT. 376) within the next 2weeks Completed by:[**2165-5-7**]

[ "403.91", "995.92", "V49.76", "038.9", "599.0", "276.2", "285.29", "041.6", "584.9", "275.41", "V45.81", "443.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7064, 7137

4737, 6850

272, 278

7270, 7307

2508, 2508

7556, 8236

2190, 2208

7158, 7249

6876, 7041

7331, 7533

2223, 2489

190, 234

306, 1477

2525, 4714

1499, 2007

2023, 2174

16,107

189,826

26885

Discharge summary

report

Admission Date: [**2170-11-13**] Discharge Date: [**2170-11-18**] Date of Birth: [**2108-2-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Fatigue and mild dyspnea on exertion Major Surgical or Invasive Procedure: CABG X1 and MVR with 28mm [**Doctor Last Name **] annuloplasty History of Present Illness: 62 year old gentleman with know coronary artery and mitral valve disease. He has been followed by serial echocardiograms which most recently showed a decreased ejection fraction from the prior study. Although he remains mostly asymptomatic, he does admit to fatigue without much exertion. Given his diminished ejection fraction, Mr. [**Known lastname 13257**] has been referred for surgery. Past Medical History: CAD IMI Stent/PTCA [**80**] years ago Prostate Biopsy [**9-5**] Polypectomy Hyperlipidemia Social History: Lives with wife. Denies excessive alcohol use. Quit smoking 16 years ago. Denies ever using IV drugs. Family History: Father with CABG at age 70. Physical Exam: Pulse 60 BP 149/83 GEN: WDWN in NAD HEENT: Within normal limits HEART: RRR, systolic ejection murmur LUNGS: CLear ABD: Benign EXT: No edema, pulses 2+, no varicosities. Pertinent Results: [**2170-11-17**] 05:30AM BLOOD WBC-7.2 RBC-2.92* Hgb-9.0* Hct-25.7* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.6 Plt Ct-185# [**2170-11-18**] 05:10AM BLOOD Hct-25.4* [**2170-11-17**] 05:30AM BLOOD Plt Ct-185# [**2170-11-17**] 05:30AM BLOOD Glucose-140* UreaN-25* Creat-1.2 Na-137 K-4.0 Cl-103 HCO3-24 AnGap-14 [**2170-11-17**] CXR There is a small left apical pneumothorax, similar in appearance compared to the film from the prior day. There continues to be bilateral lower lobe volume loss with a more linear area of atelectasis/infiltrate in the right lower lung that has progressed slightly compared to the prior day. Mildly dilated loops of bowel are seen in the mid abdomen and left upper quadrant measuring up to 6 cm. This is probably colon. Recommand clinical correlation and abdominal film if indicated. [**2170-11-13**] EKG Sinus rhythm Nonspecific inferolateral T wave abnormalities Since previous tracing of [**2170-11-7**], sinus bradycardia absent and T wave changes slightly more prominent [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Known lastname 13257**] was admitted to the [**Hospital1 18**] on [**2170-11-13**] for elective surgical management of his coronary artery and mitral valve disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to one vessel and a mitral valve repair utilizing a 28mm [**Doctor Last Name **] [**Doctor Last Name **] annuloplasty band. Postoperatively he was taken to the cardiac surgical intensive care unit. On postoperative day one, Mr. [**Known lastname 13257**] awoke neurologically intact and was extubated. Beta blockade and aspirin was started. He was then transferred to the step down unit for further recovery. He was gently diuresed toward his preoperative weight. The physical therapy service worked with him to help increase his postoperative strength and mobility. Plavix was started. His drains and epicardial pacing wires were removed per protocol. Mr. [**Known lastname 13257**] continued to make steady progress and was discharged home on postoperative day five. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 81mg daily Toprol XL 25mg daily Lipitor 20mg daily Lisinopril 5mg daily Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*400 ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD s/p MI mitral regurgitation BPH Discharge Condition: stable Discharge Instructions: You may shower, please avoid heavy lifting and driving for one month. Avoid putting any creams or other products on your sternal wound. If you experience shortness of breath, chest pain, drainage from your wound, fever >101.5 or any significant change in your medical condition please contact your [**Name2 (NI) 5059**] or return to the emergency room. Followup Instructions: Provider: [**Name10 (NameIs) 3390**] Appointment should be in [**6-10**] days Provider: [**Name10 (NameIs) **] Appointment should be in [**6-10**] days Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month please call to schedule a follow up appointment. Completed by:[**2170-12-5**]

[ "780.79", "V45.82", "424.0", "412", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.72", "36.11", "35.12" ]

icd9pcs

[ [ [] ] ]

5197, 5246

359, 424

5326, 5335

1326, 2326

5736, 6111

1093, 1122

3667, 5174

5267, 5305

3563, 3644

5359, 5713

1137, 1307

2377, 3537

283, 321

452, 844

866, 958

974, 1077

16,298

109,097

47038+58968

Discharge summary

report+addendum

Admission Date: [**2112-10-7**] Discharge Date: [**2112-10-17**] Date of Birth: [**2039-8-6**] Sex: M Service: UROLOGY HISTORY OF THE PRESENT ILLNESS: This is a 73-year-old male with refractory CIS of the bladder treated by Dr. [**Last Name (STitle) 986**] since [**2106**]. He has been treated with intravesical BCG as well as BCG and Interferon and his most recent bladder biopsy demonstrates persistent multifocal CIS. Options were discussed and he decided to proceed with cystoprostatectomy by Dr. [**Last Name (STitle) 986**] to be followed by ileal loop urinary diversion by Dr. [**Last Name (STitle) 4229**]. On examination, his abdomen was soft, nontender, nondistended, and obese. LABORATORY/RADIOLOGIC DATA: Preoperative laboratories showed a BUN and creatinine of 40/1.6, hematocrit of 35, and a urinalysis with 135 red blood cells per high-powered field. The PSA was 0.3. The patient had a preoperative stress test which showed no evidence of myocardial ischemia. His echocardiogram showed a left ventricular ejection fraction greater than 55%. He had mild to moderate aortic regurgitation and mild mitral regurgitation. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2112-10-7**]. Please see the operative dictation for details of that procedure. He was monitored by a Swan-Ganz catheter. He received 9.5 liters of crystalloid and 2 units of packed red blood cells. The EBL was estimated at 600. He underwent a radical cystoprostatectomy with ileal loop urinary diversion as well as bilateral pelvic lymph node dissection. Two JPs were left in place as well as bilateral ureteral stents. However, on KUB, the left stent was shown to be malpositioned and likely in the ileal loop. This was thus removed. Mr. [**Known lastname **] had significant output by both JPs, however, greater in the right JP than the left JP. This was especially high approximately one week postprocedure when the ostomy output dropped to zero and the right JP output was subsequently approximately 2,500. A Foley catheter was placed in the ostomy to use as a stent. It was likely that the obstruction in part was due to the ostomy appliance material. The JP output subsequently decreased; however, was still putting out on the order of close to 1,000 a day. A CT urogram was obtained on postoperative day number six which showed no ureteral leak. The Foley catheter was thus removed; however, it was again noted that the ostomy output was decreasing so this was replaced again. The right JP output remained persistently high. It looked to be the color and consistency of urine. The suction drainage was then switched over to a gravity drainage. Creatinine of both drains in the ostomy showed the creatinine of the ostomy to be 70, the creatinine of the right drain 39 and the creatinine of the left JP to be 1.1. The left JP was subsequently removed on postoperative day number nine and the patient will be discharged to rehabilitation with the Foley catheter in the stent opening the ostomy as well as the right drain to gravity drainage. 1. NEUROLOGY: The patient's pain was controlled with epidural. However, after he was extubated, he was noted to be rather somnolent. The epidural was titrated down due to this and eventually was discontinued on postoperative day number five. At this point, he was switched over to a PCA. He was noted to be somewhat more alert after the epidural was discontinued. The patient also complained of some right leg weakness. This was initially presumed to be due to epidural placement. It slowly improved with physical therapy. 2. CARDIOVASCULAR: The patient had a rule out MI protocol immediately postoperatively which showed elevated CKs up to 6,000; however, his CK MB was 22 for an MB index of 0.4. In addition, his troponin was 0.03 or less. Lopressor and Hydralazine were used to control his blood pressure. He was initially monitored with a Swan-Ganz catheter which was eventually switched to a CVL on postoperative day number two. He was kept on telemetry for monitoring. On postoperative day number eight, he experienced postprandial epigastric discomfort which resolved with Tums; however, given his significant cardiac history and diabetic history, a second rule out MI protocol was performed which showed nonspecific T wave inversions in V1 through V3; however, his enzymes were negative. He was eventually switched over to his home regimen which controlled his hypertension. 3. PULMONARY: The patient was extubated on postoperative day number two. He was weaned from his oxygen without issues. 4. GASTROINTESTINAL: Postoperatively, the patient was maintained with a NG tube and IV Pepcid. The NG tube was self-discontinued on postoperative day number four. Sips were begun on postoperative day number seven and his diet was advanced without difficulty. As stated under cardiac, the patient experienced epigastric discomfort on postoperative day number eight. This resolved with Tums and for this reason, the patient is maintained on p.o. Pepcid. 5. GENITOURINARY: Please see the main hospital course for details on his ostomy and drain functions. At this point, a loopogram will be obtained prior to discharge to evaluate for ureteral leak. The results of this will be dictated in a separate note. 6. HEME: The patient was maintained on Lovenox 40 mg b.i.d. for DVT prophylaxis. He again started complaining of right lower extremity pain on postoperative day number nine. He had a slight increase in leg swelling, 1+ pedal edema on the right compared to none on the left. His pain was diffuse including his anterior and posterior leg as well as his thigh. He reported having a history of right lower extremity pain as well as some asymmetrical swelling ever since back surgery many years ago. Although the clinical suspicion for DVT was low, LENIs were obtained on the date of discharge. The results of these will be dictated in an addendum. 7. INFECTIOUS DISEASE: The patient was given perioperative Ancef [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38941**] Dictated By:[**Name8 (MD) 99739**] MEDQUIST36 D: [**2112-10-17**] 12:45 T: [**2112-10-17**] 12:51 JOB#: [**Job Number 99740**] cc:[**Last Name (NamePattern4) **] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 15972**] Admission Date: [**2112-10-7**] Discharge Date: [**2112-10-17**] Date of Birth: [**2039-8-6**] Sex: M Service: Urology LENIs were negative for DVT. A loopogram showed contrast in the J-P [**Last Name (LF) 5715**], [**First Name3 (LF) **] there is evidence of a leak, though the location of the leak cannot be localized. There is reflux of the contrast up into the left renal collecting system with rapid emptying once the drainage is allowed. There is no obvious extravasation into the peritoneum. The patient is stable for discharge with his right sided abdominal [**First Name3 (LF) 5715**] in place. He has been evaluated by PT, and has been accepted at the [**Hospital 15973**] Rehab Facility. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Insulin dependent diabetes. 3. Nephrolithiasis. PAST SURGICAL HISTORY: 1. CABG in [**2105**]. 2. Multiple spine surgeries. 3. Multiple stone procedures. 4. Multiple bladder tumor procedures. 5. Left shoulder surgery. MEDICATIONS ON ADMISSION: 1. Valsartan 80 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Aspirin 81 mg p.o. q.d. 4. Humalog insulin 28 units q.a.m. and q.p.m., occasionally 14-16 units during lunchtime. 5. Lantus insulin 48-50 units q.h.s. ALLERGIES: Morphine causing hallucinations. MEDICATIONS ON DISCHARGE: 1. Acetaminophen 325 mg 1-2 tablets p.o. q.4-6h. prn pain. 2. Lovenox 40 mg subQ q.12h. 3. Atenolol 50 mg p.o. q.d. 4. Valsartan 80 mg p.o. q.d. 5. Percocet 5/325 1-2 tablets p.o. q.4-6h. prn pain. 6. Colace 100 mg p.o. b.i.d. 7. Lorazepam 0.5 mg to 2 mg p.o. q.4-6h. prn anxiety. 8. Calcium carbonate 500 mg two tablets p.o. q.i.d. prn indigestion. 9. Pepcid 20 mg p.o. b.i.d. 10. Ibuprofen 600 mg p.o. q.6h. prn pain. 11. Insulin glargine 48 mg subQ q.h.s. 12. Insulin Humalog 28 units subQ b.i.d. with breakfast and dinner. 13. Regular insulin-sliding scale subQ q.i.d. for fingerstick 0-150 give no units; for 151-200 give 2 units; for 201-250 give 4 units; 251-300 6 units; 301-350 8 units; 351-400 10 units, greater than 400 12 units. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Was discharged to [**Hospital 15973**] Rehab. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15974**] [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Numeric Identifier 15975**] MEDQUIST36 D: [**2112-10-17**] 14:14 T: [**2112-10-17**] 14:44 JOB#: [**Job Number 15976**] cc:[**Hospital 15977**]

[ "233.7", "997.5", "276.2", "V45.4", "458.2", "794.39", "401.9", "250.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "57.71", "40.3", "89.64", "03.90", "56.71", "96.71", "87.78", "38.93" ]

icd9pcs

[ [ [] ] ]

7773, 8515

7489, 7747

1182, 7191

7316, 7463

7213, 7293

8540, 9030

402

138,709

8203

Discharge summary

report

Admission Date: [**2155-4-25**] Discharge Date: [**2155-4-30**] Date of Birth: [**2105-9-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracyclines / Plaquenil / Chloroquine / Sulfonamides / Floxin Attending:[**First Name3 (LF) 443**] Chief Complaint: (positive blood cultures) Major Surgical or Invasive Procedure: Hickman line insertion [**2155-4-29**] PICC line insertion [**2155-4-28**] History of Present Illness: 49 y/o with hx. lupus and PAH on flolan who developed night sweats approximately 10 days ago at which time she was started on levaquin as an outpatient. Subsequent to this, her night sweats improved, but on follow up with her outpatient pulmonolgist, peripheral blood cultures were obtained (two days ago, and after 6 days of levaquin) which have grown Gram positive cocci in both aerobic bottles, in clusters, speciation and sensitivity pending. She is admitted for line change by Dr. [**Last Name (STitle) 519**] of surgery. She is in the CCU owing to her flolan infusion. Past Medical History: PMH: Pulmonary artery hypertension treated with Flolan infusion systemic lupus erythematosus (22 years) treated with prednisone and intermittent Plaquenil, mycophenolate, methotrexate, and cyclophosphamide glomerulonephritis in [**2144**] type 2 diabetes fibromyalgia migraines sinusitis frequent urinary tract infections Social History: SH: Denies etoh, illicits. Has never smoked. Family History: FH: negative for CAD Physical Exam: Blood pressure was 117/79 mm Hg while seated. Pulse was 116 beats/min and regular, respiratory rate was 14 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were clear to ascultation bilaterally with normal breath sounds and no adventitial sounds or rubs. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, clubbing or edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Imaging: [**Numeric Identifier 4684**] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [**2155-4-28**] 1:56 PM IMPRESSION: Successful exchange for new 51 cm dual lumen PICC with tip in the SVC, ready for use. . Micro: [**2155-4-25**] Blood Cx: micrococcus spp Catheter Tip: probable micrococcus spp [**4-26**] - [**2155-4-28**] Blood Cx: NGTD . Labs: [**2155-4-25**] 01:43PM PT-19.6* PTT-26.8 INR(PT)-1.9* [**2155-4-25**] 01:43PM WBC-6.0 RBC-4.05* HGB-12.0 HCT-34.9* MCV-86 MCH-29.5 MCHC-34.3 RDW-14.2 [**2155-4-25**] 01:43PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.5* [**2155-4-25**] 01:43PM estGFR-Using this [**2155-4-25**] 01:43PM GLUCOSE-242* UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18 . Operative Report: PREOPERATIVE DIAGNOSIS: Pulmonary hypertension on continuous Flolan drip with need for long-term central venous access. POSTOPERATIVE DIAGNOSIS: Pulmonary hypertension on continuous Flolan drip with need for long-term central venous access. NAME OF PROCEDURE: Placement of 9.6-French single-lumen Hickman catheter via left subclavian vein with fluoroscopy. ASSISTANT: None ANESTHESIA: MAC with local. INDICATIONS FOR PROCEDURE: Ms. [**Known lastname **] is a 49-year-old lady with a history of pulmonary artery hypertension who has been on a Flolan drip through a central venous catheter since [**Month (only) 1096**] of last year. She had an indwelling single-lumen [**Last Name (un) **] catheter in place but was admitted several days ago with a line infection with coagulase-negative Staphylococcus and Micrococcus species. The line was removed on [**4-25**] and she has been receiving intravenous vancomycin via a PICC line in the interim. She presents now for placement of a new tunneled line for the long-term administration of Flolan. The Flolan drip was to be continued throughout this operation via an indwelling PICC line in the right arm. The risks and benefits of this procedure were discussed with the patient and the consent signed. DESCRIPTION OF PROCEDURE IN DETAIL: The patient was identified in the preoperative holding area and taken to the operating room where she was positioned supine on the operating room table with her arms tucked at her side. After the adequate induction of monitored anesthesia, her bilateral upper chest and lower neck were sterilely prepped and draped in the usual fashion. A timeout was performed identifying the patient and the procedure to be performed. Intravenous vancomycin had been administered in the ICU. The left infraclavicular space was anesthetized with a 1:1 mixture of 1% lidocaine with epinephrine and 0.5% Marcaine plain. With the patient placed in the Trendelenburg position, the left subclavian vein was easily accessed on first pass with a needle. A wire was placed centrally by Seldinger technique and confirmed to be in the central circulation by intraoperative fluoroscopy. Additional local anesthetic was infiltrated upon the planned path of tunneling along the left chest wall. An incision was made contiguous with the wire exit site and a counter incision made more inferiorly on the left chest wall. A 9.6-French single-lumen Hickman catheter was then secured to a tunneling device and was then advanced through the tunnel, positioning the cuff in the mid-portion of the tunnel. The catheter was then cut to an appropriate length. A dilator peel-away sheath assembly was advanced over the wire and into the left subclavian vein without resistance. The dilator and wire were removed together with venous backbleeding from the sheath. The catheter was advanced through the sheath which was in turn removed. The tip of the catheter was located in the proximal right atrium by intraoperative fluoroscopy. The catheter was secured at the skin exit site with a single 2-0 Prolene suture. The catheter easily aspirated venous blood and was flushed with dilute heparinized saline and then with heparinized saline 100 units per mL. Sterile dressings were applied. The patient tolerated the procedure well. There were no complications. She was transferred back to the intensive care unit in good condition. Brief Hospital Course: # Bacteremia: Most likely source is permanent Flolan catheter which was removed. Blood cultures from [**2155-4-23**] showed 2/2 bottles with gram positive cocci, probable micrococcus spp. She was started on Vancomycin empirically and monitored with daily serial blood cultures, all negative since initial antibiotic therapy. Once blood cultures were negative for 2 consecutive and surgery successfully placed a new Hickman catheter for Flolan administration. Patient remained afebrile and had a successful PICC placement for the remainder of her Vancomycin therapy. . # Pulmonary artery hypertension: Likely secondary to lupus. Patient was maintained on Flolan infusion through peripheral IV until central access was obtained. She was also continued on prednisone. She was maintained on heparin anticoagulation while in house for her pulmonary artery hypertension and anti-phospholipid antibodies, and outpatient warfarin was held due to procedures. Patient had a successful Hickman catheter placement for Flolan infusion. She was started on Lovenox prior to discharge as a bridge to Warfarin and was to have her INR checked as an outpatient. . . After discussion with the patient and the medical staff, all were in agreement that [**Known firstname **] [**Known lastname **] was a suitable candidate for discharge. Medications on Admission: fluconazole 150 daily tylenol#3 [**1-21**] prn gabapentin 1800, once daily Warfarin 1 mg daily fluticasone nasal spray fexofenadine Ambien premarin allopurinol Metformin 850 [**Hospital1 **] Discharge Medications: 1. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Start after 2 days of 5mg daily of coumadin. Disp:*30 Tablet(s)* Refills:*0* 7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Line Maintenance Line Maintenance as per CCS protocol. 12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 8 days. Disp:*16 * Refills:*0* 13. Amitriptyline 50 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 14. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily) for 2 days. Disp:*10 Tablet(s)* Refills:*0* 15. Outpatient Lab Work Patient will require INR levels every 3 days and these will need to be faxed to VNA of [**Hospital3 **]. 16. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous once a day for 14 days. Disp:*14 14* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Catheter-related bloodstream infection . Secondary diagnoses: Systemic lupus Pulmonary artery hypertension Lupus anticoagulant Discharge Condition: Vital signs stable, afebrile, with new Flolan infusion access and consecutive negative blood cultures. Discharge Instructions: You were admitted due to infection from your Flolan infusion IV line. You were treated with antibiotics and your line was changed. You should continue to take the antibiotic as prescribed and complete the whole course, even if your symptoms resolve. Please call your physician or return to the emergency room if you notice fevers, chills, night sweats, or any other concerning symptoms. Your Fluconazole was stopped due to elevated liver enzymes - please don't restart this until instructed by your doctor. You will be taking 5mg daily of coumadin for 2 days, and then decreasing your dose back to 1mg daily. Please have your INR(coumadin level) checked by your visiting nurse in a few days. Continue your daily Lovenox injections until your coumadin level is normalized. Vancomycin (antibiotic) will be continued twice daily for 8 more days through your PICC line. Followup Instructions: Please follow-up with your pulmonologist in [**1-21**] weeks after discharge. . Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2155-5-28**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2155-5-13**] 10:30 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2155-5-13**] 10:30 Completed by:[**2155-5-7**]

[ "416.9", "729.1", "428.0", "346.90", "996.62", "250.00", "710.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.07", "86.05" ]

icd9pcs

[ [ [] ] ]

10190, 10251

7201, 8525

363, 440

10422, 10527

3036, 7178

11449, 11926

1469, 1492

8767, 10167

10272, 10313

8551, 8744

10551, 11426

1507, 3017

10334, 10401

298, 325

468, 1045

1067, 1390

1406, 1453

24,335

118,282

44044

Discharge summary

report

Admission Date: [**2142-3-26**] Discharge Date: [**2142-4-17**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 9240**] Chief Complaint: abdominal, L groin pain Major Surgical or Invasive Procedure: ERCP with major papillotomy History of Present Illness: This 84 yo female with multiple medical issues including diabetes has been experiencing several months history of nausea and NBNB vomiting. SHe was initially scheduled for outpatient evaluation by her pcp. [**Name10 (NameIs) **] presented [**2142-3-26**] with worsening abominal pain and was initially worked up for gastroparesis, with normal gastric emptying study. She became hypotensive with syncope and anemic [**3-31**], prompting transfer to [**Hospital Unit Name 153**] and requiring 3U PRBCs for what was discovered to be internal bleeding secondary to L groin and R psoas hematomata. After transfusion, she stabilized in the [**Hospital Unit Name 153**]. Vascular consultation suggested conservative management as she is a poor operative candidate. Her L knee was tapped [**4-1**] for swelling and tenderness; crystal analysis was consistent with pseudogout. She was transferred to the floor [**4-2**] for continued rehabilitation and placement. No clear cause of the spontaneous hematomata were identified. There was no known trauma. Initial PTT values measured in the hospital were 71, which was attributed to systemization of sQ heparin injections (DVT prophylaxis). She c/o numbness in the right lateral thigh area (suggestive of compression of right lateral femoral cutaneous nerve). Past Medical History: DM on insulin c/b retinopathy CVA x 3 many years ago - no residual neuro defects CAD with RCA stent [**2134**] hypothyroidism arthritis gout HTN hyperlipidemia Csection x 2 Social History: Born in [**Country 18084**] and came to US in [**2091**]. Lives at home with her son. walks independently. Retired [**Hospital1 18**] housekeeping/supply room worker. denies tobacco (past 1pp week x 30y quit 30y ago), no EtOH, no other drugs, herbs, vitamins. Family History: mother with DM and CAD, no cancer in family Physical Exam: PE-VS 96.9 114/72 83 18 97% RA Pleasant elderly female, cooperative, NAD. HEENT- no icteris, MM dry, no LAD, no goiter, no bruits Lungs CTA B anteriorly RRR S1S2 no m/r/g Abd BLQ ecchymoses from previous injections Groin 2+ B femoral pulses, pain on palpation of L groin but no palpable mass. Extr: Trace BLE edema, L?R knee swelling, 2+B DP pulses Pertinent Results: [**2142-3-26**] 02:40PM GLUCOSE-182* UREA N-49* CREAT-1.9* SODIUM-136 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16 [**2142-3-26**] 02:40PM estGFR-Using this [**2142-3-26**] 02:40PM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-99 AMYLASE-66 TOT BILI-0.5 [**2142-3-26**] 02:40PM LIPASE-37 [**2142-3-26**] 02:40PM CALCIUM-10.3* PHOSPHATE-3.4 MAGNESIUM-2.3 [**2142-3-26**] 02:40PM WBC-12.2*# RBC-3.54* HGB-11.4* HCT-33.6* MCV-95 MCH-32.1* MCHC-33.8 RDW-14.8 [**2142-3-26**] 02:40PM NEUTS-75.1* LYMPHS-18.3 MONOS-4.2 EOS-0.8 BASOS-1.5 [**2142-3-26**] 02:40PM MACROCYT-1+ [**2142-3-26**] 02:40PM PLT COUNT-236 [**2142-3-26**] 02:40PM PT-12.3 PTT-24.8 INR(PT)-1.1 . abd XR: Calcific density seen overlying the left upper quadrant, likely corresponding to splenic artery calcifications seen on prior CT. Tiny calcific density overlying right upper quadrant, possibly within rib costocartilage or small gallstone. . gastric emptying study: Normal gastric emptying . bilat hip XR: Stable mild degenerative changes of both hips without signs for acute bony injury. . abd/pelvic CT: 1. New large hematoma of the left groin and smaller hematoma of the right iliopsoas. A few small foci of hyperdensity within the left groin hematoma suggest slow bleeding into the hematoma. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. 3. Subcentimeter right renal hypodense lesion is too small to characterize but probably a cyst. 4. Stable appearance of the pancreas including pancreas divisum with associated prominent pancreatic duct. . L femoral vasc U/S: 1. Reidentification of known left groin hematoma with no evidence of left common femoral pseudoaneurysm or AV fistula. . MRCP w secretin: 1. Dilated main pancreatic duct and duct of Santorini with divisum. Sanorinicele with persistence of main ductal dilatation and multiple mildly dilated side branches after secretin indicates papillary dysfunction. No mass. Pancreatic exocrine function at the lower limits of normal. 2. Small bilateral pleural effusions. . RUQ U/S: 1. Small gallstones and tumefactive sludge without evidence of cholecystitis. 2. Mildly prominent pancreatic duct consistent with MR results from a day prior. Please see report from MR study for further details. . ERCP: Mildly dilated common bile duct with small filling defects in distal CBD consistent with sludge. Major papillotomy performed. Brief Hospital Course: 1.) Retroperitoneal Hematomata- likely due to accumulation of prophylactic sc heparin. Vascular was consulted. Vascular U/S showed no fistula or other abnormality. Hct subsequently stabilized and vascular did not recommend operative management. Patient walking with minimal pain at discharge. 2.) Biliary Obstruction: due to sludge and pancreatic divisum. ERCP was done with major paillotomy, to which the patient responded well. If her obstruction recurrs she may need a minor papillotomy. Her pain subsequently resolved and she was tolerating a diet. 3.) DM/gastroparesis- cont. [**Hospital1 **] NPH, SS insulin, Reglan 4.) Dispo- to rehab Medications on Admission: 1. Aspirin 325 mg daily 2. Valsartan 160 mg daily 3. Atenolol 50 mg daily 4. Levothyroxine 100 mcg daily 5. Imipramine HCl 25 mg daily 6. Atorvastatin 40 mg daily 7. Allopurinol 100 mg daily 8. NPH 20 units [**Hospital1 **] 9. RISS 10. Pantoprazole 40 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Imipramine HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous twice a day. 10. Insulin Regular Human Subcutaneous Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: PRIMARY: Biliary Obstruction Pancreatic Divisum Left Spontaneous Retroperitoneal Bleed SECONDARY: Diabetes type 2 Hypertension Coronary Artery Disease Gout Discharge Condition: Good--tolerating food and liquids. Discharge Instructions: 1. Take medications as prescribed. No changes were made in your regimen. 2. Follow up as below. 3. Please call Dr. [**Last Name (STitle) 16258**] or Dr. [**First Name (STitle) 679**] with recurrent nausea, vomiting, abdominal pain, fevers, diarrhea, or any other symptoms that concern you. Followup Instructions: Please call Dr. [**Last Name (STitle) 16258**] for a follow up appointment in next 2 weeks. Please follow up with Dr.[**Name (NI) 16937**] office: [**4-16**], Monday 1:15 pm

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icd9cm

[ [ [] ] ]

[ "51.85", "99.04", "81.91" ]

icd9pcs

[ [ [] ] ]

6680, 6765

4951, 5594

239, 269

6966, 7003

2538, 4928

7345, 7523

2100, 2145

5905, 6657

6786, 6945

5620, 5882

7027, 7322

2160, 2519

176, 201

297, 1608

1630, 1805

1821, 2084

62,237

104,649

49435

Discharge summary

report

Admission Date: [**2141-4-17**] Discharge Date: [**2141-4-25**] Date of Birth: [**2064-11-21**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: Injuries after Motor Vehicle Accident Major Surgical or Invasive Procedure: Chest tube thoracostomy History of Present Illness: 76F restrained driver in MVC, car hit wall @ 65 mph at 2 pm on [**4-17**], air bag deployed. Transferred from OSH after found to have 33% L PTX, multiple rib fx, sternal fx, cardiac contusion. Denies head trauma, no LOC. At this point her spine has not yet beencleared. Past Medical History: HTN, PVD s/p aortic endarterectomy ([**2131**]), HLD, hyperthyroidism, ovarian CA ([**2117**]), thrombocytosis ([**2133**]), GERD, osteopenia, cataracts Social History: Married Retired [**Hospital1 18**] Pathologist Family History: Non-contributory Physical Exam: Gen: WD/WN, comfortable, NAD. Neck: Supple. Lungs: CTA bilaterally, nonlabored breathing; CT in place Cardiac: RRR. Abd: Soft Back: Tender over inferior thoracic spine Extrem: Warm and well-perfused. Neuro: AAO x3 Pertinent Results: [**2141-4-18**] 12:15AM BLOOD WBC-21.3*# RBC-4.49 Hgb-14.3 Hct-44.0 MCV-98 MCH-31.8 MCHC-32.5 RDW-14.8 Plt Ct-365 [**2141-4-18**] 07:22PM BLOOD WBC-19.1* RBC-4.13* Hgb-12.8 Hct-40.0 MCV-97 MCH-31.1 MCHC-32.1 RDW-15.2 Plt Ct-326 [**2141-4-19**] 01:35AM BLOOD WBC-20.2* RBC-4.03* Hgb-13.0 Hct-38.6 MCV-96 MCH-32.1* MCHC-33.5 RDW-15.6* Plt Ct-249 [**2141-4-20**] 02:21AM BLOOD WBC-21.7* RBC-4.29 Hgb-13.9 Hct-41.6 MCV-97 MCH-32.5* MCHC-33.5 RDW-15.5 Plt Ct-324 [**2141-4-21**] 05:05AM BLOOD WBC-17.7* RBC-4.25 Hgb-13.5 Hct-41.7 MCV-98 MCH-31.8 MCHC-32.4 RDW-15.0 Plt Ct-398 [**2141-4-24**] 06:30AM BLOOD WBC-23.4* RBC-3.98* Hgb-13.5 Hct-39.3 MCV-99* MCH-33.8* MCHC-34.3 RDW-14.9 Plt Ct-402 [**2141-4-18**] 12:15AM BLOOD Neuts-94.3* Lymphs-3.3* Monos-1.7* Eos-0.2 Baso-0.5 [**2141-4-22**] 07:18AM BLOOD Neuts-88.9* Lymphs-5.1* Monos-4.1 Eos-1.5 Baso-0.4 [**2141-4-22**] 07:18AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-1+ Spheroc-1+ Ovalocy-NORMAL Schisto-1+ Burr-1+ [**2141-4-20**] 02:21AM BLOOD PT-11.9 PTT-55.0* INR(PT)-1.0 [**2141-4-18**] 12:15AM BLOOD Glucose-173* UreaN-29* Creat-1.3* Na-141 K-5.3* Cl-108 HCO3-22 AnGap-16 [**2141-4-24**] 06:30AM BLOOD Glucose-107* UreaN-28* Creat-1.3* Na-138 K-4.5 Cl-101 HCO3-28 AnGap-14 [**2141-4-18**] 12:15AM BLOOD ALT-150* AST-175* AlkPhos-92 TotBili-0.7 [**2141-4-20**] 02:21AM BLOOD ALT-74* AST-40 AlkPhos-77 TotBili-1.2 [**2141-4-18**] 12:15AM BLOOD CK-MB-13* cTropnT-0.01 [**2141-4-22**] Radiology RENAL U.S. IMPRESSION: Essentially normal renal ultrasound. [**2141-4-18**] Radiology CHEST (PORTABLE AP) Left chest tube is in place and no definite pneumothorax is appreciated. There are several areas of lucency at the left base laterally, it could represent pockets of localized pneumothorax. [**2141-4-18**] Radiology CT T-SPINE W/O CONTRAST IMPRESSION: 1. T12 compression fracture with retropulsion of the superior endplate, causing anterior thecal sac deformity, apparently the pedicles are not involved. 2. Moderate anterior wedging of the T8 vertebral body with no evidence of retropulsion, the possibility of a subacute fracture or acute fracture at this level cannot be completely ruled out. 3. Irregular contour of the spinous processes at T9 and T10 levels with sclerotic changes, the possibility of acute fractures cannot be completely ruled out, if there is any suspicion for spinal cord injury, ligamentous injury or other fractures, correlation with MRI of the thoracic spine is recommended if clinically warranted. 4. Bilateral lung opacities, likely related with a combination of atelectasis and aspiration and also possibly pulmonary contusions. 5. Anterior wedging of the T8 vertebral body, an acute/subacute fracture in this vertebral body cannot be completely ruled out. 6. Bilateral wedge renal hypodensities, suggesting multiple renal infarcts, laceration or contusion are also considerations. The left anterior pneumothorax described on the prior CT of the torso is not included in this examination. Brief Hospital Course: Dr. [**Known lastname **] was admitted to the TSICU after being transfered to [**Hospital1 18**] s/p high speed MVC with resulting injuries. She sustained a pneumothorax in the accident and had a chest tube placed prior to her transfer to [**Hospital1 18**] with resolution of the pneumothorax on the 1st follow up film. The tube was subsequently put to water seal without re-accumultation of the PTX and ultimately reomved without incident. She was also diagnosed with a chronic SDH and an acute T12 compression fracture for which Neurosurgery was consulted and recommended a TLSO when HOB>45 or out of bed (inculding showering). The brace should be worn as instructed until follow up with Neurosurgery. Dr. [**Known lastname **] will need to follow up with neurosurgery 8 weeks post discharge with a non-contrast CT Head and non-contrast T-spine. Nephrology was consulted for Dr.[**Name (NI) 103480**] acute renal failure (baseline Cr 0.6), which was initially thought to be secondary to contrast nephropathy however her Cr at the sending facility prior to her CT scan was elevated at 1.3 She will need to follow up with nephrology as an outpatient 1-2 weeks post discharge. Hematology was consulted due to a persistent leukocytosis with an abnormal peripheral smear. Initially the leukocytosis was postulated to be the result of a stress response, but given its persistence and abnormal smear Hematology was consulted. After their evaluation given the lack of any symptoms and the possibility that this may be an acute stress response and not a primary blood dyscrasia they recommended follow up in 1 week with a CBC with diff prior to that appointment. Dr. [**Known lastname **] was transfered to the floor where she remained afebrile with stable vital signs, tolerating a regular diet, and with adaquate pain control inculding on the day of her discharge. PT worked with Dr. [**Known lastname **] and recommended rehab. Medications on Admission: Toprol, Lipitor Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain: Do not drink, drive or operate machinery while taking this medication. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for constipation. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain: Do not drink, drive or operate machinery while taking this medication. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Lipitor 10 mg Tablet Sig: 0.5 Tablet PO qpm. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**] Discharge Diagnosis: 1) T12 compression fracture 2) Right [**7-18**] rib fractures 3) Left [**12-13**] rib fractures 4) Left Pneumothorax 5) Bilateral Pulmonary Contusions 6) Subacute subdural hematoma 7) Acute renal failure 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 [**Hospital1 69**] after sustaining injuries in a motor vehicle accident. A chest tube was placed to treat your pneumothorax, and was removed prior to your discharge. You were diagnosed with a compression fracture of your 12th thoracic vertebral body, and will need to wear the TLSO brace that you were given while in the hospital anytime the head of your bed is elevated greater than 45 degress or you are out of bed (including showering). You will need to use this brace until your follow up appointment with Neurosurgery in eight weeks. Followup Instructions: Follow up with Neurosurgery in four weeks. Call ([**Telephone/Fax (1) 26566**] to schedule a follow- up appointment in 8 weeks, with a Non-contrast CT scan of the head, and CT of the thoracic spine(without contrast). The Neurosurgery office is located in the [**Hospital **] Medical Building, [**Hospital Unit Name 12193**]. Follow up with Nephrology in [**12-10**] weeks to have your renal function checked to ensure it is recovering. Call for an appointment ([**Telephone/Fax (1) 10135**] Follow up with Hematology: Call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9840**] for appointment in 1 week please have a repeat CBC with differential prior to the appointment [**Telephone/Fax (1) 103481**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7476, 7568

4205, 6143

310, 336

7816, 7816

1161, 4182

8587, 9440

893, 911

6209, 7453

7589, 7795

6169, 6186

7999, 8564

926, 1142

233, 272

364, 637

7831, 7975

659, 813

829, 877

5,313

183,404

14928

Discharge summary

report

Admission Date: [**2191-7-9**] Discharge Date: [**2191-7-15**] Date of Birth: [**2118-12-29**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: This is a 72-year-old male with hypertension and hyperlipidemia transferred from [**Hospital3 1442**] Hospital for treatment of a biliary obstruction and further Intensive Care Unit management of multiorgan failure. The patient sought medical attention in early [**2191-5-21**] at [**Hospital3 1443**] Hospital after developing the gradual onset of dyspnea, left shoulder pain, low-grade fevers, and a 30-pound weight loss. A chest x-ray suggested bibasilar consolidation, with chest CT showing mediastinal and hilar adenopathy as well. He was treated for community-acquired pneumonia with clinical improvement and was discharged from the hospital. He presented again later in the month with right lower extremity swelling and shortness of breath. He was diagnosed with deep venous thrombosis and pulmonary embolism. The patient underwent a hypercoagulability workup which showed he was heterozygous for the factor V Leiden. He was placed on enoxaparin and Coumadin and discharged from the hospital; eventually achieving a supratherapeutic INR. He returned to the hospital on [**6-29**] with new left lower extremity pain, and swelling, and increased dyspnea, as well as fever and was found to have a new left lower extremity deep venous thrombosis and likely recurrent pulmonary emboli despite anticoagulation. His subsequent hospital course was complicated. He received [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter and underwent a malignancy workup including an abdominal CT which revealed pancreatic fullness. A CA19-9 level measured greater than 3000, suspicious for pancreatic cancer. He developed increasing abdominal distention with ascites and visible jaundice with total bilirubin of greater than 10, and an alkaline phosphatase level of greater than 1000. An endoscopic retrograde cholangiopancreatography was attempted on two occasions; however, the bile duct could not be cannulated. In the midst of this, he developed multiorgan failure with hypoxemic respiratory failure and oliguric renal failure, requiring intubation, fluid resuscitation, and the institution of pressors and antibiotics. He was noted to be in right heart failure; presumably as a result of multiple pulmonary emboli. He was transferred to [**Hospital1 346**] for biliary drainage and further management of his multiorgan dysfunction. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of positive purified protein derivative. 3. Hypercholesterolemia. 4. Low back pain. 5. Gastroesophageal reflux disease. MEDICATIONS ON TRANSFER: Medications on transfer included heparin drip, Flagyl, gentamicin, vancomycin, Protonix, Unasyn, morphine as needed, as well as Ativan as needed. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was married with one son and daughter. [**Name (NI) **] is a retired mailman. He is a former tobacco user; having a 60-pack-year history and quit 10 years ago. No history of ethanol abuse. FAMILY HISTORY: Family history was positive for coronary artery disease in his father. [**Name (NI) **] cancer in his mother and brother. [**Name (NI) **] had a brother with prostate cancer. Another brother had kidney cancer. Another brother had pancreatic cancer. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on presentation revealed an intubated, sedated, obese, elderly, white male. His temperature was 100.6, heart rate was 126, blood pressure was 95/66, respiratory rate was 22, SpO2 was 96% on assisted control ventilation, 800 X 22, with an FIO2 of 1.00. Head, eyes, ears, nose, and throat revealed scleral icterus. Pupils were constricted and sluggish. The oropharynx was edentulous with an endotracheal tube in place. Neck was full with a right internal jugular venous catheter in place. Heart was tachycardic and regular with a right ventricular heave. Lungs revealed crackles at the right base; otherwise, clear anteriorly. The abdomen was markedly distended. No guarding or rebound. Decreased breath sounds. Positive fluid wave. Extremities revealed 2+ pitting edema bilaterally. The extremities were cool. Pulses were dopplerable. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission to [**Hospital1 69**] showed a white blood cell count of 25.9 (with 84% neutrophils and 8% bands), hematocrit was 37.2, platelets were 654. PT was 19.2, INR was 2.6, PTT was 77.7. Sodium was 132, potassium was 5.1, chloride was 97, bicarbonate was 17, blood urea nitrogen was 66, creatinine was 3.7, blood glucose was 118. Total bilirubin was 13.2, AST was 77, ALT was 42, alkaline phosphatase was 814, albumin was 2.1. Calcium was 7.9, magnesium was 2.3, phosphate was 7.9. Vancomycin level was 16.3. Urinalysis revealed a specific gravity of 1.025, cloudy/brown with large blood, pH was 6.5, trace ketones, protein of 30, large amount of urobilinogen, red blood cells of [**Pager number **], white blood cells of 4, no bacteria. Urine sodium was less than 10. Urine eosinophils were not seen. Arterial blood gas on the above-listed ventilatory settings showed a pH of 7.34, PCO2 of 33, PO2 of 139, lactate measured 2.4. HOSPITAL COURSE: The patient was transferred to [**Hospital1 346**] for further management of biliary obstruction and multiorgan dysfunction. He underwent immediate endoscopic retrograde cholangiopancreatography with biliary drainage and stenting. The drainage was noted to be purulent and ultimately grew out enterococcus, coagulase-negative Staphylococcus, and lactobacillus. He was placed on broad spectrum antibiotics, including piperacillin, and tazobactam, levofloxacin, and vancomycin. He was maintained on assist-control ventilation with high positive end-expiratory pressures to maintain oxygenation and to compensate for his high pleural pressures, as extrapolated from esophageal balloon measurements. A Swan-Ganz catheter was placed which revealed a high cardiac index and low systemic vascular resistance, consistent with septic shock. His pulmonary artery pressures were severely elevated, presumably as a result of massive pulmonary emboli. He required pressors despite adequate volume resuscitation. He was noted to have gram-negative species in his sputum, and chest imaging revealed a moderate, multiloculated, right-sided pleural effusion with associated consolidation. He underwent a thoracentesis under ultrasound guidance which showed an exudative process with a pH of 7.1, and a glucose of less than 60. A chest tube was placed for drainage, as it was determined under surgical consultation that he would unlikely tolerate a video-assisted thoracotomy. He underwent multiple therapeutic paracenteses in order to assist with his ventilator management, given a markedly distended abdomen. The peritoneal fluid was sterile, though had a low serum albumin to ascites gradient, consistent with peritoneal carcinomatosis. Cytology from the peritoneal specimen ultimately showed adenocarcinoma. The hepatobiliary Surgical Service followed closely throughout his hospitalization; however, the patient continued to deteriorate. He continued to require pressors and fluids with continued high fevers and worsening renal function. Given his grave prognosis, his family ultimately elected to withdraw further care; taking into account the patient's prior stated wishes. The patient was extubated on [**7-15**]. He was pronounced dead shortly thereafter at 4:15 p.m. His family was present at the bedside. Postmortem examination was declined. DISCHARGE DIAGNOSES: 1. Adenocarcinoma; presumably of pancreatic origin. 2. Biliary sepsis. 3. Multiorgan failure. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 23338**] MEDQUIST36 D: [**2191-8-2**] 17:17 T: [**2191-8-9**] 19:05 JOB#: [**Job Number 43742**]

[ "584.9", "789.5", "276.5", "453.8", "038.9", "415.19", "576.1", "518.81", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.72", "38.91", "34.91", "96.04", "54.91", "51.87", "99.15" ]

icd9pcs

[ [ [] ] ]

3150, 5312

7704, 8092

5330, 7683

162, 2525

2727, 2912

2547, 2701

2929, 3133

68,162

126,761

38942+58246+58252

Discharge summary

report+addendum+addendum

Admission Date: [**2192-3-30**] Discharge Date: [**2192-4-3**] Date of Birth: [**2135-8-16**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5378**] Chief Complaint: Fall, seizure Major Surgical or Invasive Procedure: None History of Present Illness: This note is written with information provided by records from EMS and OSH ([**Doctor First Name 5279**] Med. Center in [**Location (un) 5450**], NH). There is no telephone contact number for any relatives or her boyfriend either in EMS or [**Name (NI) 5279**]??????s notes. This is a 56yo woman with a PMH remarkable for ETOH abuse/dependence (she denies current intake), asthma, HTN brought in by EMS from [**Hospital 5279**] Hospital in [**Location (un) 5450**], NH. Per EMS reports, patient was at home today when she was found down by her husband/ boyfriend and subsequently had a seizure; seizure activity, including posturing, witnessed by EMS on arrival. It was described as a GTC episode. We do not know whether the pt fell and seized or initially seized. During the examination she was able to interact with the team (though intubated, nodding or shaking her head). She denied having a seizure disorder or seizures in the past. She also denied current ETOH. She confirms that she remembers falling down the stairs. She was not pushed. At OSH, patient was noted to have ecchymoses over R eye and was intubated after several episodes of emesis. BPs were elevated to 210s/120s. No FSG was noted. CT head and c-spine were verbally reported to be negative, but no reports accompanied patient. We saw the films: they are of very poor quality. She had no evidence of a bleed or a fracture in her CNS scan. The ventricles looked normal. C-spine was normal too. On arrival in the ED at [**Hospital1 18**] her FSBG was 162. She was immediately transferred to the TSICU where we met her. Past Medical History: HTN Asthma ETOH abuse/dependence Osteoporosis Arthritis Social History: Reported ETOH abuse/dependence. Tobacco 1ppd x 20yrs. Married, lives w/ husband. Family History: Not obtained Physical Exam: Physical Exam: propofol 60mcg/kg/min, stopped 3 minutes prior to our examination VS- 99.7, 81, 127/65, RR 24, 100%on CPAP 50, FIO2 50% Gen- Overweight, appears stated age, intubated, Skin- Pinpoint, non-raised, non-blanching erythematous rash on upper torso, L upper arm, R arm to fingers; purple/pink ecchymoses on lateral R eyelid, R shoulder, R MCPs, R lateral ankle CV- RRR; S1S2; no m/r/g Lungs- CTA-BL Abd- +BS; soft; ND; Bowel sounds +. no grimace to palpation Extremities: erythema in her RIGHT maleolus in ankle. Same in her right knuckles. Lines/Tubes- 2 PIVs, foley, OG. No central line access. Neuro *Mental status: Alert (without propofol); responds to voice; following axial and appendicular verbal commands; nodding to yes/no questions *Cranial nerves: PERRLA (3mm to 2mm); EOMI; no nystagmus, corneal, gag reflex intact; no facial asymmetry *Motor: moving 4 limbs spontaneously, purposefully against gravity; increased tone in BL LE; normal tone in UE *Sensation: Intact to light touch; unable to adequately test pain/temp/vibration due to communication, cooperation difficulties *Reflexes: Pa 3+; [**Hospital1 **] 1+; BR 1+, ankles absent, downgoing toes Pertinent Results: ADMISSION LABS [**2192-3-30**] 11:26PM NA+-119* K+-4.6 CL--84* TCO2-30 GLUCOSE-100 UREA N-8 CREAT-0.6 SODIUM-117* POTASSIUM-2.1* CHLORIDE-76* TOTAL CO2-29 ANION GAP-14 CALCIUM-8.6 PHOSPHATE-1.7* MAGNESIUM-2.5 URIC ACID-4.4 LACTATE-0.9 K+-2.0* freeCa-1.02* LIPASE-109* ALT(SGPT)-55* AST(SGOT)-81* ALK PHOS-96 TOT BILI-1.4 EEG Study Date of [**2192-4-1**] IMPRESSION: Abnormal portable EEG due to the very low voltage beta rhythm background with bursts of generalized slowing. These findings appear most likely to represent medication effect. The overall impression is that of an encephalopathy, likely due to the medication. There were no focal abnormalities, but encephalopathies may obscure focal findings. There were no epileptiform features. CT HEAD W/O CONTRAST Study Date of [**2192-3-30**] 4:25 PM IMPRESSION: 1. No intracranial hemorrhage or acute intracranial abnormality. 2. Moderate right frontal subgaleal hematoma. 3. Pansinus disease with mucosal thickening throughout the paranasal sinuses. Soft tissue densities in the inferior maxillary sinuses may represent mucus retention cysts. 4. Fluid in the sphenoid air cells, likely related to intubation. CT CSPINE IMPRESSION: 1. No fracture or malalignment of the cervical spine. Mild degenerative changes without appreciable canal narrowing. 2. Fragment of bone at C7 spinous process noted, without soft tissue changes indicating old trauma or unfused apophyses. IMPRESSIONS: 1. No fracture or traumatic injury to the torso. 2. Moderate dependent atelectasis in the lungs, without consolidation or effusion. 3. No peripancreatic inflammatory change. Note that this does not rule out pancreatitis. In the absence of IV contrast, cannot assess for sequelae of pancreatitis. 4. Fatty liver. 5. 8-mm right adrenal adenoma. 6. 2.4 cm lobulated low-attenuation cystic structure adjacent to the left ovary, likely a paraovarian or ovarian cyst. Ultrasound may be useful for further characterization, but the ovary is located high in the pelvis and may be difficult to visualize. If so, MRI can be obtained. 7. Fatty infiltration of the terminal ileum, which can be a normal finding in patients without inflammatory bowel disease. No imaging findings to suggest IBD. 8. Moderate diverticulosis without diverticulitis. 9. Gallbladder likely filled with sludge, although without evidence of acute cholecystitis. 10. 8 mm nodular density in the left lower lobe appears to have supplying and draining vessels, although respiratory artifact limits assessment. This may represent a pulmonary AVM. Contrast enhanced chest CT recommended for further assessment, after recovery from acute event. Brief Hospital Course: Ms. [**Known lastname 86386**] is a 56 year old woman who was transferred from [**Hospital 5279**] hospital with report of fall and seizure. NEURO: The patient was intubated and sedated when she arrived from [**Hospital 5279**] hospital. Neurology was consulted and she was treated with dilantin initally and subsequently transitioned to Keppra. While her mental status seemed significantly impaired post extubation, she cleared quickly over the course of her hospitalization. There was no further seizure activity noted; eeg was notable for encephalopathy. The patient was seen by physical therapy and was discharged with a walker for ambulation. She was instructed to follow up with her PCP as well as a local neurologist. At the time of discharge, the patient was slightly dysmetric (R>L), slightly inattentive with normal strength, though she and her family felt that she was close to baseline. Legs had increased tone, bilaerally. FEN: The patient was hyponatremic (114) on admission to [**Doctor First Name **] hospital. While here, she recieved IF fluids to correct her hyponatremia. She was treated with multivitamins throughout her hospitalization. At the time of discharge, serum sodium was HEME: The patient was noted to have a microcytic anemia. B12 levels where elevated (post IV vitamin supplementation). She was instructed to take a supplement with thiamin and folate. She should have a CBC and ID: Ms. [**Known lastname 86386**] had low grade temperatures. Urine and blood studies where without evidence of ifection. No antibiotics where given. Medications on Admission: HCTZ Zocor Citalopram Discharge Medications: 1. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Zocor Oral 4. Hydrochlorothiazide Oral 5. Citalopram Oral Discharge Disposition: Home Discharge Diagnosis: 1) Mechanical Fall 2) Generalized tonic clonic seizure 3) Alcohol Abuse 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 following a fall and a seizure. You where started on a new seizure medication called Keppra. You should take this medication until instructed otherwise. You will need to follow up with a neurologist. Because of your seizure, you cannot drive for at least 6 months. We encourage you to stop drinking, as this is one of the best things you can do for your health. Followup Instructions: Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 19395**], MD [**Last Name (un) 86387**] [**Location (un) 5450**], [**Numeric Identifier 86388**] ([**Telephone/Fax (1) 86389**] Appointment: [**4-5**] 1:30 Neurology: Dr. [**Last Name (STitle) 86390**] will be making a referral for you with a local neurologist. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**] Completed by:[**2192-4-3**] Name: [**Known lastname 13675**],[**Known firstname 13676**] Unit No: [**Numeric Identifier 13677**] Admission Date: [**2192-3-30**] Discharge Date: [**2192-4-3**] Date of Birth: [**2135-8-16**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3273**] Addendum: Addendum to brief hospital course Please note, pt had a macrocytic anemia SOCIAL: The patient had a history of alcohol abuse. While she had been sober for some time, she began drinking again in [**2191-7-27**] when she lost her job. She was encouraged to stay sober and seek appropriate community support, counseling. Discharge Disposition: Home [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 3275**] MD, [**MD Number(3) 3276**] Completed by:[**2192-4-4**] Name: [**Known lastname 13675**],[**Known firstname 13676**] Unit No: [**Numeric Identifier 13677**] Admission Date: [**2192-3-30**] Discharge Date: [**2192-4-3**] Date of Birth: [**2135-8-16**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3273**] Addendum: Seizure was likely secondary to alcohol abuse with subsequent hyponatremia. Encephalopathy was felt to be multifactorial and secondary alcohol abuse, hyponatremia, sedatives required for intubation, as well as a post-ictal confusion. Sodium at discharge was normal at 139. Discharge Disposition: Home [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 3275**] MD, [**MD Number(3) 3276**] Completed by:[**2192-5-4**]

[ "571.8", "303.90", "401.9", "348.39", "733.00", "780.39", "715.90", "E937.8", "E849.7", "920", "276.9", "276.1", "562.10", "493.90", "E880.9", "276.8", "518.89", "227.0", "959.01" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

10746, 10911

6048, 7628

329, 336

8066, 8066

3379, 6025

8655, 9864

2155, 2169

7700, 7921

7971, 8045

7654, 7677

8246, 8632

2199, 2799

276, 291

364, 1961

2954, 3360

8081, 8222

1983, 2041

2057, 2139

2,293

141,335

15894+56705

Discharge summary

report+addendum

Admission Date: [**2128-11-26**] Discharge Date: [**2128-12-13**] Date of Birth: [**2069-8-10**] Sex: F Service: Blue General Surgery HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 45627**] is a 59-year-old female who is otherwise healthy, who presented with a several month history of distal bile duct stricture, jaundice, and a 37 pound weight loss occurring over approximately four months. She had undergone four prior ERCPs that had ultimately been stented. Recently prior to her Whipple procedure, she underwent a esophagogastroduodenoscopy with stent change by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and this had shown a mass pushing on the duodenum consistent with a pancreatic adenocarcinoma. Interesting in her preoperative workup, she had undergone an pancreatic head mass, although this was nondefinitive. She had prior CT scans that really did not show anything consistent with an actual mass. Although on her prior scans, they did show a segment seven lesion in the liver that was approximately 1.5 cm in diameter that was suspicious for possible metastatic disease. After informed consent has been obtained, the patient was consented to a Whipple procedure, wedge liver biopsy, lymph node biopsy, and cholecystectomy. She was admitted to the [**Hospital1 69**] on [**2128-11-26**]. She underwent a Whipple procedure with a wedge liver biopsy, lymph node biopsy, and cholecystectomy. She got an antecede pancreaticojejunostomy, antecede choledochojejunostomy, and gastrojejunostomy. There was a pancreatic stent left as well as a T tube placed, as well as having [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain placed near the biliary anastomosis. She had a 1500 cc estimated blood loss, 400 cc urine output during the operation, and received 8.5 liters of Crystalloid. She recovered well from the operation, and she was extubated in the operating room, and was sent to the floor, where she did well over the next several days postoperatively. Her bowel function was watched and she was given serial examinations. Postoperative BUN and creatinine was 6 and 0.3. She had a potassium of 4. Her sodium levels were within normal limits. Her blood glucose was otherwise normal. She had LFTs with an alkaline phosphatase of 131, an ALT and AST of 91 and 66 with an amylase of 13 and a total bilirubin of 0.7 with a lipase of 42. Drainage output from her J-P drain was followed serially to make sure that there was no evidence of a pancreatic leak or fistula. Ultimately on postoperative day #3, the amylase and total bilirubin was sent from this drain which revealed an amylase of 12 and total bilirubin of 0.7. This was repeated on postoperative day six. She underwent a T-t cholangiogram at this time as well. Under fluoroscopy, the T tube was injected with 35 cc of Conray. There was no apparent leak and an opacification of the left and right biliary ducts were demonstrated. The tip of the T tube had appeared to be in the common hepatic duct and the ducts were mildly prominent, but no focal abnormalities were identified. Given this rather otherwise normal study postoperatively, this was encouraging. She was continued on TPN support as we awaited for return of bowel function. She was out of bed and ambulating. On postoperative day #8, she was noted to have some mild distention, nausea, and vomiting. Abdominal x-ray was acquired at this time, which showed the stomach to be somewhat distended. The drains were seen posterior to the stomach and the drainage tube to the right upper quadrant was also seen consistent with a recent Whipple procedure. The distribution of gas within the abdomen was otherwise unremarkable and there was no evidence of frank obstruction seen, and there was no free air seen. Given her distended stomach and her evidence of nausea and vomiting, it was likely she was suffering from delayed gastric emptying. She was started on erythromycin and Reglan to help with motility. Intermittently, she was tried on clear liquid diet while she was being supported with total parenteral nutrition. Over the next several days postoperatively, the Nutrition service followed and ultimately performed calorie counts. Intermittently, she would do well, however, this will be followed by episodes of nausea and vomiting. Ultimately, this course improved and by postoperative day #15, she began tolerating much greater po intake. A CT scan was acquired on postoperative day #15 to rule out any abnormal fluid collection, abscess, etc to explain why she may in-fact be having difficulty with oral intake and nausea and emesis. CT scan at that time showed postsurgical changes that were noted in the region of the pancreatic body consistent with the patient's recent Whipple procedure, but there were no abnormal fluid collections or abscess formations seen given a relatively normal study. This is encouraged and she was continued to be tried on an oral diet. Ultimately by postoperative day #17, she was tolerating over a liter of po. She had a normal bowel movement. She was still cycling her TPN at night, however, this has been chosen to be turned off and Nutrition service just recommended for her to continue taking [**4-12**] cans of Boost per day to support her nutritional status as well as to keep a close eye on her po intake. The patient at this time had remained afebrile. Her temperature was 98.7 with a heart rate of 73, a blood pressure of 128/66, respiratory rate was 18, and 96% on room air saturation. She was taking 1,088 cc po prior 24 hours before discharge. She is making greater than a liter of urine per day. Her lungs were clear. Heart was regular. Abdomen was soft and nontender. She had bowel sounds in all four quadrants. Her incision was clean, dry, and intact with Steri-Strips in place. Her extremities were warm and nonedematous. Neurologically she had a nonfocal examination. Her discharge laboratories are noted for a white count of 6.4, hematocrit of 33.1, and a platelet count of 293. Her sodium was 140, potassium was 4.5, her chloride was 107 with a bicarb of 20, BUN and creatinine were 15 and 0.3 with a glucose of 138. Her calcium, magnesium, and phosphorus levels were 9.3, 1.7, and 4.0 respectively. She had an albumin of 3.6, total bilirubin of 0.4, amylase of 31, ALT was 60 with an AST value of 39, alkaline phosphatase was 284 and lipase 47. All of these values were stable and had not increased. Given all of these findings and her overall clinical improvement, it was deemed that she was appropriate and stable for discharge. She will go home without services. She will be encouraged to take her Boost supplements 3-4x/day and to watch her hydration status. She will be staying with her daughter during the week before her follow-up appointment with Dr. [**Last Name (STitle) **]. Dr.[**Name (NI) 1369**] secretary will be in touch with the patient to assess how well the patient was doing from a po intake and caloric intake standpoint. The patient has had all of these issues explained extensively. Patient's past medical history is significant for the biliary stricture. The final pathology shows frozen sections revealed left lateral segment bile duct hemartoma with lymph node showing lipogranuloma, but no carcinoma. She had a left hepatic artery lymph node that showed no carcinoma just lipogranuloma. The proximal bile duct margin showed no cancer. The left lateral segment bile duct was a hemartoma as stated above. She did have a liver nodule to 1.5 cm nodule previously mentioned. Was sent for frozen section that just showed a dense nodule with focal calcification and chronic inflammation, but no evidence of malignancy. The mass from the head of her pancreas revealed a pancreatic adenocarcinoma that was moderately differentiated. It was measuring 5.0 x 4.5 x 2.9 cm. There was evidence of vascular invasion. There was extensive perineural invasion. Otherwise, there is no local organ invasion. She had 0/7 lymph nodes that were negative, and with this in mind, the patient will receive followup with Dr. [**Last Name (STitle) **], and at that time will be referred to Hematology/Oncology to reassess her need for further chemoradiotherapy. The patient's past medical history is none. Surgical history is just as above. Allergies are no known drug allergies. Outpatient medications included Cipro, Augmentin, Percocet. Her discharge medication list will be the following: Reglan 20 mg po qid ac and hs, Protonix 40 mg po q day, erythromycin 250 mg po q6. The Reglan and erythromycin will be for procanetic agents. She can take milk of magnesia 30-60 cc po q6 prn. Additionally she can take Percocet 5/225 1-2 tablets po q4-6 prn pain as well as being recommended to utilize a stool softener, Colace 100 mg po bid, and Bisacodyl 10 mg pr q day prn. Her discharge instructions are to encourage her po intake [**4-12**] Boost cans per day, to keep track of her caloric intake, and take a documented diary of her nutritional input. Her daughter will be assisting her with this. She will be staying with her daughter in the interim prior to her follow-up appointment. Dr.[**Name (NI) 1369**] office will be in touch with the patient within a week's time of discharge to assess her nutritional status and overall clinical situation status post discharge and she will follow up approximately a week from this Wednesday which will be [**2128-12-22**] for her postoperative physical with Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2128-12-13**] 09:27 T: [**2128-12-13**] 09:27 JOB#: [**Job Number 45628**] cc:[**Last Name (un) 45629**] Name: [**Known lastname 8385**],[**Known firstname **] Unit No: [**Unit Number 8386**] Admission Date: [**2128-11-26**] Discharge Date: [**2128-12-11**] Date of Birth: [**2069-8-10**] Sex: F Service: BLUE GENERAL SURGERY HISTORY OF PRESENT ILLNESS: This is a 59-year-old female with jaundice who underwent an endoscopic retrograde cholangiopancreatography with stent placement who was found to have a stricture of the common bile duct. CT scan revealed a mass at the end of the pancreas overriding the pain, fevers, chills, nausea and vomiting requiring intravenous antibiotics and repositioning the stents and was discharged from the hospital previously. After that admission, she returned for a planned Whipple operation. PAST MEDICAL HISTORY: Significant for hypertension. retrograde cholangiopancreatographies and a right forearm surgery. ALLERGIES: She has no known drug allergies. MEDICATIONS: She takes OxyContin, Prevacid, and anti-emetics. PHYSICAL EXAMINATION: Her vitals are afebrile. Heart rate of 60. Blood pressure 128/76. Respiratory rate 16, 98% on room air. Her lungs are clear to auscultation bilaterally. Her heart was regular rate and rhythm with no murmurs, rubs or gallops. Her abdomen is soft, nontender, nondistended, bowel sounds are present. Her Extraocular muscles were intact. Her pupils equal, round and reactive to light. Her neck was supple with no lymphadenopathy. She was anicteric. She had 2+ carotids. Her extremities were warm and well-perfused with no cyanosis, clubbing or edema. LABORATORIES: Her white blood cell count was 3.1, hematocrit of 28.0, platelet count 206,000. Sodium 143, potassium 4.1, chloride 110, bicarbonate of 28, BUN 6, creatinine 0.5, blood glucose of 96, calcium 8.2, magnesium 1.7, phosphorus 3.8, ALT 61, AST 42, alkaline phosphatase of 438, T bilirubin 0.9, albumin at 2.8. Her electrocardiogram was normal with no ST segment changes. Her chest x-ray was normal as well. HOSPITAL COURSE: Patient was taken to the Operating Room on [**2128-11-26**] where a Whipple procedure was performed along with a liver biopsy and cholecystectomy. Patient was transferred to the Post Anesthesia Care Unit postoperatively. Due to low blood pressure, she required Neo-Synephrine drip and was kept on a ventilator. She spent the night in the Intensive Care Unit. Her epidural was shut off at that time in order to increase her blood pressure. Patient did well with her epidural off and was able to be extubated. She did well after extubation and was able to be transferred to the floor. She was continued on her intravenous antibiotics at that time and her nasogastric tube was kept to suction. She was started on TPN at that time. She was also transfused for a low hematocrit. The patient did well and she was taken down to Radiology where an upper gastrointestinal was performed which showed that her gastrojejunostomy anastomosis was intact and there was no leak. Furthermore, she was also taken to Interventional Radiology where a tube study was performed which showed that the choledochojejunonastamosis was intact and there was no leak and that bile was flowing into the small bowel. At that time the T tube was clamped. Physical Therapy was consulted to work with her in terms of ambulation and strength. She did well and was able to walk ad lib and tolerate climbing stairs. Her nasogastric tube was removed after the upper gastrointestinal and patient had episodes of nausea and vomiting. She was started on anti-emetics including Zofran, Reglan and erythromycin and her diet was slowly advanced. Her JP drain which had high output slowly decreased over time and was removed postoperatively. Nutrition was also consulted to assess her ability to take adequate po nutrition. Calorie counts were done and the patient was encouraged to take as much high caloric foods as possible. Patient had full return of bowel function and did well. Her nausea persisted however, her vomiting stopped and patient was advanced to a regular diet. Patient did well and was continued on her TPN throughout her hospital course and found that she was able to tolerate adequate po. Patient was planned for discharge at this time on [**2128-12-11**] only after she is able to tolerate adequate po and take in enough calories to be weaned off of her TPN. Please see addendum for change in discharge date and her nutritional assessment. DISCHARGE CONDITION: Patient is discharged in stable condition. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tablets po q. 4 hours prn. 2. Colace 100 mg po b.i.d. 3. She is also given Reglan and erythromycin for her nausea. Patient is encouraged to take as much po high calorie foods as possible and Nutrition is following her. Patient is currently planned for discharge on [**2128-12-11**]. DISCHARGE DIAGNOSES: 1. Pancreatic head carcinoma, status post Whipple procedure. 2. Hypertension. 3. Right forearm surgery. 4. Endoscopic retrograde cholangiopancreatography. DISCHARGE FOLLOW-UP: Follow-up with Dr. [**Last Name (STitle) **] in one to two weeks. Please see addendum for changes in discharge date and discharge medications. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366 Dictated By:[**Doctor Last Name 8387**] MEDQUIST36 D: [**2128-12-9**] 10:43 T: [**2128-12-9**] 12:22 JOB#: [**Job Number 8388**]

[ "759.6", "157.0", "228.09", "458.2", "276.2", "263.9" ]

icd9cm

[ [ [] ] ]

[ "40.11", "52.7", "99.15", "51.22", "87.54", "50.12" ]

icd9pcs

[ [ [] ] ]

14371, 14415

14763, 15345

14438, 14742

11910, 14349

10912, 11892

10179, 10657

10680, 10889

46,960

153,896

34838

Discharge summary

report

Admission Date: [**2194-11-5**] Discharge Date: [**2194-11-8**] Date of Birth: [**2134-6-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Atrial fibrillation Major Surgical or Invasive Procedure: s/p emergent removal of retained EP catheter, bilateral PVI, MAZE, resection of left atrial appendage History of Present Illness: 60 year old male with history of proxysmal atrial fibrillation who was admitted as an outpatiet for pulmonary vein isolation and ablation with the ep service. Cardiac surgery was consulted after they were unable to remove the catheter. Past Medical History: Paroxysmal atrial fibrillation hypertension dyslipidemia s/p right ear surgery Social History: Divorced with two children. Lives with his girlfriend. Retired police officer. Averages 4 beers/night Family History: noncontributory Physical Exam: Discharge: 98.7 141/84 79 20 92% RA General: pleasant to speak with Chest: Lungs clear to auscultation. Sternum stable COR: regular, no murmurs appreciated Sternal incision: dry and intact without drainage Extremities: warm with trace pedal edema Pertinent Results: [**2194-11-7**] 05:15AM BLOOD WBC-10.3 RBC-3.40* Hgb-11.1* Hct-31.6* MCV-93 MCH-32.7* MCHC-35.3* RDW-13.1 Plt Ct-199 [**2194-11-6**] 02:24AM BLOOD WBC-11.3* RBC-3.66* Hgb-12.3* Hct-33.2* MCV-91 MCH-33.5* MCHC-36.9* RDW-13.2 Plt Ct-204 [**2194-11-5**] 08:35AM BLOOD WBC-7.1 RBC-4.66 Hgb-15.5 Hct-42.3 MCV-91 MCH-33.2* MCHC-36.7* RDW-12.7 Plt Ct-291 [**2194-11-8**] 07:10AM BLOOD PT-16.6* INR(PT)-1.5* [**2194-11-7**] 05:15AM BLOOD PT-14.8* INR(PT)-1.3* [**2194-11-5**] 08:35AM BLOOD PT-16.3* INR(PT)-1.5* [**2194-11-7**] 05:15AM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-31 AnGap-8 [**2194-11-5**] 08:35AM BLOOD Glucose-108* UreaN-18 Creat-1.0 Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 [**2194-11-7**] 05:15AM BLOOD Mg-2.4 [**2194-11-6**] 02:24AM BLOOD Mg-2.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79774**] (Complete) Done [**2194-11-5**] at 1:54:02 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2134-6-9**] Age (years): 60 M Hgt (in): 80 BP (mm Hg): 140/80 Wgt (lb): 185 HR (bpm): 90 BSA (m2): 2.23 m2 Indication: Left ventricular function. Right ventricular function. Tamponade. ICD-9 Codes: 440.0 Test Information Date/Time: [**2194-11-5**] at 13:54 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW06-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 1.8 cm <= 2.5 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. ASD. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal regional LV systolic function. 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. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Suboptimal image quality - poor echo windows. Emergency study. Results were Conclusions PreBypass: 1. The patient is V paced. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is no pericardial effusion. 8. A RV catheter/pacing wire is seen. A separate wire/catheter is seen traversing the intraatrial septum and extending into the right inferior pulmonary vein. Post Bypass: The patient is in sinus rhythm. Left and right ventricular function is preserved. The aorta is intact. The entrapped wire/catheter has been successfully removed. An atrial septal defect is now present. The left atrial appendage has been removed. The remainder of the examination is unchanged. Dr. [**Last Name (STitle) 914**] was notified in person of the results intraoperatively. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2194-11-5**] 22:40 Brief Hospital Course: Patient was brought to the operating room urgently from the electrophysiology lab. He underwent emergent removal of retained catheter, pulmonary vein isolation, MAZE, and left atrial appendage removal with Dr [**Last Name (STitle) 914**]. Please see operative note for full details. Post-operatively he was admitted to the CVICU for invasive hemodynamic monitoring. Drips were weaned and he was extubated on POD 0. By POD 1 he was transferred to the step down floor. Physical therapy was consulted to work on strength and conditioning. He was re-started on coumadin and his home doses of propafenone. By POD 3 he passed physical therapy and was cleared for discharge home. Medications on Admission: Propafenone 225 mg po qam and qpm, 150 mg po at lunch coumadin 2.5 mg po saturday, 5 mg every other day Simvastatin 80 mg po daily HCTZ 25 mg po daily Viagra 50 mg po prn Atenolol 50 mg po daily MVI Fish oil benadryl Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(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 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): Please take this dose 12/20 and [**11-9**]. Dr[**Name (NI) 79775**] office will call with dose adjustment monday after INR drawn. Disp:*50 Tablet(s)* Refills:*0* 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Propafenone 225 mg Tablet Sig: One (1) Tablet PO QAM AND QPM (). 8. Propafenone 150 mg Tablet Sig: One (1) Tablet PO AFTERNOON (). 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: s/p emergent removal of retained EP catheter, bilateral PVI, MAZE, resection of left atrial appendage AFIB Dyslipidemia Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr. [**Last Name (STitle) 5051**] in 1 week ([**Telephone/Fax (1) 6256**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Completed by:[**2194-11-8**]

[ "427.32", "E879.0", "458.29", "272.4", "V58.61", "996.09", "401.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.28", "38.93", "39.61", "37.78", "37.33", "99.61" ]

icd9pcs

[ [ [] ] ]

7908, 7970

5881, 6555

339, 443

8134, 8141

1248, 5858

8653, 8998

945, 962

6822, 7885

7991, 8113

6581, 6799

8165, 8630

977, 1229

280, 301

471, 708

730, 810

826, 929

23,577

102,904

5703

Discharge summary

report

Admission Date: [**2186-9-3**] Discharge Date: [**2186-9-8**] Date of Birth: [**2142-12-16**] Sex: M Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 1145**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Pacemaker/ICD generator change [**2186-9-5**] History of Present Illness: 42 yo M CAD s/p MI '[**78**] (tx with TPA with rescue PCI of p LAD), no significant dz on cath in '[**84**], ESRD on HD, former smoker, h/o recent tunnelled HD line sepsis (pulled 2 weeks ago, on vanco at HD since) p/w n/v and respiratory distress. Found by EMS to be bradycardic HR 50 with agonal respirations at a rate of 4/min, then became pulseless with wide complex irregular rhythym, shocked 3 times, unclear number of shocks delivered by patients own device, pulse regained, but with wide complex rhythym. Intubated in the field. Self extubated en route to [**Location (un) **]. . At [**Location (un) **] vitals V paced at 70, BP 140/113 R 17 sat 100% NRB, had ABG 7.19/32/116 K 5.2 HCO3 12 trop I 0.11, treated with: lidocaine gtt (which had been stopped prior to arrival to [**Hospital1 **]), D50, insulin, Ca; He was then medflighted to [**Hospital1 **] for further management. . On arrival to [**Hospital1 **], vital signs remained stable. ABG 7.27/36/228 K 5.6 lactate 2.6, given D50, insulin, bicarb, Ca, and kayexylate. K peaked at 6.3, but most recently is 5.0. EKG here shows V paced rhythym at 82 bpm. EP interrogated the device. Past Medical History: ESRD on HD via L forearm AV graft at [**Location (un) 1157**] North County Kidney Center CAD s/p MI '[**78**], tPA and rescue PCI of LAD EF 20% LV thrombus h/o VT s/p pacer and ICD recent line sepsis, line pulled, treating with vanco at HD Social History: former smoker Family History: non-contributory Brief Hospital Course: Overnight: Renal came to see patient and felt K was not the precipitant for these rhythyms. EP interogated his paced and found several episodes of VT and VF, many of the VT episodes were below his lower rate threshold to shock (> 188 bpm). His device was reprogrammed to treat VT at rate > 170 and record rates >150. There was no inappropriate function of ICD detected. We increased his toprol from 25 to 50, left his amio at 200 daily, plan for possible EPS in next few days. . A/P 42 yo M CAD s/p MI '[**78**], no significant dz on cath in '[**84**], EF 20%, ESRD on HD, presents with V-fib/v-tach arrest with delayed ICD response. 1. V-tach/v-fib: Interrogation of the device revealed that the pt had episodes of V-tach which degenerated into v-fib. The device was found to be functioning appropriately to the parameters with which it was programmed. The device was not programmed to detect V-tach so it only shocked him when it degenerated into v-fib. The EP consultant changed v tach sensing parameters to detect rates below 188 and added in anti-tachycardia pacing function. The device will try ATP twice, then shock. The pt underwent a prcedure for the generator change of the device. The pt underwent this procedure without complications. The pt remained stable without further episodes of arrhythmia during the hospitalization. . 2. CHF: pt currently well compensated. EF 20% by report. Echo was done at [**Hospital1 18**] to eval cardiac fxn. The coumadin which the pt takes for mural thrombus and CHF was held for the EP procedure, then restarted afterwards. The pt was continued on his home medications. . 3. Renal failure Pt was found to be in metabolic acidosis with bicarb 17. K 6.3. Pt recieved calcium, insulin, bicarb, kayhexelate in ED. He was dialyzed while in the hospital. The AV graft was not functioning optimally for dialsis, with elevated pressures and suboptimal flow, although he was able dialyze. A AV fistulogram was obtained which revealed venous obstruction. Renal and transplant surgery teams followed the pt. The pt was informed of the need to see his regular renal physician for planning to revise the AVF. . 4. CAD: no active ischemia during hospitalization. ASA/statin/BB were continued . 5. ID: being treated for tunneled r IJ line infection. R IJ was pulled 2 weeks ago. Vanco with HD was recommended for an additional week, because a device was implanted. . 6. Ppx: heparin when INR <2 . 7. FEN: follow K, renagel 2400, NPO p MN Medications on Admission: ASA 81 po qd dig 0.125 po qfriday Toprol XL 25 po qd Warfarin 2.5 daily Lipitor 40 PO qd Amio 200 po qd Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses. 7. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD (each hemodialysis) for 7 days. 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia Unstable arrhythmia Discharge Condition: good Discharge Instructions: Please take all of your medicines as directed. . Please continue the vancomycin for one week with the dialysis sessions to prevent the new pacemaker device from becoming infected. . If you have chest pain that lasts longer than 20 minutes, or if you have episodes of passing out or dizziness, please call your doctor or go to the emergency room. Followup Instructions: Provider DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2186-9-14**] 1:30. . Please make an appointment to see your nephrologist regarding sugery to improve the function of the AV fistula.

[ "272.0", "403.91", "428.0", "412", "285.9", "276.2", "V53.39", "414.01", "427.41", "V45.82", "427.1", "998.12" ]

icd9cm

[ [ [] ] ]

[ "88.49", "89.45", "39.95", "37.87" ]

icd9pcs

[ [ [] ] ]

5220, 5226

1859, 4331

282, 330

5314, 5321

5715, 5963

1818, 1836

4486, 5197

5247, 5293

4357, 4463

5345, 5692

228, 244

358, 1507

1529, 1771

1787, 1802

12,695

191,386

11260+56222

Discharge summary

report+addendum

Admission Date: [**2134-5-28**] Discharge Date: [**2134-6-10**] Date of Birth: [**2077-1-30**] Sex: F Service: Purple Surgery HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female referred for evaluation of gastric resection surgery and the treatment management of obesity by her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient was seen and evaluated in gastric bypass [**Hospital 33018**] clinic on [**1-4**] and [**2134-2-2**]. [**Known firstname **] has class III obesity with a weight of 323 lbs, BMI 49.6. Her previous weight loss efforts have increased Weight Watchers, lost 50 lbs in [**3-21**] months, Nutri-System, lost 90 lbs in [**3-21**] months, and Weight Loss Clinic 80 lbs in 3 months. In all instances she could not maintain weight loss and regained weight within 3-4 months. Her lowest weight as an adult was 180 in her early 20's. She has weighed over 300 lbs for the past 20 years. She states she has developed significant weight problems and most events related to her weight gain are sexual abuse by family. Factors attributable to her excess weight include poor exercise, stress, emotional causes as well as lack of exercise. She denies eating disorders but admits to food obsessions. She has a history of depression and is seeing a social worker for family sexual abuse. Finished therapy 6 years ago with no psychiatric hospitalization, no medication. PAST MEDICAL HISTORY: Hypertension since [**2131**], type 2 non-insulin dependent diabetes with neuropathy in lower extremities since [**2131**], gallbladder disease in [**2114**], Bell's palsy in [**2128**], osteoarthritis in knees and ankles, chest pain, palpitations in [**2120**] with a negative stress test. She has a history of eczema, denies heart disease, asthma, sleep apnea, dyslipidemia, thyroid disease, GERD, post menopausal. PAST SURGICAL HISTORY: Cholecystectomy in [**2114**], umbilical hernia repair in [**2129**] under general anesthesia. MEDICATIONS: Adalat 90 mg q day, Hydrochlorothiazide 25 mg q day, Glucophage 500 mg [**Hospital1 **], Ecotrin 325 mg q day, Senna for constipation. ALLERGIES: Penicillin, Erythromycin, Sulfa. SOCIAL HISTORY: Smoked for 10 years, quit age 25, no alcohol or recreational drugs. Drinks 2 cups of coffee in the morning, 2 large diet [**Doctor Last Name **], caffeine free daily. FAMILY HISTORY: Both parents deceased, age 77 for father with obesity and liver disease, mother at age [**Age over 90 **] with obesity and renal cancer. There is a history of diabetes and Paget's disease in siblings. Employed as a computer technician at an insurance company. Married, living with husband, a program analyst for the state, and son. She has a married daughter outside the home. PHYSICAL EXAMINATION: Upon presentation blood pressure was 132/76, pulse 94. On brief physical exam there were no skin lesions. Sclera was anicteric. Pupils equal, round and reactive to light. Oropharynx without exudate. Funduscopic exam was noted to be within normal limits. There was no cervical lymphadenopathy, thyromegaly or carotid bruits. Lungs were clear to auscultation bilaterally and nor heart sounds are present, regular rate and rhythm without murmurs, rubs or gallops. Abdomen is obese, soft, nontender, with good bowel sound activity. There is a well healed incision in the right upper abdomen and midline periumbilical area without evidence of hernias. Lower extremities were noted for a mild erythema bilaterally, right greater than left, without warmth, tenderness or swelling. She has edema in the right lower extremity. Neurologically left facial droop is noted, speech impairment and there is a decreased sensation in both extremities. EKG showed normal sinus rhythm at 94 with a left bundle branch block, not new, present on the [**2130-4-25**] tracing. PVC with P waves. Fasting laboratory data from [**2134-1-4**] showed blood glucose of 191, hemoglobin A1C 8.3, remainder of electrolytes, LFTs, chemistries, TSH, B12, CBC, basic labs were within normal limits. Albumin 4.1, chloride decreased to 98, serum Folate greater than 20, BUN slightly elevated at 25, total protein slightly elevated 80.2, cholesterol 219, HDL 67, LDL 127, triglycerides 123. Exercise treadmill test on [**2128-10-27**], left bundle branch block. Persantine sestamibi myocardial perfusion scan in 9/96 was inconclusive but a resting myocardial perfusion scan on [**2128-10-29**] was negative for ischemia. IMPRESSION: Patient is a 57-year-old class III obesity, BMI 50 with significant co morbidities and thought to be an excellent candidate for gastric resection surgery. Risks and benefits were discussed and patient decided to proceed with gastric resection surgery. For details of surgery please see operative note. Postoperative day #1 the patient had borderline urine output. She was afebrile, vital signs were stable. She had only made 273 cc in the operating room and PACU and 41 cc in the last two hours that were checked. Her exam was appropriate. She was continued on LR with 20 of potassium at 150. Her NG tube was discontinued. She was started on a stage I diet and encouraged to get out of bed and ambulate. On postoperative day #2 the patient had a T max of 101.4 and pulse of 114. Urine output was adequate. Her abdomen was soft and the G tube was in place and incision was clean, dry and intact. A hematocrit done on postoperative day #1 was 30.7, potassium 4.8, creatinine 1.2 and on postoperative day #2 she was considered stable, started on stage II diet and her IV was Hep-Locked. She was started on po Lopressor and Hydrochlorothiazide though urine output was decreased yesterday and picked up during postoperative day #2 and continued the Foley to monitor urine output. She was started on Roxicet an Zantac po for pain control and prophylaxis respectively. On the night of postoperative day #2 to postoperative day #3 resident was called to see patient for left upper quadrant discomfort, incisional pain and shortness of breath. At this point in time patient was afebrile, was making adequate urine output, had decreased breath sounds at the bases bilaterally but otherwise exam was appropriate. The patient was 92% on room air and 97% on three liters. The chest x-ray was done at that point in time which showed extensive bibasilar atelectasis and left hemidiaphragm obscured because of atelectasis. The patient's respiratory rate was 20. Respiratory care was called and patient was given a nebulizer treatment which patient stated she subjectively felt better. During the day, postoperative day #3, the patient was stating that she still feels that her breathing was limited but she denied chest pain in the morning, was afebrile, vital signs stable, adequate urine output with decreased breath sounds at the bases. Abdomen was soft, slightly distended. She was continued on Roxicet, continued on pulmonary toilet. Her Foley was discontinued. For diabetes she was started on a regular insulin sliding scale which she had been started on in the recovery room after surgery. Her Heparin subcutaneous was changed to Lovenox. During the day on postoperative day #3 the patient started complaining of substernal chest pain without radiation and slightly increasing shortness of breath. She stated that her abdominal pain had decreased because her G tube was actually placed to gravity. Her vital signs at this point were stable except her pulse was 129. She was slightly short of breath and slightly diaphoretic with decreased breath sounds at the bases. A Chem 10 done on that day showed that she had sodium of 137, potassium 4.1, chloride 88, CO2 23, BUN 19, creatinine .9, glucose 233 and EKG showed a heart rate of 117 and left bundle branch block which did not change from her previous EKG except for the tachycardiac. Thus, at this time on postoperative day #3 she had self limited chest pain with continued shortness of breath and tachycardia. Cardiovascularly she was ruled out for an MI with serial enzymes, started on telemetry and her po Lopressor was changed to IV. Because of slight abdominal pain patient had a swallowing study done and was made npo and started on IV fluids, continued on supplemental oxygen. Postoperative day #3 because of the patient's shortness of breath and abdominal pain, the patient had a CTA and CT of her abdomen done. Swallow study was inconclusive since patient could not complete the study secondary to dyspnea and tachycardia. CT angiogram on postoperative day #3 showed evidence of pulmonary embolus in the right upper lobe and right lower lobe. CT of her abdomen showed no evidence of active extravasation with slight amount of fluid around the sleep. The patient continued to be tachycardic and tachypneic, continued to make adequate urine output, decreased breath sounds bilaterally. Abdomen was slightly distended. The patient was ruled out for an MI with CKs of less than 200 and troponins of less than .3 times two. Because of tachycardia, Lopressor was increased to 7.5 mg q day. Also on postoperative day #4, due to patient's critical status, patient required frequent blood draws and was a difficult stick and thus a three lumen catheter was placed at the bedside sterilely without any complications with a chest x-ray post procedure that showed adequate placement. On postoperative day #5 the patient still felt dyspneic without any chest pain, no nausea, vomiting or flatus. The patient was afebrile with a T max of 100.7 with a stable blood pressure, respiratory rate of 24, continuing to make adequate urine output. The patient looked distressed upon exam, using accessory muscles for breathing. She was tachypneic and tachycardic. Chest CTA showed an anterior segment of right upper lobe that had filling defects and right lower lobe had filling defects with atelectasis of the left lower lobe and small left pleural effusion with a high probability of PE read out for this final CT. Labs over the last several days, on [**5-31**] patient's hematocrit was 33, on [**5-31**] at 7 p.m. was 29, [**6-1**] at 11 p.m. was 27, 12 a.m. 27.3 and on [**6-2**] at 4:30 a.m. had nadired to 26.5 with normal PTT. LFTs were drawn which were within normal limits with an amylase of 41, lipase 16, total bilirubin .8, alkaline phosphatase 69, ALT 17, AST 37 with a white count of 17.8 with 88% neutrophils and 6% bands. On postoperative day #5 the patient was continued on Morphine which had been switched from Roxicet when patient was made po. Cardiovascularly the patient was continued on telemetry and continued to be tachycardic. Pulmonary, patient was started on Heparin sliding scale which started actually on evening of postoperative day #4 and was adjusted for a goal PT between 60 and 80. Renal, patient continued to make adequate urine output. ID, patient actually was started on Levaquin on postoperative day #4, continued leukocytosis. GI, patient was again started on a stage II diet after CT showed no extravasation. A Foley was replaced. Heme, patient received one unit of packed red cells with hematocrit to be checked, with a drop in hematocrit in the face of increasing abdominal pain. Endocrine, patient was continued on increasing sliding scale. On postoperative day #5 at 5:45 p.m. the patient, because of abdominal pain, fluid that was seen around the spleen during original CT, patient underwent a CT guided drainage with a left upper quadrant collection, with a 10 French catheter without any complications. 50 cc of old blood was aspirated. Sample was sent for culture and a pigtail drain was left in place. At this point in time patient was transferred to the surgical ICU for closer monitoring secondary to patient's pulmonary embolism and status post drain placement due to intraperitoneal process. The patient remained stable in the ICU and on postoperative day #6 Levaquin day 3, patient was afebrile, remained tachycardic and tachypneic, was making adequate urine output and exam was unchanged with white count of 19.6, hematocrit 27.6 after one unit of blood on postoperative day #4. PTT was 36.6, normal electrolytes. Culture from aspiration of intra-abdominal fluid showed gram positive cocci in chains with 4+ PMNs. The patient was clinically improving, neurologically continued on Morphine PCA with aggressive pulmonary toilet and continued on IV Lopressor. The patient's antibiotic regimen was changed to include Vancomycin, Levofloxacin and Flagyl for empiric coverage of the abdominal process. Heme, patient continued to be anticoagulated on Heparin with a goal PTT between 60 and 80. The patient was seen by PT to help with ambulation. On postoperative day #7, Levaquin day #4, Flagyl and Vanco day #2, patient's pain was controlled and clinically looked improved, was afebrile, was making adequate urine output, white count was 18.6, hematocrit 26.4, electrolytes were within normal limits. PTT was 56.2. Exam showed decreased breath sounds at the bases. At this point in time the patient was continued on Morphine, IV Lopressor, antibiotics for empiric coverage, continued on anticoagulation with Heparin for goal between 60 and 80, was encouraged to ambulate. On postoperative day #8, Levaquin day #5, Flagyl and Vanco day #3, patient was able to receive Coumadin along with Heparin and was able to ambulate times two. The patient was afebrile, vital signs were stable. Patient's ABG was within normal limits while patient was in the SICU. White count was 17.1, hematocrit 21.4, potassium 3.2 which was repleted. Culture continued to show gram positive cocci, question of staph at this point in time. Exam was unchanged. The patient was transferred to the floor at this point in time. Was changed to po Roxicet. Cardiovascular, po Lopressor and Nifedipine and Hydrochlorothiazide. Respiratory, patient was ambulated and continued on IV Heparin, started on Coumadin on postoperative day #8. GI, patient was started on stage III diet. The patient continued to make adequate urine output thus the Foley was discontinued on postoperative day #8. ID, the patient was continued on antibiotics. Heme, patient was continued on Heparin. The patient was continued on Zantac for prophylaxis. The patient was actually started on TPN on postoperative day #7 and this was continued while patient was on the floor for adequate nutrition and continued on an insulin sliding scale. Postoperative day #9 the patient was still short of breath without any chest pain but was able to ambulate and void without difficulty. She was afebrile, her vital signs were stable, she continued to make urine output which was adequate. White count was 17.6, hematocrit 25.4. Electrolytes were within normal limits. PTT 70.5. Micro showed coag negative staph with no fungus or anaerobes and Vanco peak of 25.1. The patient started to clamp her G tube, we did not check residuals to see whether this made the patient uncomfortable. The patient was continued on Heparin. The patient was made KVO and allowed to continue on the stage III diet. Physical therapy came to see patient for home recommendations. Postoperative day #10 the patient continued to have decreasing shortness of breath, was able to ambulate and void without difficulty. She had a T max of 100.5, her vital signs were stable, urine output was within normal limits. The patient's fingersticks were greater than 200. The patient had decreased breath sounds bilaterally. White count had gone up from 17.1 to 24 and hematocrit was stable at 26.6. PTT most recently was 110 with micro showing MRSA Methicillin resistant staph aureus sensitive to Vancomycin, no evidence of anaerobes or fungus and intraabdominal fluid which was drained. Postoperative day #10 ID, the patient was afebrile but white count had increased as a chest x-ray was checked and central line was discontinued with a PICC line being placed. Heme, hematocrit was stable, INR was 1.5, PTT 110. The patient was continued on Heparin and Coumadin for pulmonary embolus. GI, patient tolerated G tube clamping. GU, patient continued to make urine output. Neuro, patient was continued on Roxicet and Zantac for prophylaxis. Postoperative day #10 events, when patient had PICC line placed it was actually placed by the venous access nurse and during chest x-ray for checking placement, it was seen that PICC line was actually in the right IJ and it was pulled at that point in time. The patient had a peripheral IV placed overnight and a PICC line was actually placed on postoperative day #11 without difficulty and adequate placement checked by chest x-ray. The night between postoperative day #10 and postoperative day #11, the patient had 9 beats of non sustained wide complex tachycardia in the evening at 7:30 p.m. and at 2:30 a.m. the patient started complaining of increasing shortness of breath which patient thought was secondary to anxiety and at that point in time patient's telemetry was within normal limits. The patient as given ?????? mg of Ativan without any help but was given Benadryl for sleep which seemed to alleviate the shortness of breath. On postoperative day #11, Levo day #8, Flagyl and Vanco day #5, patient's pain was controlled, she was slightly more increased short of breath than yesterday, no lightheadedness, dizziness or chest pain. Patient as afebrile. Her vital signs were stable. Fingersticks were less than 200, making adequate urine output. She had decreased breath sounds at the bases. White count was 22.3 on postoperative day #11. Hematocrit was 24.1. Electrolytes were within normal limits. PTT was actually 24.7. Line culture was negative. Chest x-ray was done which showed mild bibasilar atelectasis with a small left pleural effusion with no infectious process. Management on postoperative day #11 because of patient's increasing shortness of breath and wide complex tachycardia, patient was again ruled out for an MI. She was ruled out with serial enzymes of 57, 52 and 45 with troponins less than .3 times three. The patient remained afebrile with vital signs stable, sugars less than 200, exam unchanged. The patient received a unit of blood overnight. Patient's hematocrit went from 21.2 to 22. The patient received another unit of blood during postoperative day #12. CVC tip culture was negative. Electrolytes were within normal limits. The patient was continued on IV Heparin. Because of patient's stable hematocrit, though patient received two units of blood. The patient had a repeat CT of her abdomen at which time her Heparin was stopped which showed a persistent subphrenic collection consistent with a hematoma, a new subcapsular fluid collection consistent with a hematoma injury to the left hepatic lobe and a stable 10 cm subcutaneous fluid collection. On postoperative day #13 there were no events overnight. The patient remained in control of the nausea and vomiting, afebrile, vital signs stable, adequate urine output. Patient's exam was unchanged. White count had gone done to 17.4. Hematocrit 22.1, most recent PTT 26.8. Electrolytes were within normal limits. Blood cultures of the CVC tip was negative. Peritoneal fluid showed Oxacillin resistant staph. Because of the hematoma, patient overnight between postoperative day #12 and 13 was made npo, her Heparin was stopped, she was given 2 mg of IV Vitamin K and her Coumadin was held. A type and screen was sent and a stat coag was sent at 4 a.m. to get patient ready for a CT guided drainage of the fluid collections in her abdomen with possible drain placement for the subcapsular fluid collection anterior to the left hepatic lobe. On postoperative day #13 she was continued on Roxicet. She was continued on telemetry and ruled out for an MI times two during this hospital stay. Pulmonary, she has a history of PE. We are holding the Heparin. She was continued on incentive spirometry and pulmonary toilet, sats greater than 94% on two liters. GI, she was on a stage II diet which she was tolerating but made npo for the CT guided drainage. She continued to make adequate urine output. Heme, at this point in time holding the anticoagulation for procedure and anticoagulation was reversed with Vitamin K 2 mg given IV. The patient was started on D5 ?????? normal saline while patient was npo. ID, the patient's white count had gone down to 12.7. She was continued on antibiotics for Oxacillin resistant staph. The patient's platelets were 370,000, most recent PTT was 26.1, INR 1.4, electrolytes were within normal limits. This dictation will be continued once patient is ready to be discharged with an addendum dictation. DISCHARGE DIAGNOSIS: 1. Status post gastric bypass for morbid obesity. 2. Pulmonary embolism. 3. Anterior peritoneal bleed. 4. Type 2 diabetes. 5. Hypertension. CONDITION ON DISCHARGE: Cannot be stated at this point in time since patient is not being discharged. DISCHARGE MEDICATIONS: Cannot be noted. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) 6763**] MEDQUIST36 D: [**2134-6-10**] 11:21 T: [**2134-6-10**] 13:33 JOB#: [**Job Number 36160**] Name: [**Known lastname 388**], [**Known firstname **] Unit No: [**Numeric Identifier 6446**] Admission Date: [**2134-5-28**] Discharge Date: [**2134-6-16**] Date of Birth: [**2077-1-30**] Sex: F Service: General Surgery Purple Team This is an addendum to a discharge summary by Dr. [**Last Name (STitle) **], which was from [**2134-5-28**] to [**2134-6-10**]. On postoperative day 13, Interventional Radiology inserted a 10 French catheter in the right upper quadrant for a collection of clotted blood which was removed. Decision was made to leave the catheter in place for a few days. Later that same postoperative day the patient complained of palpitations. Patient was found to be afebrile and vital signs are stable. Electrolytes are within normal limits and episode lasting 15 minutes. No chest pain, no shortness of breath, no nausea, vomiting, no diaphoresis. An electrocardiogram was done which showed no changes from preoperative electrocardiogram. The patient is seen by physical therapy and felt to be improving. The patient on postoperative day 14, pain controlled, Vancomycin and Flagyl day 8, levofloxacin day 11. Tolerating Stage III diet. The patient was afebrile and vital signs were stable and the peritoneal fluid which was drained was growing oxacillin resistant coag negative Staph sensitive to Vancomycin. Infectious Disease service recommended discontinuing Flagyl, and levofloxacin, and continuing antibiotics of Vancomycin only. On postoperative day 15, the patient continued to be afebrile. Vital signs stable except for a slight tachycardia at 106. Incision was clean, dry, and intact. No erythema. Incision with drain sites x3. Catheter tip had showed no growth. Wound drainage from the [**12-10**] showed 1+ polies and no growth of organisms and from the 17th, showed 4+ polies, 3+ Gram positive cocci. Oxacillin Staphylococcus aureus sensitive to Vancomycin. On postoperative day 16, the patient continued to be afebrile and mild tachycardia to 103 and otherwise stable. On postoperative day 17, patient continued to be afebrile, now tachycardic to 114. Complete blood count showed a drop in hematocrit from 26 to 24 and now 19.3. Patient was transfused 2 units of packed red blood cells with improvement. Hematocrit going to 21.6, 21.7, 25 now on postoperative day 18. The patient is afebrile, tachycardia at 100, otherwise vital signs stable. The patient appears to have had active bleed for anticoagulation for PE and scheduled for placement of an IVC filter after transfusion of some fresh-frozen plasma on a unit of red blood cells was transfused and 2 units of fresh-frozen plasma was then transfused. Patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6447**] IVC filter placed. On postoperative day 19, the patient continued to be afebrile and vital signs stable. Hematocrit checks continued to be stable now with the Heparin discontinued. The patient is felt to be ready for discharge to rehabilitation. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Rehabilitation. DIAGNOSES: Status post Roux-en-Y gastric bypass, status post placement of [**Location (un) 6447**] IVC filter, pulmonary embolism, anterior peritoneal bleed, type 2 diabetes, hypertension. The patient is going to be discharged home with Roxicet elixir for pain, Zantac x2 months, vitamin B12 1 mg x2 months. Patient will be following up with Surgical [**Hospital 3966**] Clinic in postoperative appointment in two weeks with Dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D. [**MD Number(1) 2750**] Dictated By:[**Name8 (MD) 2182**] MEDQUIST36 D: [**2134-11-4**] 09:27 T: [**2134-11-4**] 09:40 JOB#: [**Job Number 6448**]

[ "998.12", "518.0", "415.11", "357.2", "427.1", "278.01", "250.60", "997.3", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "99.15", "44.31" ]

icd9pcs

[ [ [] ] ]

2462, 2844

21034, 24370

20760, 20906

1967, 2259

2867, 20739

171, 1501

1524, 1943

2276, 2445

24395, 25169

7,232

183,794

22937+22938+57329

Discharge summary

report+report+addendum

Admission Date: [**2176-7-1**] Discharge Date: [**2176-7-14**] Date of Birth: [**2136-1-13**] Sex: M Service: MEDICINE Allergies: Toradol Attending:[**First Name3 (LF) 5119**] Chief Complaint: ETOH intoxication Left Wrist pain Major Surgical or Invasive Procedure: None History of Present Illness: History and phyical is as per DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD 40yo M h/o polysubstance/ETOH abuse, chronic pancreatitis, DVT, non-hodgkins lymphoma who presnted with ETOH intoxication and L wrist pain. Pt denies diplopia, double vision, chest pain, SOB, hemoptysis, cough, melena, BRBPR. He reports chronic abd pain unchanged. ROS otherwise negative. Past Medical History: Alcohol abuse Chronic Pancreatitis and chronic abdominal pain Diabetes II, insulin-requiring GERD Hepatitis C with abnormal LFTs Hypertension History of atrial fibrillation Bipolar Disorder Non-Hodgkin's lymphoma dxed [**2-10**], s/p lymphnode resection underneath R ear, planned to have radiation, followed at [**Hospital1 756**]/DF DVT's in left arm (on lovenox) S. Aureus skin infections in left arm (on outpt abx) Depression Social History: Graduated from [**Hospital1 498**] [**2160**] - worked for telephone company until [**2166**] and then became homeless with alcoholism. Homeless - lives in rehabs, hospitals, shelters. No tobacco use or other illicits. Family History: diabetes pancreatitis -father, mother, and siblings Physical Exam: Physical Exam: Appearance: NAD Vitals: Tmax: T: 94.2 BP: 111/72 HR: 114 RR: 18 O2: 96 % RA Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no exudate ENT: Moist Neck: No JVD, no LAD, no thyromegaly, no carotid bruits Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, TTP RUQ, no rebound or guarding, non-distended, no hepatosplenomegaly, normal bowel sounds Musculoskeletal/Extremities: LUE arm swelling tenderness noted.no clubbing, no cyanosis, no edema in the bilateral extremities Neurological: Alert and oriented x3, fluent speech, no pronator drift, no asterixis, very mil tremorsensation WNL, CNII-XII intact Integument: warm, no rash, no ulcer Psychiatric: appropriate, mildly depressed Hematological/Lymphatic: No cervical, supraclavicular, axillary, or inguinal lymphadenopathy Pertinent Results: [**2176-6-30**] 09:30PM WBC-6.9 RBC-4.89 HGB-12.7* HCT-39.5* MCV-81* MCH-25.9* MCHC-32.1 RDW-15.7* [**2176-6-30**] 09:30PM NEUTS-62 BANDS-0 LYMPHS-31 MONOS-4 EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-1* [**2176-6-30**] 09:30PM GLUCOSE-290* UREA N-5* CREAT-0.7 SODIUM-147* POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-21* ANION GAP-25* [**2176-6-30**] 09:30PM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.0 [**2176-6-30**] 09:30PM CRP-8.4* [**2176-6-30**] 09:30PM ASA-NEG ETHANOL-487* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2176-7-1**] 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2176-7-1**] 03:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2176-7-1**] 03:49AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Joint fluidL No polys, no organisms EKG sinus tach @ 100 normal axis, No acute ST-T changes xray L wrist: No acute fracture Brief Hospital Course: 40yo M h/o polysubstance/ETOH abuse, chronic pancreatitis, DVT, non-hodgkins lymphoma who presnted with ETOH intoxication and L wrist pain. 1. Enterobacter bacteremia: The patient had blood culture drawn [**7-2**] that grew [**12-8**] Abiotrophia. Pt initally started on Vanco/Zosyn. A midline was placed. Repeat blood culture [**7-3**] grew enterobacter cloacae. The patient was supected of cheeking his oral meds and injecting them directly and this may have been the source of his enterobacter bacteremia. The patient did not have any other source of infection. His left wrist joint was tapped before antibiotics and did not grow bacteria. The abiotrophia was beleived to be a contaminant because it only grew in 1 of 4 bottles. 2D echo was negative for endocarditis. ID was consulted for recommendations for antibiotics. They recommended completing a 10 course of antibiotics with ceftrixone. Midline catheter was removed and the tip came back negative for bacteria. The pt finished his course [**Hospital 18887**] hospital and was discharged to the pine street inn in stable condition. 2. Type 2 DM - Pt had very labile blood sugars in the hospital. [**Hospital1 **] diabetes consult was obtained and they adjusted the patients insulin. the pt will be discharged on Lantus 50units SC bid and a humalog sliding scale with meals. The patient stores his insulin at the pine street inn and the physician in the clinic there should adjust his regimen accordingly. The pt was very noncompliant with his [**Doctor First Name **] diet, often going to the kitchen to get snacks. 3. Polysubstance abuse: Pt was given MVI, thiamine and folate. The addiction specialist followed the pt while he was in the hospital to provide the pt with supprt and resourses. 4. Elevated LFTs - ALT and alk phos were noted to be slightly elevated at admission. All other LFTs were within normal limits. RUQ ultrasound was unremarkable. The elevation was likely secondary to the pts ETOH abuse. They were monitored and trended back down. 5. Hx of DVT: the patient has been on lovenox for about 1 month for his DVT. He should continue this for at 3 months total. He was instructed to follow up with PCP regarding this. The pt does not seem like a good candidate for coumadin given his med noncompliance in the past. 6. Depression; the pt was continued on citalopram 7. F/E/N - [**Doctor First Name **] diet 8. Proph - Lovenox 9. Code Full Medications on Admission: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: [**12-6**] injection Subcutaneous Q12H (every 12 hours). 2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). [**Month/Day (2) **]:*30 Cap(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 7. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Five (35) units Subcutaneous at bedtime. 8. Sliding Scale Insulin Please follow the sliding scale QACHS. [**12-6**] if pt is npo. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Glucometer Please dispense 1 glucometer to patient. 11. Glucometer Test Strips Please dispense 3 month supply of glucometer test strips compatible with test system. Discharge Medications: 1. Lantus 50 units sc bid 2. Lovenox 80 sc q12h 3. Citalopram 60mg po daily 4. Pantoprazole 40mg po daily 5. Thiamine 100mg po daily 6. Folate 1mg po daily 7. Pancreatic enzymes 2 tabs po tid w/meals 8. Humalog insulin sliding scale For FSBS 76-120 Give 18 units with B/L/D. Give 0 units qhs For FSBS 121-160 Give 22 units with B/L/D. Give 4 units qhs For FSBS 161-200 Give 24 units with B/L/D. Give 5 units qhs For FSBS 201-240 Give 26 units with B/L/D. Give 6 units qhs For FSBS 241-280 Give 28 units with B/L/D. Give 7 units qhs For FSBS 281-320 Give 30 units with B/L/D. Give 8 units qhs For FSBS 321-360 Give 32 units with B/L/D. Give 9 units qhs For FSBS 360-400 Give 34 units with B/L/D. Give 10 units qhs Discharge Disposition: Extended Care Facility: St Pine Inn Discharge Diagnosis: ETOH Intoxication/withdrawal Enterobacter bacteremia DM2 Uncontrolled Discharge Condition: Good Discharge Instructions: -Take all meds as prescribed -Return if having fevers, chills, profuse sweats, significant lethargy. -Try to abstain from alcohol and drugs. Followup Instructions: Follow up with physician at pine street inn [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2176-7-16**] Admission Date: [**2176-7-15**] Discharge Date: [**2176-7-24**] Date of Birth: [**2136-1-13**] Sex: M Service: MEDICINE Allergies: Toradol Attending:[**First Name3 (LF) 1666**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 40 yo male with etoh abuse, chronic pancreatitis, ?h/o upper extremity DVT, NHL lymphoma, just discharged from [**Hospital1 18**] <24hours ago to pine street inn after admit for +blood cultures in the setting of suspected self-line tampering. He completed a course of antibiotics during his last admission. Since discharge, he has felt well, says his blood sugars were 120's. Went to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] buffet with friends and felt ill upon returning, went to pine street for his pain meds but it was closed, so he walked to [**Hospital1 336**] ER where he got 10 units regular insulin and 1.5mg total of IV dilaudid for chronic pancreatitis symptoms. He felt well and wanted to leave, but ER staff was concerned about R forearm redness and cellulitis and requested transfer back for further care. Regarding his R forearm, he says he had redness and tenderness of R forearm at prior IV site, which was being treated with warm compressess and elevation on day of discharge. He says it is slightly more swollen, more red and more tender. He has no fever, no other new systemic symptoms. He denies iv drug use, or etoh use since discharge less than 24hrs ago. He is candid in his conversation regarding possible line tampering on last admit and says he was 'flushing his line because he did not want the line to clot.' Past Medical History: Alcohol abuse Chronic Pancreatitis and chronic abdominal pain Diabetes II, insulin-requiring GERD Hepatitis C with abnormal LFTs Hypertension History of atrial fibrillation Bipolar Disorder Non-Hodgkin's lymphoma dxed [**2-10**], s/p lymphnode resection underneath R ear, planned to have radiation, followed at [**Hospital1 756**]/DF DVT's in left arm (on lovenox) S. Aureus skin infections in left arm (on outpt abx) Depression Social History: Graduated from [**Hospital1 498**] [**2160**] - worked for telephone company until [**2166**] and then became homeless with alcoholism. Homeless - lives in rehabs, hospitals, shelters. No tobacco use or other illicits. Family History: diabetes pancreatitis -father, mother, and siblings Physical Exam: t:99.9 bp 148/90 hr:111 rr 20 98%RA gen: resting comfortably nad ent: mmm cv: rrr, no m/r/g, tachy, no murmurs appreciated resp: cta bilat abdm: sft, mildly tender LQ, epigastrum, no rebound, +bs msk/skin: R forearm with erythema, edema, tenderness on both surfaces, +palpable cord in R antecubital, improves w elevation, no obvious entry point, no exudate, +radial pulse, +distal sensation, good cap refill Pertinent Results: wbc 8.7 [**2176-7-15**] 11:15AM ALT(SGPT)-121* AST(SGOT)-119* LD(LDH)-265* CK(CPK)-177* ALK PHOS-133* AMYLASE-46 TOT BILI-0.4 LIPASE-10 UDS: +benzo etoh negative Brief Hospital Course: 1. CELLULITIS -presented with evidence of possible cellulitis at site of prior superficial thrombophlebitis. received iv Unasyn at [**Hospital1 336**] ER. no fever, elevated wbc, or other systemic symptoms. empiric Unasyn was continued with marked improvement in cellulitis. He was switched to Augmentin to complete a course for cellulitis from prior site of superficial thrombophlebitis 2. THROMBOPHLEBITIS -superficial at site of prior iv, though presented with evidence of surrounding cellulitis, differential also included chemical (vanc) or septic thrombophlebitis given his recent + blood cultures (Enterobacter) and concern for self-line tampering. He had no fever, no purulence, and no systemic symptoms to suggest more involved process such as septic thrombophlebitis. Ultrasound of the forearm was negative for abscess and showed only thrombosis of the superficial cephalic vein which is consistent with clinical exam. 3. DMII UNCONTROLLED WITH COMPLICATIONS -he had labile blood sugars requiring [**Last Name (un) **] inpatient consultation. His sliding scale was adjusted and he was counselled again regarding diet and sliding scale usage with lantus. 4. ?H/O UPPER EXTREMITY DVT -he carries a diagnosis of upper extremity dvt he says in his Left arm in the setting of an iv or PICC during a previous admit at [**Hospital6 **] and has been on lmwh since [**5-12**]. Since he has likely received at least 2 months of therapy for an asymptomatic upper extremity thrombosis in the setting of an IV which is now removed, there is probably little if any additional benefit to continuing lmwh; therefore, will not continue on discharge. 5. CHRONIC PANCREATITIS -he complained of his usual pain on admission and requested Dilaudid since it was given at [**Hospital1 336**]. on my review of last admission orders, he did not receive Dilaudid for the past 10 days, and was not discharged on Dilaudid on his last two [**Hospital1 18**] admissions. Additionally, there was concern for abuse raised on his last admission. Since he was out of this hospital for less than 24hrs, was eating, ambulating, and resting comfortably, I did not see any clinical indication for narcotic pain medications. Additionally, he refused to comply with blood draws in his words "if he can't get pain meds" which further complicated efforts to address his medical care. 6. ABUSIVE BEHAVIOR / CONCERN FOR SUBSTANCE ABUSE -Mr. [**Known lastname **] was again noted by nursing staff and iv therapy to be tampering with his iv line, this admission after requesting and receiving Ambien for sleep. He was also noncompliant with medical care, refusing blood draws and verbally abusing staff. This was difficult since he does have erratic blood sugars which require monitoring, however his refusal to comply with dietary restraints counteracted all efforts to adequately address his blood sugar. He refused lab draws to follow up on his elevated liver enzymes. Additionally, on [**2176-7-18**] he left the floor against staff advice for approximately 1-2 hours, could not be found by security, then returned exhibiting slurred speech, erratic behavior and continued to be verbally abusive and threatening towards staff. He refused urine drug screen requested after he returned to his room. Given his abusive and noncompliant behavior, there was no clinical benefit for him to remain hospitalized and was therefore discharged with the aid of social work to arrange for his return to his shelter. I see little benefit of re-hospitalization if he continues to refuse care and verbally abuse and threaten the staff. If re-hospitalization is clinically required in the future, use of a security sitter should be considered until he proves he can safely and reliably cooperate and interact with his care team. Medications on Admission: same as last dc <24hrs prior. returned with his prescriptions from last admit Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Three (3) 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. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. insulin lantus 45 units sq twice a day 8. insulin humalog sliding scale with meals as directed Discharge Disposition: Home Discharge Diagnosis: cellulitis, resolved superficial thrombophlebitis hcv chronic pancreatitis transaminitis -> refused blood draws and follow up Discharge Condition: stable, afebrile, no abdominal pain, ambulating, eating. Discharge Instructions: you were admitted with concerns of a cellulitis or infection at the site of a prior IV. You were treated with iv antibiotics with resolution of your cellulitis, and there was no evidence of any blood stream infection. Your liver function tests were elevated, however, your continued refusal to comply with our care plan, has limited our ability to address this. You are being discharged on the same medicines you were admitted on, except you no longer need to take lovenox shots as we discussed. You should follow up with your new primary care physician at [**Hospital6 1708**]. Followup Instructions: your new primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2176-7-18**] Name: [**Known lastname 10507**],[**Known firstname **] Unit No: [**Numeric Identifier 10880**] Admission Date: [**2176-7-15**] Discharge Date: [**2176-7-24**] Date of Birth: [**2136-1-13**] Sex: M Service: MEDICINE Allergies: Toradol Attending:[**First Name3 (LF) 10881**] Addendum: Chief Complaint: mental status change Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 40 y.o. M w/ HCV, ETOH abuse, DMII, NHL, chronic pancreatitis and prior LUE DVT [**5-12**] and hx of enterobacter bacteremia about to be discharged today following treatment with Unasyn/augmentin for R arm cellulitis now transferred to [**Hospital Unit Name 1863**] for acute mental status changes. He has a hx of line-tampering and noncompliance with medical advice, with the last occurrence on [**7-15**] when witnessed crushing ambien and injecting Dilaudid and indomethacin into his IVs. He had episode of being unable to be found for 1hr, and then was discovered to be somnolent, dilated pupils and diaphoretic. His FS was 300, adn he was given 45 lantus, 10 humulog with normalization of levels. Labs now revealed new transaminitis. RUQ U/s showed no interval change. UA was positive for benzos. Last seen at [**Hospital1 8**] for Left wrist pain with a negative tap, but c/b blood cultures positive for Enterobacter bacteremia [**7-3**] thought to be [**1-6**] to self-injection of po meds (abiotrophia contaminant). He initiated a course of Vanco/Zosyn, and then finished 10 day course of ceftriaxone. At that time, his LFTs were elevated but amylase and lipase were within normal limits (ALT-121* AST-119* LD-265* CK-177* ALK PHOS-133* AMYLASE-46 TOT BILI-0.4 LIPASE-10). Past Medical History: Alcohol abuse Chronic Pancreatitis and chronic abdominal pain Diabetes II, insulin-requiring GERD Hepatitis C with abnormal LFTs Hypertension History of atrial fibrillation Bipolar Disorder on SSRI (no mood stabilizer) Non-Hodgkin's lymphoma dxed [**2-10**], s/p lymphnode resection underneath R ear, planned to have radiation, followed at [**Hospital1 **]/DF DVT's in left arm (on lovenox) S. Aureus skin infections in left arm (on outpt abx) Social History: Graduated from [**Hospital1 10882**] [**2160**] - worked for telephone company until [**2166**] and then became homeless with alcoholism. Homeless - lives in rehabs, hospitals, shelters. No tobacco use or other illicits. Pt has recently been living at Pinestreet facility, but has not been happy there. Reports parents moved this past spring from [**Location 2786**] to [**State 10883**] (loss of social support). Family History: diabetes pancreatitis -father, mother, and siblings Physical Exam: GEN: agitated, responds inappropriately to questions HEENT: + alcohol odor. no nystagmus. Mydriasis bilaterally. EOMI. sclera anicteric, MMM, OP Clear NECK: No JVD, carotid pulses brisk, trachea midline COR: tachycardic PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND EXT: No C/C/E NEURO: will not comply with exam. asterixis could not be assessed. no nystagmus. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Labs on admission: [**2176-7-17**] 01:00PM BLOOD WBC-6.7 RBC-3.86* Hgb-10.0* Hct-30.1* MCV-78* MCH-25.9* MCHC-33.2 RDW-16.3* Plt Ct-576* [**2176-7-16**] 05:00PM BLOOD WBC-6.9 RBC-3.80* Hgb-9.9* Hct-29.8* MCV-78* MCH-26.0* MCHC-33.2 RDW-16.3* Plt Ct-574* [**2176-7-15**] 11:15AM BLOOD WBC-8.7 RBC-3.67* Hgb-9.7* Hct-28.5* MCV-78* MCH-26.4* MCHC-34.0 RDW-16.3* Plt Ct-577* [**2176-7-17**] 01:00PM BLOOD Neuts-64.2 Lymphs-24.5 Monos-5.7 Eos-5.7* Baso-0 [**2176-7-16**] 05:00PM BLOOD Neuts-73.8* Lymphs-13.6* Monos-8.1 Eos-3.9 Baso-0.5 [**2176-7-15**] 11:15AM BLOOD Neuts-80.7* Lymphs-8.5* Monos-6.8 Eos-3.5 Baso-0.4 [**2176-7-17**] 01:00PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2176-7-17**] 01:00PM BLOOD Plt Smr-HIGH Plt Ct-576* [**2176-7-16**] 05:00PM BLOOD Plt Ct-574* [**2176-7-16**] 05:00PM BLOOD PT-12.2 INR(PT)-1.0 [**2176-7-17**] 01:00PM BLOOD Glucose-227* UreaN-11 Creat-0.7 Na-135 K-4.2 Cl-99 HCO3-25 AnGap-15 [**2176-7-17**] 01:00PM BLOOD ALT-874* AST-802* AlkPhos-312* Amylase-35 TotBili-0.6 [**2176-7-17**] 01:00PM BLOOD Lipase-10 [**2176-7-18**] 05:00PM BLOOD Osmolal-426* [**2176-7-18**] 05:00PM BLOOD ASA-NEG Ethanol-522* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Labs on discharge: [**2176-7-24**] 06:15AM BLOOD WBC-5.8 RBC-4.53* Hgb-11.5* Hct-36.3* MCV-80* MCH-25.5* MCHC-31.8 RDW-16.6* Plt Ct-445* [**2176-7-24**] 06:15AM BLOOD Glucose-236* UreaN-16 Creat-0.8 Na-135 K-5.0 Cl-103 HCO3-23 AnGap-14 [**2176-7-24**] 06:15AM BLOOD ALT-339* AST-143* LD(LDH)-200 AlkPhos-268* TotBili-0.4 [**2176-7-20**] 09:40AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0 Microbiology: [**2176-7-15**] Blood culture - negative [**2176-7-15**] Urine culture - negative [**2176-7-19**] HCV viral load - 2,040,000 IU/mL Imaging: [**2176-7-19**] Gallbladder U/S: CONCLUSION: No significant abnormalities seen. No evidence for acute cholecystitis or gallstones. No change from [**2176-7-9**]. Examination was terminated on patient's request, kidneys and the spleen were not evaluated. Brief Hospital Course: 40 year old man with history of ETOH abuse, HCV, uncontrolled DMII, chronic pancreatitis admitted for acute mental status change. . # altered mental status: The patient's altered mental status was attributed to alcohol intoxication, followed by withdrawl. He was initially managed in the intensive care unit, on standing benzodiazepines along with CIWA scale. Psychiatry was also involved. He stabilized and came to the regular floor on a benzodiazepine taper, and had normal mental status on discharge. . # Transaminitis: Patient was noted to have transaminitis during hospital course, with a 1:1 AST/ALT ratio. This was suggestive of toxic ingestion (drug use). Liver service was involved. HCV viral load was sent which was elevated at 2 million. The transaminitis was resolving at time of discharge, and patient was discharged with follow up scheduled in liver clinic. . # DMII: poorly controlled with last Hgb a1c 8.6%. [**Last Name (un) 616**] was involved in forming an insulin regimen and the patient was discharged on lantus and humalog sliding scale with improved glucose control. . # POlysubstance abuse: Thiamine and folate and MVI were given throughout hospital course. Social work was involved in patient's care. . # chronic alcoholic pancreatitis-inactive: Continued Amylase-Lipase-Protease enzymes supplements. . # Depression: continued citalopram . # GERD: continued pantoprazole. . # Non-Hodgkin's lymphoma: planned to have radiation, followed at [**Hospital1 **]/DF. Medications on Admission: Diazepam 5-10 mg IV Q3H:PRN if CIWA >10; Citalopram Hydrobromide 20 mg PO TID; FoLIC Acid 1 mg PO DAILY; Haloperidol 0.5 mg IV PRN Naloxone HCl 0.4 mg IV ONCE Pantoprazole 40 mg PO Q24H, Pangestyme-EC 2 CAP PO TID W/MEALS Thiamine 100 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Three (3) 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. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. insulin lantus 45 units sq twice a day 8. insulin humalog sliding scale with meals as directed 9. Lantus 100 unit/mL Solution Sig: Forty (40) units Subcutaneous twice a day. Disp:*2 vials* Refills:*0* 10. Humalog 100 unit/mL Solution Sig: according to scale up to 60 units a day Subcutaneous four times a day: per sliding scale. Disp:*2 vials* Refills:*0* 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: cellulitis superficial thrombophlebitis hx UE DVT hcv chronic alcoholic pancreatitis transaminitis Bipolar disorder poloysubstance abuse (opiates, etoh) Diabetes mellitus Discharge Condition: stable, afebrile, no abdominal pain, ambulating, eating. Discharge Instructions: You were admitted with concerns of a cellulitis or infection at the site of a prior IV. You were treated with iv antibiotics with resolution of your cellulitis, and there was no evidence of any blood stream infection. Your liver function tests were elevated, however, requiring continued monitering. You are being discharged on the same medicines you were admitted on, except you no longer need to take lovenox shots as we discussed. You should follow up with your new primary care physician at [**Hospital6 10884**]. Followup Instructions: Please follow up with your new primary care physician at [**Hospital1 10885**] ([**Telephone/Fax (1) 10886**]. Please follow up in the liver center ([**Telephone/Fax (1) 10887**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 833**] on [**2176-8-2**] at 1pm. Liver center is located on the [**Location (un) 601**] of the [**Hospital Unit Name **] on the [**Hospital3 **] Hospital campus. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10888**] MD [**MD Number(2) 10889**] Completed by:[**2176-7-24**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

25101, 25107

22302, 22444

17436, 17442

25322, 25381

20248, 20253

25949, 26524

19675, 19728

24099, 25078

25128, 25301

23827, 24076

25405, 25926

19743, 20229

17376, 17398

21507, 22279

17470, 18759

20267, 21488

22459, 23801

18781, 19227

19243, 19659

20,019

172,281

20465

Discharge summary

report

Admission Date: [**2165-5-24**] Discharge Date: [**2165-5-27**] Date of Birth: [**2107-12-9**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old right-handed woman who was evaluated by a neurologist for vertigo. She indicates she was in her usual state of good health until approximately five days prior to her evaluation when she had complaints of the acute onset of vertigo, a sensation of being off balance, and vomiting. She also reports associated blurry vision with no headache, tinnitus, sensory symptoms, or speech difficulties. Her daughter, however, who was present during the interview today indicates that her speech was somewhat slurred. She was taken to [**Hospital **] Hospital where a head computed tomography showed "an abnormality." She had a magnetic resonance imaging/magnetic resonance angiography of the brain which showed evidence of a right posterior communicating artery aneurysm. She was referred to Dr. [**Last Name (STitle) 1132**] for endovascular vs. surgical therapy. She was admitted on [**2165-5-24**] for a conventional angiogram and consideration for endovascular treatment. PHYSICAL EXAMINATION ON PRESENTATION: She was a well-developed woman who appeared in mild discomfort. Her blood pressure was 120/80, her pulse was 72, her respiratory rate was 12, and she was afebrile. She was alert, awake, and fully oriented. Speech and language function were intact. Judgment, memory, and calculations were intact. Affect was appropriate. There was no apraxia, agnosia, or neglect. Cranial nerve examination revealed visual acuity was normal. She had a slight anisocoria with the left pupil approximately 4 mm in diameter and the right 3 mm. Both were equal, round, and reactive to light. There was no Horner syndrome or ptosis. The visual fields were full. Extraocular movements were full in all directions. Facial movement was intact. There was decreased sensation to touch on the left side of the face. Hearing was intact to rub. The palate elevated symmetrically. Motor examination revealed normal tone and muscle strength throughout. Cerebellar function was normal except for subtle clumsiness of the finger-to-nose on the left side. She also had slight difficulty drawing a figure eight with the left foot compared to the right. Deep tendon reflexes were 2+ throughout. SUMMARY OF HOSPITAL COURSE: She was admitted for angiogram for coiling of the right posterior communicating artery aneurysm. There were no intraoperative complications. Postoperatively, she was monitored in the Intensive Care Unit for close neurologic observation. She was started on heparin. The patient was in the Intensive Care Unit recovering from the coiling when she had the onset of unresponsiveness and bilateral pinpoint pupils. Her blood pressure rose to greater than 180 for a few minutes and then she had slight twitching of her head. She was immediately intubated and sedated and brought to head computed tomography which showed no evidence of bleeding or stroke. She was loaded prophylactically with Dilantin and started on Decadron. Her blood pressure was kept at less than 140. On [**5-25**], the patient was alert, awake, and oriented times three. She had some double vision in the left lateral gaze. She had negative drift. She had a slight hematoma of the right leg. Her iliopsoas were [**6-19**]. Her pulses were intact. Her Decadron was decreased. She was continued on Dilantin. She was out of bed to chair. On [**5-26**], there was no seizure activity. She was alert, awake, and oriented times three and moving all extremities with good strength. No drift. She continued to have a left lateral gaze minimal diplopia. She was stable, and she was transferred to the regular floor. On [**5-27**], she continued to be neurologically stable without any evidence of seizures. Alert, awake, and oriented times three. Moving all extremities. Her speech was fluent. DISCHARGE DISPOSITION: She was discharged on [**5-27**] in stable condition with followup with Dr. [**Last Name (STitle) 1132**] in one week. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets by mouth q.4h. as needed. 2. Decadron 2 mg by mouth q.6h. (for three days). 3. Famotidine 20 mg by mouth twice per day. 4. Dilantin 100 mg by mouth three times per day. 5. Aspirin 325 mg by mouth once per day. CONDITION AT DISCHARGE: Stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2165-5-27**] 13:56 T: [**2165-5-29**] 14:13 JOB#: [**Job Number 54801**]

[ "E878.8", "437.3", "780.39", "300.00", "997.09", "368.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.72", "93.90", "88.41" ]

icd9pcs

[ [ [] ] ]

4012, 4132

4158, 4415

2412, 3987

4430, 4719

169, 2383

7,809

156,942

48885

Discharge summary

report

Admission Date: [**2134-8-4**] Discharge Date: [**2134-8-11**] Date of Birth: [**2078-12-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1973**] Chief Complaint: fever, hyperglycemia Major Surgical or Invasive Procedure: L subclavian CVL TEE History of Present Illness: 55 year-old female with Type 1 Diabetes, severe gastroparesis, Benign Hypertension, Grave's Disease and Hep C who presents with fever and hyperglycemia. The patient has had multiple admissions to [**Hospital1 18**] for DKA, most recently in [**5-29**], felt to be [**2-22**] coag negative staph bacteremia vs gastroparesis. Prior to this current presentation, she has had nausea and [**Month/Day (2) **] for the past week with blood sugars of 600 at home. Also decreased PO intake, abdominal pain, and chest pain. The abdominal pain is consistent with previous episodes of gastroparesis. The chest pain is similar to chest pain she has had in the past. She spiked a temp of [**Age over 90 **] yesterday. She reports that she has been taking her lantus at home, but not her humalog because she was not eating. In the ED, initial vs were: T 98.6, P 118, BP 194/108, R 18, O2 sat 100% RA. She looked dry with a diffusely tender but soft abdomen. The ED team placed R femoral line for difficult access. Anion gap was 24. She received 4L NS followed by D5 1/2NS with potassium. Insulin drip was started. CXR was clear. UA was negative. Received morphine 4mg IV x 2 and zofran. BP rose as high as 227 systolic and she was given 10mg IV hydralazine with good effect. Blood and urine cultures were sent and she was transferred to the [**Hospital Unit Name 153**] for further management. On arrival to the [**Hospital Unit Name 153**], she complains of pain in her abdomen and across her lower back. Subsequently she grew out 3 bottles of Coagulase Negative Staphylococcus and was started on vancomycin. Past Medical History: 1. DM Type 1: Years w/ DM: 5 Age of Diag: 48 Year Diag: [**2127**]. Several episodes of DKA, managed on 28U Lantus [**Hospital1 **] plus HISS 2. Diabetic polyneuropathy and gastroparesis 3. Hypertension 4. Grave's disease s/p RAI [**2129**] 5. Reactive airway disease 6. Seronegative arthritis, followed in rheumatology 7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation, never been on antiviral therapy, acquired via blood transfusion during surgery in [**2110**] 8. GERD 9. Migraines 10. Bilateral knee arthroscopy in [**5-24**] 11. s/p TAH and pelvic floor surgery with bladder lift 12. Depression 13. Bone spurs in feet 14. Bilateral foot drop requiring wheelchair use Social History: Patient lives in a multi apartment building in the same apartment with a daughter, grandaughter, and grandson. She has a son, daughter and another brother who live on another floor. She is a never smoker and does not use alcohol or drugs. She has not worked for many years Family History: Her mother died of colon cancer. There are multiple family members with DM Physical Exam: General: Soft-spoken female lying in bed on her back. [**Date Range 4459**]: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, regular, normal S1 + loud S2. No m/r/g. Abdomen: soft, diffuse mild tenderness to palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: + diffuse multi joint pain with some violaceous lesions on finger tips (c/w finger sticks?), Warm feet, 2+ pulses. Cold hands, 2+pulses. no clubbing, cyanosis or edema PICC in place Pertinent Results: [**2134-8-11**] 05:32AM BLOOD WBC-5.6 RBC-3.12* Hgb-8.6* Hct-27.3* MCV-88 MCH-27.4 MCHC-31.3 RDW-16.1* Plt Ct-393 [**2134-8-7**] 04:18AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.4* Hct-25.6* MCV-85 MCH-27.7 MCHC-32.7 RDW-15.1 Plt Ct-193 [**2134-8-4**] 01:00AM BLOOD WBC-7.8# RBC-4.52# Hgb-12.3 Hct-39.4# MCV-87 MCH-27.3 MCHC-31.3 RDW-14.3 Plt Ct-428 [**2134-8-4**] 01:00AM BLOOD Neuts-71.6* Lymphs-24.3 Monos-3.4 Eos-0.3 Baso-0.3 [**2134-8-4**] 05:45AM BLOOD PT-12.2 PTT-38.8* INR(PT)-1.0 [**2134-8-11**] 05:32AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-99 HCO3-32 AnGap-10 [**2134-8-7**] 04:18AM BLOOD Glucose-156* UreaN-2* Creat-0.7 Na-138 K-4.1 Cl-111* HCO3-22 AnGap-9 [**2134-8-4**] 09:53AM BLOOD Glucose-67* UreaN-11 Creat-0.8 Na-135 K-4.5 Cl-105 HCO3-20* AnGap-15 [**2134-8-4**] 05:45AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-138 K-3.2* Cl-110* HCO3-15* AnGap-16 [**2134-8-4**] 01:00AM BLOOD Glucose-383* UreaN-18 Creat-1.1 Na-131* K-4.3 Cl-96 HCO3-11* AnGap-28* [**2134-8-10**] 06:28AM BLOOD CK(CPK)-53 [**2134-8-4**] 01:00AM BLOOD ALT-18 AST-18 CK(CPK)-26 AlkPhos-108 [**2134-8-4**] 01:00AM BLOOD Lipase-30 [**2134-8-4**] 01:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2134-8-11**] 05:32AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.7 [**2134-8-5**] 04:23AM BLOOD Calcium-8.8 Phos-2.2* Mg-1.9 [**2134-8-4**] 05:24PM BLOOD Calcium-9.1 Phos-1.4* Mg-2.2 [**2134-8-4**] 09:53AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7 [**2134-8-4**] 05:45AM BLOOD Calcium-8.4 Phos-1.0*# Mg-1.6 [**2134-8-4**] 01:00AM BLOOD Albumin-4.2 [**2134-8-6**] 05:00AM BLOOD TSH-0.068* [**2134-8-6**] 05:00AM BLOOD Free T4-1.2 [**2134-8-8**] 05:09AM BLOOD Vanco-20.7* [**2134-8-6**] 10:39AM BLOOD O2 Sat-66 [**2134-8-4**] 02:35AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014 [**2134-8-4**] 12:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029 [**2134-8-4**] 02:35AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2134-8-4**] 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2134-8-4**] 12:30AM URINE RBC-0-2 WBC-[**12-10**]* Bacteri-MOD Yeast-NONE Epi-[**12-10**] [**2134-8-4**] 1:00 am BLOOD CULTURE **FINAL REPORT [**2134-8-7**]** Blood Culture, Routine (Final [**2134-8-7**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. Please contact the Microbiology Laboratory ([**7-/2431**]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Aerobic Bottle Gram Stain (Final [**2134-8-5**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2134-8-5**] AT 0600. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2134-8-5**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2134-8-4**] 1:25 am BLOOD CULTURE **FINAL REPORT [**2134-8-10**]** Blood Culture, Routine (Final [**2134-8-10**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. Please contact the Microbiology Laboratory ([**7-/2431**]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Aerobic Bottle Gram Stain (Final [**2134-8-5**]): GRAM POSITIVE COCCI IN CLUSTERS. [**2134-8-4**] 5:50 am MRSA SCREEN NASAL SWAB. **FINAL REPORT [**2134-8-6**]** MRSA SCREEN (Final [**2134-8-6**]): No MRSA isolated. [**2134-8-5**] 5:10 pm CATHETER TIP-IV Source: CVL. **FINAL REPORT [**2134-8-8**]** WOUND CULTURE (Final [**2134-8-8**]): No significant growth. [**2134-8-6**] 5:00 am BLOOD CULTURE Source: Line-cvp. **FINAL REPORT [**2134-8-10**]** Blood Culture, Routine (Final [**2134-8-10**]): PRESUMPTIVE VEILLONELLA SPECIES. ISOLATED FROM ONE SET ONLY. NEISSERIA SPECIES. ISOLATED FROM ONE SET ONLY. PIGMENTED, NON-PATHOGENIC. Anaerobic Bottle Gram Stain (Final [**2134-8-9**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **] @ 1015AM, [**2134-8-9**]. GRAM NEGATIVE COCCI. Aerobic Bottle Gram Stain (Final [**2134-8-9**]): GRAM NEGATIVE COCCI. ECG Study Date of [**2134-8-3**] 11:01:38 PM Sinus tachycardia. Vertical axis for age. Increased precordial QRS voltage. Probable left ventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing of [**2134-6-14**] the axis is more vertical. QRS voltage is more prominent. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 118 142 82 328/429 90 79 63 CHEST (PORTABLE AP) Study Date of [**2134-8-4**] 2:28 AM IMPRESSION: Essentially normal chest radiograph. TTE (Complete) Done [**2134-8-5**] at 12:35:54 PM Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. MR [**Name13 (STitle) **] W &W/O CONTRAST Study Date of [**2134-8-8**] 2:04 PM IMPRESSION: Diffuse edema involving the superficial soft tissues in the lower thoracic spine and lumbar spine region without evidence of fluid collection or abscess, extending from T10/T11 through L5 levels. There is no evidence of discitis or osteomyelitis. Given the extension of the inflammatory changes, cellulitis is a consideration. Multilevel disc degenerative changes from L2/3 through L5/S1 as described in detail above. CHEST PORT. LINE PLACEMENT Study Date of [**2134-8-9**] 12:33 PM FINDINGS: Right PICC terminates in the lower superior vena cava. Pre-existing left subclavian catheter is unchanged. Heart size remains normal, and the lungs remain clear. Costophrenic sulci are not well demonstrated, possibly due to overlying breast tissue, but small effusions cannot be excluded. CT PELVIS W/CONTRAST Study Date of [**2134-8-10**] 10:42 AM IMPRESSION: 1. No evidence of acute appendicitis or inflammatory changes within the right lower quadrant to explain pain. 2. Unchanged hypodense lesion measuring 1.9 cm in the lower pole of the left kidney since [**2132**] which is not fully characterized but could reflect a cyst. 3. Stable compression deformity of L4 since lumbar spine MRI several days previous yet new since [**2132**]. 4. Broad neck left pelvic spigelian hernia with a small amount of colon herniated within without evidence of ischemia/strangulation. Brief Hospital Course: 1. Type 1 Diabetes with Diabetic Ketoacidosis: Patient has had many admissions in the past few years for DKA. On this admission there was an inciting event of Coag (-) Staph infection from an unknown source, which most likely was the trigger for the DKA. Patient??????s gap closed on [**8-5**] and her insulin drip was stopped. She was placed on an insulin sliding scale with fixed dose 21 Lantus [**Hospital1 **] (her home dose is 28 [**Hospital1 **]) which was initiated shortly after. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained on the floor, which did not make significant changes. 2. Septicemia - Coag Negative Staphylococcus, Bacteremia: Patient started having tachycardia and low SBP (80-90s), flat JVP, CVP=6 on [**8-5**]. This was consistent w/ a septic picture, due to her Coag (-) Staph bacteremia. Her BP was responsive to IVF boluses. Her hypotension and tachycardia are were most likely a mixed picture of sepsis and hypovolemia. Pt's HR and BP stabilized on [**8-6**], HR 90s-100s, BP 90s-120s/50s-70s. Blood cultures grew Coag (-) Staph, and she was started on Vancomycin on [**8-5**]. Also with questionable baseline belly/back pain vs abscess vs osteo. TEE showed no vegetations. Abd CT as above for other etiologies mentioned above. She has been afebrile throughout admission. ID consultation was obtained, and the patient will be discharged on vancomycin to complete [**7-20**]. 3. Benign Hypertension: Hypertensive on arrival to the [**Hospital Unit Name 153**], but then became hypotensive due to Coag (-) Staph sepsis and hypovolemia. Home BP meds were held until resolution of septicemia then restarted. 4. Pain: diffuse polyarthralgias / Diabetic Neuropathy Presumed secondary to longstanding rheumatoid arthritis and diabetes. the patient was treated with a fentanyl patch and her home neurontin was increased from 600 TID to 900 TID. 5. Rheumatoid Arthritis: Patient complains of diffuse polyarthralgias but this is probably her baseline RA. We continued her on home sulfasalazine. 6. [**Doctor Last Name 933**] disease: On last admission her TSH was suppressed, but TFTs are now consistent with [**Doctor Last Name **] euthyroid. Methimazole has been continued. 7. GERD: Currently on protonix for GERD, which has been continued during this hospitalization. 8. Depression: Currently on amitriptyline for depression, which has been continued during this hospitalization. 9. Spigalian Hernia Incidentally noted on abdominal CT. This will be seperately communicated to the PCP for referral for outpatient surgical consultation. Medications on Admission: Singulair 10mg PO daily Zomig 2.5mg PO daily prn Protonix 40mg PO daily Lantus 28u [**Hospital1 **] Tapazole 10mg PO TID Reglan 10mg PO daily Diazepam 5mg PO BID Naprosyn 500mg PO BID Sulfasalazine 1000mg PO BID Zocor 10mg PO daily Cozaar 50mg PO daily Amitriptyline 25mg PO qHS Oxycodone-Acetaminophen 5mg-325mg 1 tab q6 prn Docusate 100mg PO BID Neurontin 600mg Po TID Flovent 50mcg inhaler Serevent 50mcg inhaler Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Methimazole 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Zolmitriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for cough. 5. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28) Units Subcutaneous twice a day. 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Disp:*50 ML(s)* Refills:*0* 17. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection PRN as needed for Line Flush. Disp:*100 ml* Refills:*0* 18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 8 days. Disp:*16 gram* Refills:*0* 19. Outpatient Lab Work Weekly CBC/Diff, BUN/Cr and Vancomycin Trough with results to fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**] 20. PICC CARE PICC Care per protocol Discharge Disposition: Home With Service Facility: Uphams Corner Home Care Discharge Diagnosis: Type 1 Diabete with Diabetic Ketoacidosis Septicemia - Staphylococcus Coag Negative Bactermia Diabetic Neuropathy Rheumatoid Arthritis Benign Hypertension Gastroparesis Grave's Disease Discharge Condition: Good Discharge Instructions: Return to the hospital with fever/chills, nausea/vomitting, swelling of the arm with the PICC line. It is critical that you keep the PICC line clean. Followup Instructions: Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2134-8-13**] 4:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2134-8-18**] 2:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2134-10-19**] 9:15

[ "401.1", "530.81", "242.00", "536.3", "276.8", "250.63", "311", "346.90", "714.0", "250.13", "070.70", "038.10", "357.2" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

17257, 17311

12331, 14936

292, 314

17539, 17545

3683, 12308

17744, 18175

2955, 3031

15403, 17234

17332, 17518

14962, 15380

17569, 17721

3046, 3664

232, 254

342, 1941

1963, 2649

2665, 2939

6,960

178,048

49887

Discharge summary

report

Admission Date: [**2120-10-30**] Discharge Date: [**2120-11-29**] Date of Birth: [**2053-11-23**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old woman who was admitted status post elective anterior communicating artery aneurysm clipping and smaller posterior communicating artery clipping on [**2120-10-30**]. There were no was monitored in the surgical Intensive Care Unit. Her vital signs were stable. She was on Nipride to keep her blood pressure less than 140. She had CPKs drawn that were 156, an MB of 3 and a troponin less than .3. Chest x-ray showed mild cardiac enlargement. Lungs were essentially clear. The patient was awake but sleepy, oriented to day, date and year. name of the surgeon, smile was equal, tongue midline. 5/5 strength. The patient was neurologically stable. At 2:30 a.m. on [**2120-10-31**] the patient developed labile fluctuating blood pressure requiring increasing Nipride with systolic blood pressures up in the 160-180 range and tachycardia up to 118. The patient was given Lopressor and shortly before 3 a.m. the patient was noted to be less responsive, less alert and did not follow commands but opened her eyes briefly with stimulation, but moved all four extremities. The patient had a head CT without contrast which showed no acute hemorrhage or bleed or shift. At 3:45 a.m. the patient was moving all extremities with bilateral graft, initially equal, but over the next 20-30 minutes the patient was noted to be not moving her right upper extremity spontaneously and essentially no withdrawal to pain of the right upper extremity. She was continued to be easily arousable, opening her eyes and appeared attentive, but had been non verbal since 2:30 a.m. The patient was taken back for CTA which showed decreased flow distal to the clipped aneurysm which was treated with a fluid bolus and blood pressure was increased the 160-180 range. On [**2120-10-31**] the patient was taken at 5:30 am to the endovascualr suite and underwent emergent angiography which revealed vasospasm of the distal left MCA superior division which was treated with intraluminal injection of papaverine with good result. The angiogram also showed that both aneurysms were clipped with good result. On [**2120-11-1**] the patient continued to have left/right upper extremity paresis. CTA demonstrated left MCA branch vasospasm and patient continued to be lethargic. The patient had Swan Ganz catheter placed and was started on triple A therapy. The patient was intubated and sedated. PAST MEDICAL HISTORY: Included type 2 diabetes, CAD with MI in [**Month (only) 216**] and lateral wall ischemia, hypertension, hypercholesterolemia and cervical carcinoma. On [**2120-11-1**] the patient also developed coffee ground emesis and EKG changes. She had T wave changes. A TTE showed diffuse left wall hypokinesis. Her troponin levels came back at 17, CK was 504 and MB was 6. HOSPITAL COURSE: In the afternoon she developed coffee ground from her NG tube, she was lavaged and cleared after 800 cc. She had no melena or bright red blood per rectum and no further coffee ground. She was seen by the GI service who recommended holding tube feeds for 24 hours, starting her on Protonix, checking hematocrit and not allowing NSAIDS. The patient, after the bleeding stopped, was allowed to start on a baby Aspirin for cardiac problems. The patient ruled in for a non Q wave MI in the inferior leads with T wave changes in 2, 3 and AVF. Chest x-ray at the time showed no CHF. On [**2120-11-5**] the sedation was shut off, patient did not follow commands, neuro signs were unchanged, she did move the right lower extremity spontaneously, arousable to voice, does not follow commands, moving the right leg on the bed, left leg lifts and falls occasionally, tries to bring the left arm up to head level. Right arm not moving spontaneously. Does not withdraw to noxious stimulation. Pupils were 3 mm and briskly reactive bilaterally. Left eye remains swollen. On [**2120-11-7**] the patient had a vent drain placed. The patient had problems with elevated blood sugars in the Intensive Care Unit. She was on an insulin drip briefly. She was also continued on sedation on [**2120-11-11**]. She was not following commands, head rear, spontaneous movement of the lower extremities, upper extremities were edematous. Cardiac-wise she was stable with some potassium level related ectopy, and occasional hypertension. On [**2120-11-14**] the patient spiked a temperature to 101.5. The patient was given Tylenol and blood cultures were sent as well as chest x-ray and CBC were sent. At this point patient was on C pap on the vent. She remained awake and restless and repeat head CT on [**2120-11-11**] was unchanged. On [**2120-11-7**] the patient had head CT which showed a left frontal infarct from basal spasm. The patient spiked a temperature to 103 on [**11-7**] and [**2120-11-8**]. The patient had MRI on [**2120-11-7**] which again showed evidence of small left frontal infarct. On [**2120-11-8**] the patient had positive blood cultures for gram positive cocci. CSF had no growth. Patient was started on Oxacillin for gram positive cocci in her blood. The patient also had CSF from the 16th that grew staph aureus. Sputum came back positive for Klebsiella pneumonia on [**2120-11-7**]. The patient continued on Rocephin and Oxacillin for antibiotic coverage. On [**2120-11-12**] the patient developed coffee drainage from the incision site on her left side of her scalp from her aneurysm clipping. The patient was taken emergently to the OR and had evacuation of the subgaleal empyema and debridement of the tissue and removal of bone flap. There were no intraoperative complications. Postoperative patient's temperature was down to 101. White count was 12, hematocrit 30.4, platelet count 437,000. Neurologically she was opening her eyes spontaneously, withdrawing to pain in the left upper extremity and both lower extremities and had minimal withdrawal to pain in the right upper extremity. The patient grew staph from her left subclavian line on [**2120-11-8**] that was sensitive to Oxacillin. On [**2120-11-12**] the patient also had an episode of atrial fibrillation, atrial flutter which required electric cardioversion which was successful in converting her to normal sinus rhythm. She was seen by the ID service who recommended Ceftriaxone. Patient also had CT of the chest on [**11-12**] which was consistent with an acute thrombus of the left brachiocephalic vein and possibly extending into the left subclavian and consolidation at the lung bases with bilateral pleural effusion. The patient also continued on Oxacillin 2 gm IV q 4 hours and Ceftriaxone for antibiotic coverage. On [**2120-11-18**] the patient had LP. Opening pressure was 18, closing pressure was 11, 12 cc of CSF was drained off and sent for culture, cell count, protein and glucose. Neurologically patient was not following commands consistently. Right upper extremity was still flaccid, moves toes to command, withdraws bilateral lower extremities to pain, toes were downgoing. Incision was clean, dry and intact and there continued to be a fluid collection under the incision but it was not tense, it was easily ballottable. Pupils were 3.5 mm and equally reactive. The patient was extubated on [**2120-11-20**]. On [**2120-11-21**] the patient was awake, alert, attentive, stating her name, smiling, showing thumb on the right hand. Attempts to show two fingers on the left, moving the right lower extremity less than the left lower extremity but still moving spontaneously. Withdraws the left lower extremity to pain. Pupils were 2.5 down to 2 bilaterally. Her wound continue to be ballottable, clean, dry and intact with no leakage. Her labs were within normal limits. Her white count was 9.5, sodium 138, potassium 4.2, CVP was [**2-3**]. She continued on insulin drip at 1-2 units per hour. Blood pressure was 165/71, T max was 102.2. On [**11-21**] the patient had a chest x-ray which showed right lower lobe consolidation. She continued on Oxacillin for MSSA extra axial fluid collection. Continued on Vancomycin for coag negative staph and Levo for pneumonia and coag negative line sepsis, pneumonia and sinusitis. The patient was seen by physical therapy an occupational therapy and found to require rehab prior to discharge to home. The patient remained in the Surgical Intensive Care Unit until [**2120-11-25**] when she was transferred to the regular floor. She continued to be followed by the ID service who recommended a full six week course of Oxacillin for her gram negative line sepsis and a two week course of Vancomycin for her brain abscess, line sepsis pneumonia and sinusitis. The patient had swallow study on [**2120-11-27**]. She failed the swallow study and they recommended that she remain npo with an NG tube in for retry of po in 5 days. Neurologically at the time of discharge the patient was moving the left upper extremity with 5/5 strength. The right upper extremity was [**1-29**], lower extremities were moving spontaneously. The patient was out of bed to chair with assist of two people. Continued to be afebrile with stable vital signs and will continue on antibiotics, Oxacillin for a six week course, Vancomycin for a two week course. The patient should be maintained on fall precautions secondary to the lack of bone flap in her incision. Preventing falls is one of the most important issues to be aware of. The patient will need to have swallow study done at rehab. DISCHARGE MEDICATIONS: Impact with fiber with 25 gm of ProMod at 65 cc per hour, Albuterol and Atrovent nebs q 4 hours, Dilantin 200 mg per NG tid, Lipitor 20 mg per NG q day, ASA 81 mg per NG q day, Lopressor 150 mg NG tid, Vancomycin 1 gm IV q 12 hours for complete two week course, the medication was started on [**2120-11-22**], Levofloxacin 500 mg IV q day, started on [**2120-11-21**] and should continue for a 14 day course, Captopril 150 mg NG q 8 hours, NPH 20 units subcu [**Hospital1 **], Heparin 5,000 units subcu tid, Prevacid 30 mg NG [**Hospital1 **], Epogen [**Numeric Identifier **] units subcu q 7 days, Mag Oxide 800 mg NG tid. Patient is on a sliding scale for regular insulin 61-120 2 units, 121-200 4 units, 201-250 6 units, 251-300 8 units, 301-350 10 units, 351-400 12 units, Amiodarone 200 mg NG [**Hospital1 **], Tylenol 650 mg q 6 hours prn, Oxacillin 2 gm IV q 6 hours. The patient should have weekly LFTs, CBC and BUN and creatinine checked while on antibiotics. Follow-up with Dr. [**Last Name (STitle) 1132**] in one week, [**Telephone/Fax (1) 2992**] to book follow-up appointment. CONDITION ON DISCHARGE: Stable. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D., Ph.D. 14-133 Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2120-11-29**] 15:26 T: [**2120-11-29**] 16:01 JOB#: [**Job Number 104219**]

[ "038.19", "996.74", "578.9", "997.1", "437.3", "998.59", "410.71", "997.02", "482.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "42.23", "96.6", "03.31", "01.59", "88.72", "89.64", "39.51" ]

icd9pcs

[ [ [] ] ]

9644, 10737

2964, 9620

154, 2555

2578, 2946

10762, 11020

9,311

125,591

28259

Discharge summary

report

Admission Date: [**2161-10-8**] Discharge Date: [**2161-10-15**] Date of Birth: [**2088-12-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Abnormal Stress Test/Chest Pain/Dyspnea on exertion Major Surgical or Invasive Procedure: [**2161-10-8**] - CABGx5 (LIMA->LAD, Vein->Diagonal, Vein->Ramus sequentialed to Obtuse marginal, Vein->Posterior descending artery) History of Present Illness: 72 year old gentleman with chest pain and dyspnea on exertion. He underwent an ETT which was positive for ischemia. A cardiac catheterization was performed which revealed severe three vessel disease. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. He now presents as a same day admission for bypass grafting. Past Medical History: CAD s/p PTCA Hyperlipidemia HTN Diabetes Colon Cancer GERD Social History: Smoked 1.5 ppd for 30 years quitting in [**2143**]. Retired and widowed. Lives with daughter and grandson. Drinks 1-2 drinks per month. Family History: Father died of MI at age 39. Physical Exam: 74 172/81 71" 213lbs GEN: NAD lying fl;at in bed SKIN: Unremarkable HEENT: Unremarkable NECK: Supple, FROM LUNGS: Clear HEART: Irregularly irregular, no murmur ABD: Soft, NT, ND, NABS EXT: Warm, no edema, 2+ pulses, No varicosities NEURO: Nonfocal Pertinent Results: [**2161-10-12**] 04:51AM BLOOD WBC-13.3* RBC-3.15* Hgb-9.8* Hct-27.5* MCV-87 MCH-31.0 MCHC-35.5* RDW-14.2 Plt Ct-199 [**2161-10-12**] 04:51AM BLOOD Plt Ct-199 [**2161-10-12**] 04:51AM BLOOD UreaN-32* Creat-1.0 Na-134 K-4.2 Cl-101 HCO3-22 AnGap-15 [**2161-10-8**] ECHO PRE-CPB No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 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 descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 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. POST-CPB Normal biventricular systolic function. No changes from pre-CPB study. [**2161-10-10**] CXR Single portable radiograph of the chest demonstrates interval removal of the right-sided chest tube seen on [**2161-10-8**]. No pneumothorax. The endotracheal tube and nasogastric tube have been removed as well. Swan-Ganz catheter has been removed, but the right internal jugular introducer sheath remains in place. Cardiomediastinal contours are unchanged. Lungs are clear. Right costophrenic angle is excluded from the imaged field of view. There may be a very small left-sided pleural effusion. [**2161-10-13**] 09:55AM BLOOD WBC-10.9 RBC-3.24* Hgb-10.2* Hct-28.2* MCV-87 MCH-31.6 MCHC-36.3* RDW-14.2 Plt Ct-302# [**2161-10-13**] 09:55AM BLOOD PT-12.9 PTT-21.5* INR(PT)-1.1 [**2161-10-13**] 09:55AM BLOOD Plt Ct-302# [**2161-10-13**] 09:55AM BLOOD Glucose-138* UreaN-32* Creat-1.1 Na-138 K-4.2 Cl-103 HCO3-23 AnGap-16 [**2161-10-13**] 09:55AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 68637**] was admitted to the [**Hospital1 18**] on [**2161-10-8**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to five vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mr. [**Name13 (STitle) 4469**] was awake, extubated and neurologically intact. Beta blockade, an ace inhibitor and a calcium channel blocker were started for hypertension. Aspirin and a statin were resumed. Mr. [**Known lastname 68637**] developed atrial fibrillation and was started on amiodarone with eventual conversion back into a normal sinus rhythm. On postoperative day four, Mr. [**Known lastname 68637**] was transferred to the step down unit for further recovery.Coumadin started for anticoagulation. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued to make steady progress and was discharged home on postoperative day #6. He will follow-up with Dr. [**Last Name (STitle) 914**] and Dr. [**Last Name (STitle) 4469**] as an outpatient. First blood draw scheduled for [**10-17**] with results to be called to Dr. [**Last Name (STitle) 4469**]. Medications on Admission: Actos Torpol XL Avalide Metformin Folic Acid Zocor Norvasc Altace Multivitamin Protonix Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: Take 2 tabs(40mg) once daily for one week then discontinue. Disp:*14 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*0* 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 12. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: Check INR [**10-17**] with results to Dr. [**Last Name (STitle) 4469**]. Disp:*60 Tablet(s)* Refills:*0* 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every [**4-2**] hours. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD s/p CABGx5 Hypercholesterolemia HTN Diabetes Colon Cancer GERD AF Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. Followup Instructions: First blood draw [**10-17**] with results to be called to Dr. [**Last Name (STitle) 68638**] office. Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with cardiologist/Primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] in 2 weeks. ([**Telephone/Fax (1) 24747**] Completed by:[**2161-10-15**]

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Discharge summary

report

Admission Date: [**2136-11-24**] Discharge Date: [**2136-12-5**] Date of Birth: [**2063-4-26**] Sex: F Service: MEDICINE Allergies: Vioxx / Compazine / Phenergan Attending:[**First Name3 (LF) 13386**] Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This is a 73 yo female with multiple medical problems including CRI, cervical spondylosis, and L sciatica x10 yrs who presents with complaints of worsening lower extremity weakness. The pt states that she was able to stand and walk with a walker until today when she was getting into the car and collapsed. She has noted that in the past several days her knees have been buckling and she has nearly fallen. She has also noted increased lower back pain over the past several weeks. The pt has had a gradual decline in mobility over recent months. She thinks she has had increased lower extremity weakness while being treated for a urinary tract infection. The pt admits to numbness down her L leg into her foot x 10 yrs and partly into her R leg as well. She also has some numbness in her upper extremities (mostly in her hands) which is stable for years. She admits to some baseline UE weakness. She does not have urinary retention but does admit to urinary incontinence and wears pads (this is baseline). She is unsure if she has fecal incontinence since she has an ileostomy. She admits to poor appetite and eats only [**2-6**] meals/day. She limits how much she drinks since she has dysuria related to her UTI. She has had less energy and has been sleeping more over the past several weeks. The pt denies f/c s, CP, SOB, dizziness. . In the ED, the pts vitals were: T 97.5 P 60 BP 144/55 R 18 Sat 96%RA. EKG revealed NSR, LAD, inverted T in III, Q in III, and upright T waves in anterior leads (this is similar to [**8-8**] EKG but changed from [**2-10**] EKG in which there were TWI in I, AVL, and anterior leads, and T was upright in III). The pt was noted to have 5/5 strength on dorsi/ plantar flexion bilaterally, but [**3-11**] strength on hip flexion bilaterally. She had no saddle anesthesia and had good rectal tone. Neurology was consulted and recommended L spine/C spine. While at MRI, the pts K returned at 7.2 without peaked T waves on EKG. MRI was not completed and the pt was given Insulin 10 U IV x1, 1 amp D50, 1 amp NaHCO3, and 30 gram of Kayexalate. Her glucose dropped to 50 so the pt received another amp of D50. The pt was also found to have a continued urinary tract infection on UA, so she was given Levofloxacin 500 mg po x1. Prior to transfer to the floor, the pts K was down to 6.0. . ROS: The pt denies n/v, CP, SOB. She has some baseline DOE which has not worsened. She denies dizziness/lightheadedness. She has had a chronic UTI for nearly 8 mos treated with a variety of abx including levoflox, bactrim, without relief. Per husband, pt has poor hygiene after cleaning her ostomy and he thinks this is why she has UTIs. She c/o occ palpitations at night. She has chronic nausea, but no emesis. . PMH: 1. Lumbar disk disease. 2. Migraine headaches. 3. Coronary artery disease in which an echocardiogram in [**2-7**] showed left ventricular ejection fraction greater than 55%, trace aortic regurgitation, 1+ MR. 4. Questionable hypothyroidism. 5. Ulcerative colitis, status post ileostomy and total colectomy. 6. Peptic ulcer disease, GERD. 7. Status post TAH/BSO. 8. Esophageal strictures, status post dilation times five. 9. Hypertension. 10. Pulmonary hypertension. 11. MDS, however, no records how diagnosed.Cardizen 60 12. Chronic renal failure, baseline creatinine 1.4 to 1.8 13. Pernicious anemia. 14. Cervical spondylosis 15. L sciatica 16. Hyperlipidemia 17. Chronic UTI 18. Severe bilat venous pedal edema 19. Partial thyroidectomy for hyperthyroidism 20. Hysterectomy 21. Allergic rhinitis 22. R hearing loss 23. Cataracts x2 L x1 R OT with prosthetic lenses . MEDS: Diovan 60 mg [**Hospital1 **] Prilosec 20 mg [**Hospital1 **] Protonix 40 mg [**Hospital1 **] Sodium Bicarb 650 mg tid Lopressor 100 mg [**Hospital1 **] Cardizem 60 mg qid Tigan 300 mg [**Hospital1 **] Norvasc 5 mg qd Calcitriol 0.5 mcg qam and 0.25 mcg qpm Zyrtec 10 mg qpm Allopurinol 100 mg qod Procrit 20,000 U 2 x/week Lomotil prn Albuterol prn Bactrim DS qd Septra DS 1 cap [**Hospital1 **] for 10 days Clotrimazole ointment . All: Vioxx, Compazine . SH: She lives at home with her husband. She ambulates at baseline with a walker, and at times uses a wheelchair. Non-smoker, no EtOH. They have 2 children. . FH: Diabetes . PE: Vitals: T 97.1 P 75 BP 144/68 R 20 Sat 95% 3LNC Gen: overweight female, laying flat in bed, NAD HEENT: NCAT, sclerae anicteric/noninjected, impaired lateral gaze BL, PERRL, OP clear, uvula midline, dry MM Neck: JVP difficult to assess due to obese neck CV: distant heart sounds, nl S1/S2, no m/r/g noted Lungs: CTAB, no w/r/r Ab: soft, NTND, NABS, no HSM by percussion, stoma pink with brown liquid outpt in ostomy bag, no rebound or guarding Extrem: wwp, 3+ pitting edema in BL LE up to knees and 2+ pitting edema in BL lateral thighs Neuro: a and ox3, 4/5 strength throughout BL UE, [**4-8**] BL hip flexion, [**6-8**] BL hip extension, [**5-9**] BL knee extension/flexion, [**6-8**] BL foot dorsiflexion/plantarflexion, +straight leg raise BL, BL essential tremor, no knee reflexes, 1+ BL UE biceps reflexes, sensation decreased over both feet, downgoing toes BL Skin: blanching patches over erythema over pts shins BL . Labs: See below . Studies: . EKG: NSR, LAD, inverted T in III, Q in III, and upright T waves in anterior leads (this is similar to [**8-8**] EKG but changed from [**2-10**] EKG in which there were TWI in I, AVL, and anterior leads, and T was upright in III). Thus, pt has pseudonormalization of T waves from [**2-10**]. . A/P: 73 yo female with multiple medical problems including CRI, cervical spondylosis, and L sciatica x10 yrs presents with complaints of worsening lower extremity weakness resulting in mechanical fall. She has had a functional decline over several weeks/months as well. . #Lower Extremity Weakness (and mild upper extremity): 73 yo female with multiple medical problems including CRI, cervical spondylosis, and L sciatica x10 yrs who presents with complaints of worsening lower extremity weakness. The pt has 2 conditions which could explain her acute decline: UTI and hyperkalemia. One of the first manifestations of significantly elevated potassium is diffuse weakness. In addition, the pt has had LE weakness for years, which seems to be related to sacral/lumbar radiculopathy. With the worsening and progressive symptoms, however, cord compression is also of concern. She has no saddle anesthesia and has good rectal tone, making conus medullaris syndrome less likely. She also has downgoing toes, decreased LE sensation, and absent reflexes in her LE, arguing for peripheral nerve impingement or a cauda equina syndrome. Similarly, pt has UE weakness, likely due to nerve impingement as well. --treat elevated K as per below --PT consult (pt likely needs acute rehab) --treat UTI as per below --order MRI C/L spine to r/o cord impingement/compression, root impingement --Work up for secondary causes of peripheral neuropathy including HbA1c, TSH, SPEP and UPEP, RPR and Lyme serology. --Neurology following, appreciate input --oxycodone/tylenol prn back pain . #ARF: The pts BL Cr is 1.7-2.1. She has a h/o ARF in the past in the setting of dehydration. The pt has not been drinking much fluids at home which could explain a hypovolemic component. In addition, the pt has been on bactrim which could lead to an interstitial nephritis (although pt has no peripheral eosinophilia). Pt received 2 L NS in the ED. --check urine lytes --renally dose levofloxacin and allopurinol --hold diovan --give 1 more L NS --check urine eos . #UTI: Pt has dirty UA. Pt has frequently grown Klebsiella in the past, pansensitive to all but nitrofurantoin. Pt may have poor hygiene leading to recurrence as stated in HPI. --ostomy hygiene discussed with pt --treat with 14 day course of levofloxacin --f/u Urine cx . #Hyperkalemia: This is likely related to pts ARF as well as being on [**Last Name (un) **]. She was treated with insulin, D50, Na bicarb, and kayexalate in the ED. --give amp of calcium gluconate --pt likely cannot be restarted on diovan or needs to have a lower dose due to h/o hyperkalemia --trend K . #Pseudonormalization of T waves: Pt has pseudonormalized T waves from prior EKG in [**2-10**], but this is similar to her EKGs in [**2135**]. It is possible pt had ischemia on the last EKG, or perhaps this is now a change. --add on cardiac enzymes to ED labs --trend cardiac enzymes --monitor on tele --Pt will need outpt stress (pharmacologic) --give ASA; continue lopressor . #HTN: Well controlled at this time. --continue norvasc, lopressor, cardizem; hold diovan due to ARF . # Fatigue, poor appetite: DDX includes depression, medication, metabolic. --screen for depression --hold tigan as this is an anticholinergic (replace with anzemet) --nutrition consult --f/u TSH . #H/o Anemia: Hct 37 currently --continue procrit for ACD --monitor hct . #FEN: low K, renal, cardiac diet . #PPX: SC heparin, Protonix . #Contact: [**Name (NI) 4906**] [**Telephone/Fax (1) 24723**], cell [**Telephone/Fax (1) 24724**] . #FULL CODE . #Dispo: Pending workup as per above; pending PT eval; nutrition consult Past Medical History: 1. Lumbar disk disease. 2. Migraine headaches. 3. Coronary artery disease in which an echocardiogram in [**2-7**] showed left ventricular ejection fraction greater than 55%, trace aortic regurgitation, 1+ MR. 4. Questionable hypothyroidism. 5. Ulcerative colitis, status post ileostomy and total colectomy. 6. Peptic ulcer disease, GERD. 7. Status post TAH/BSO. 8. Esophageal strictures, status post dilation times five. 9. Hypertension. 10. Pulmonary hypertension. 11. MDS, however, no records how diagnosed.Cardizen 60 12. Chronic renal failure, baseline creatinine 1.4 to 1.8, started on Epo on [**4-6**]. 13. Pernicious anemia. Social History: She lives at home with her husband. She ambulates at baseline with a walker, and at times uses a wheelchair. Non-smoker, no EtOH. They have 2 children. Family History: diabetes Physical Exam: VITALS: Tm in ICU 101.2 on [**11-28**], TM in past 24 hours 99.8. HR 70s-80s, BP 120-130s/50-60s, Sat 95-99% on 5L NC. GEN: In NAD, wearing C-collar. HEENT: No dentures, fair oral hygiene. NECK: Limited exam [**3-8**] body habitus, collar. RESP: Bilateral inspiratory crackles, possible bronchial breathing at left base. CVS: RRR. Distant heart sounds. GI: Obese abdomen. Ostomy with liquid stool. No gross blood. EXT: 1+ bilateral LE edema, L>R, no obvious palpable cord. Pertinent Results: [**2136-11-24**] 02:00PM PT-12.7 PTT-29.6 INR(PT)-1.1 [**2136-11-24**] 02:00PM PLT COUNT-197 [**2136-11-24**] 02:00PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-3+ [**2136-11-24**] 02:00PM NEUTS-76.6* LYMPHS-18.7 MONOS-3.1 EOS-1.4 BASOS-0.2 [**2136-11-24**] 02:00PM WBC-8.0 RBC-3.23* HGB-12.0 HCT-37.8 MCV-117* MCH-37.1* MCHC-31.7 RDW-16.8* [**2136-11-24**] 03:00PM URINE RBC-[**4-8**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2136-11-24**] 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2136-11-24**] 03:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2136-11-24**] 04:00PM CALCIUM-8.7 PHOSPHATE-5.0* MAGNESIUM-1.7 [**2136-11-24**] 04:00PM CK-MB-3 cTropnT-0.01 [**2136-11-24**] 04:00PM CK(CPK)-20* [**2136-11-24**] 04:00PM GLUCOSE-69* UREA N-47* CREAT-3.0* SODIUM-140 POTASSIUM-7.2* CHLORIDE-116* TOTAL CO2-15* ANION GAP-16 [**2136-11-24**] 06:36PM K+-7.1* [**2136-11-24**] 08:02PM K+-6.0* Brief Hospital Course: ASSESSMENT AND PLAN: 73 year-old female with CAD, HTN, CRI, cervical spondylosis and multilevel degenerative changes, and s/p ileostomy with poor hygiene and recurrent UTIs, admitted with ARF on CRI, hyperkalemia, probable UTI, LE weakness, with course complicated by probable aspiration event and hypoxemia, diagnosed with HAP. * 1) Nosocomial pneumonia: Probable aspiration pneumonia, with requirement for ICU care. Her antibiotic regimen was initially broadened to include anti-staphylococcal and antipseudomonal coverage. narrowed her regimen to Levofloxacin which should offer adequate GN/GP coverage, and Flagyl given probable aspiration and only fair oral hygiene. continue Levofloxacin and Flagyl complete 14 days from [**11-28**]. Supplemental oxygen prn. weaned down to 1 L. Pulmonary hypertension of unclear etiology, consider further work-up as an out-patient. * 2) Hypoxemia: Likely multifactorial, with contributions from mild interstitial edema, aspiration pneumonia/pneumonitis, pulmonary hypertension. was diuresed to remove fluid and improve suspected pulm edema. weaned down to 1 L. on lasix 40 qd. no DVT in [**Last Name (un) **] or lower extr. * 3) ARF on CRI: Creatinine stable, calcium stable, phosphate down, potassium within normal limits. Renal following. Presumed multifactorial, with background of chronic renal disease , further exacerbated by Bactrim administration, Diovan (currently on hold), poor PO intake. Work-up with negative UPEP and SPEP, renal U/S without hydronephrosis. Continue Bicitra, Calcitriol, multivitamin. consider starting Diovan as an outpt * 4) LE weakness: Multifactorial, in a background of obesity, cervical spondylosis and long-standing sciatica. MRI C and L-spine did not show any new abnormality. Neurology involved, with recommendation for conservative management, C-collar at night. No need for neurosurgical consult in house. * 5) Probable UTI: In background of neurogenic bladder, poor ostomy hygiene. Covered with Levofloxacin. Will need follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology. foley d/c'ed. pt able to void by herself . 6) Rash: Evaluated by dermatology, with impression of stasis dermatitis versus EN. Follow-up as an out-patient. * 7) Anemia: Status post transfusion of 2 units of PRBCs. the ileostomy output looked was guaiac +. however HCT stable. has a GI f/u appointment. . 8) Thrombocytopenia: Plt drop >50% in hospital. She did receive heparin products at the time of admission. baseline plt 200. had dropped to 130s . now up to 150s. HIT antibody pnd. PCP will need to f/u. was put on coumadin for DVT prophylaxis. * 9) FEN: Evaluated by S&S, who recommended pureed solids, thin liquids, PO meds whole with thin. Aspiration precautions. * 10) Ppx: Hold off on heparin products. Started on low-dose Coumadin for ppx. PPI. Medications on Admission: Diovan 60 mg [**Hospital1 **] Prilosec 20 mg [**Hospital1 **] Protonix 40 mg [**Hospital1 **] Sodium Bicarb 650 mg TID Lopressor 100 mg [**Hospital1 **] Cardizem 60 mg QID Tigan 300 mg [**Hospital1 **] Norvasc 5 mg QD Calcitriol 0.5 mcg QAM and 0.25 mcg QPM Zyrtec 10 mg QPM Allopurinol 100 mg QOD Procrit 20,000 U 2 x/week Lomotil PRN Albuterol PRN Septra DS 1 tab PO BID for 10 days Clotrimazole ointment Discharge Medications: 1. Calcitriol 0.5 mcg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY (Daily). 2. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 3. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution [**Hospital1 **]: Sixty (60) ML PO BID (2 times a day). 7. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 8. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**2-6**] Sprays Nasal QID (4 times a day) as needed. 10. Trazodone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 11. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a day). 12. Diltiazem HCl 60 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times a day). 13. Amlodipine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 14. Levofloxacin 250 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q48H (every 48 hours) for 7 days: last dose on [**2136-12-11**]. 15. Metronidazole 500 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day) for 7 days: last dose [**2136-12-11**]. 16. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed. 17. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed. 18. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 19. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 20. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 21. Dolasetron 12.5 mg/0.625 mL Solution [**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Aspiration pneumonia . Secondary cervical spondylosis sciatica CAD Ulcerative colitis, status post ileostomy and total colectomy Peptic ulcer disease, GERD Esophageal strictures, status post dilation times five. Hypertension Chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: We have stopped your Diovan, Tigan and Lomotil. We have strated the antibiotic levofloxacin. You need to take it one tablet every other day till [**2136-12-11**]. . WE HAVE STOPPED YOUR COUMADIN WHICH WAS GIVEN TO YOU DURING THIS HOSPITALIZATION. . If you have chest pain, shortness of breath, palpitations, dizziness, weakness in legs, pain in abdomen, fever, cough, nausea, vomitting please call the physician on call at the rehab or go to the emergency room . Followup Instructions: Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2136-12-7**] 8:00 . Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Date/Time:[**2137-1-7**] 10:45 . Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 3524**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2137-1-7**] 1:00 . Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2137-1-25**] 1:15 . Please make a follow up appointment with your primaru care physician Dr [**Last Name (STitle) 713**] ([**Telephone/Fax (1) 719**]) within 2 weeks of discharge . PLEASE DO NOT GIVE COUMADIN. PATIENT'S INR TODAY WAS 6.4. MONITOR IF IT TRENDS DOWN. PATIENT RECEIVED 1 MG VIT K SC TODAY . Will need a sleep study as an outpatient per geriatrics Completed by:[**2136-12-5**]

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

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317, 323

17724, 17733

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10302, 10312

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14719, 15128

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33003

Discharge summary

report

Admission Date: [**2172-11-21**] Discharge Date: [**2172-12-1**] Date of Birth: [**2114-6-30**] Sex: M Service: CARDIOTHORACIC Allergies: AVASTIN Attending:[**First Name3 (LF) 4679**] Chief Complaint: empyema Major Surgical or Invasive Procedure: 1. Right thoracotomy. 2. Decortication of lung. 3. Completion right middle lobectomy. History of Present Illness: 58M, Polish speaking, s/p RUL lobectomy [**11-6**] for Stage III NSCLC, discharged home on [**11-17**] (4d prior to this presentation) on 2L home O2, returns to ED c/o 2 days of productive cough and fevers as high as 102. Also notes decreased PO intake, nausea, weakness, and fatigue. In the ED, the patient was afebrile, and temp increased to 100.1. Hemodynamically stable, and maintaining O2 sat of 99% on 3L. CXR showed a right-sided infiltrate. Labs notable for WBC 20.9, Na 129, Cr 1.8 from baseline 1.4. The patient was given vancomycin and Zosyn, and thoracic surgery was consulted. Pt received RMLobectomy for RML collapse. The patient was admitted to the ICU for emergent bronchoscopy. On arrival to the ICU, he denies any pain or discomfort, but does note subjective dyspnea. Past Medical History: PMH: CAD, MI, HTN, HLD, COPD (FEV1 69% [**2171**]), CVA, Stage III NSCLC s/p neoadjuvant chemoradiation PSH: hip repair, elbow fracture repair, [**2172-11-6**]:Right thoracotomy, Right upper lobectomy, Buttressing of bronchial closure with intercostal muscle flap. [**2172-11-8**], [**2172-11-9**], [**2172-11-10**]: Bronchoscopy Social History: Polish speaking. Former 40 year pack history. No etoh, no drugs. Currently unemployed but former factory worker in Poland. Family History: sister with CAD. No family history of cancers Physical Exam: PE on discharge: Vitals: 99.3, 85, 110/60 18 95% RA GEN: A+O x3, NAD Cardiac: RRR, normal S1/S2, no MRG Resp: CTA bilat with mild RLL crackles and some expiratory weezing. Incisions c/d/i, minimal drainage from one chest tube site. Abd: soft, ND/NT, +bs ext: no edema, palpable DP pulses bilaterally Pertinent Results: [**2172-11-21**] 03:12PM BLOOD WBC-20.9*# RBC-3.30* Hgb-9.8* Hct-30.0* MCV-91 MCH-29.6 MCHC-32.7 RDW-14.1 Plt Ct-672* [**2172-11-22**] 01:54AM BLOOD WBC-17.9* RBC-2.70* Hgb-7.8* Hct-24.5* MCV-91 MCH-29.0 MCHC-32.0 RDW-14.1 Plt Ct-638* [**2172-11-29**] 08:50AM BLOOD WBC-13.5* RBC-3.44* Hgb-10.1* Hct-30.9* MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt Ct-575* [**2172-11-30**] 09:00AM BLOOD WBC-13.9* RBC-3.24* Hgb-9.4* Hct-29.0* MCV-90 MCH-29.1 MCHC-32.5 RDW-14.9 Plt Ct-511* [**2172-12-1**] 07:10AM BLOOD WBC-13.9* RBC-3.32* Hgb-9.8* Hct-30.0* MCV-90 MCH-29.4 MCHC-32.6 RDW-15.0 Plt Ct-462* [**2172-12-1**] 07:10AM BLOOD Plt Ct-462* [**2172-12-1**] 07:10AM BLOOD PT-14.0* PTT-31.8 INR(PT)-1.2* [**2172-11-23**] 01:22AM BLOOD Plt Ct-569* [**2172-11-24**] 01:45AM BLOOD Plt Ct-536* [**2172-11-21**] 03:12PM BLOOD Glucose-102* UreaN-31* Creat-1.8* Na-129* K-5.4* Cl-92* HCO3-24 AnGap-18 [**2172-11-22**] 01:54AM BLOOD Glucose-100 UreaN-30* Creat-1.6* Na-132* K-4.4 Cl-97 HCO3-22 AnGap-17 [**2172-11-30**] 09:00AM BLOOD Glucose-116* UreaN-14 Creat-1.2 Na-141 K-4.4 Cl-105 HCO3-28 AnGap-12 [**2172-12-1**] 07:10AM BLOOD Glucose-88 UreaN-13 Creat-1.2 Na-140 K-4.6 Cl-104 HCO3-26 AnGap-15 [**2172-11-29**] 01:00PM BLOOD ALT-34 AST-47* LD(LDH)-183 AlkPhos-168* TotBili-0.2 [**2172-11-22**] 5:00 pm BRONCHIAL WASHINGS RIGHT BRONCHIAL WASHING. **FINAL REPORT [**2172-11-26**]** GRAM STAIN (Final [**2172-11-22**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2172-11-26**]): Commensal Respiratory Flora Absent. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Piperacillin/Tazobactam Sensitivity testing [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], PA ([**Numeric Identifier 76748**]). Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S CXR [**11-21**]: Comparison is made to the prior chest radiograph performed six hours earlier, as well as the chest CT. There has been worsening of the area of consolidation with air-fluid levels within the right upper lobe. This is consistent with suspected empyema following right upper lobe resection. There has been placement of endotracheal tube whose distal tip is 7 cm above the carina, appropriately sited. The side port of nasogastric tube is above the gastroesophageal junction and this could be advanced 5-10 cm for optimal placement. The right lung is relatively clear. CT chest 11/12:1. Status post chest tube removal with increased fluid accumulation in the right anterior and superior pleural spaces in the post-surgical cavity. The presence of locules of air is concerning for infection. A bronchopleural fistual cannot excluded. 2. Persistent right middle lobe collapse with obliteration of the right middle lobe bronchus. Evaluation for torsion is limited but the configuration of the collapsed right middle lobe appears similar to the prior examination where there was not evidence for torsion. 3. Improved aeration of the right and left lower lobes. 4. Moderate-to-severe emphysema, stable. CXR 11/13:2 right chest tubes in place. Suture line s/p right upper lobectomy is seen, apical hydropneumothorax remains.SQ gas is post operative. Left lung clear CXR [**11-23**]: Unchanged appearance of the mild right apical hydropneumothorax CXR [**11-24**]: Moderate volume right apical pneumothorax is unchanged. New opacification in the right mid lung could be atelectasis, pneumonia, or hemorrhage. Only a small volume of right pleural effusion, if any, remains. Two apical and one basal pleural drain are still in place. Small left pleural effusion and moderate left basal atelectasis are more pronounced. CXR [**11-26**]: 1. Unchanged right pneumothorax since removal of basilar chest tube. No evidence of tension. 2. Slight worsening of left basilar atelectasis and small effusion. CXR [**2172-11-30**] FINDINGS: In comparison with the study of [**11-28**], the right chest tube has been removed. There is progressive decrease in the pleural air collection in the upper zone. The left lung remains essentially clear. On the lateral view, there is an air-fluid level anteriorly at the mid-to-lower zone, consistent with small loculated hydropneumothorax. Brief Hospital Course: The patient was admitted to the thoracic surgery service on [**2172-11-21**] and had 1. Right thoracotomy 2. Decortication of lung and 3. Completion right middle lobectomy. There were no complications during the procedure and the patient tolerated the procedures well overall. Post op he was transferred to the unit for close monitoring. On [**11-6**] he underwent a successful RU lobectomy via thoracotomy for for Stage III non-small-cell lung cancer. Then on [**11-21**] he was admitted to ICU. Non-con chest CT was suspicious for empyema. He was intubated for bronchoscopy, which was largely unrevealing. He became hypotensive while on propofol, initially responded to fluid bolus but did require phenylephrine. An a-line was attempted without success. OG tube put out 450 mL overnight, looked like old blood. The next day he went to OR for redo thoracotomy, RML lobectomy and washout, received 2500 IVF and 2 u PRBC. He was extubated post-op in OR. He had stridors initially that resolved with albuterol but +crackles and a CXR consistent with fluid overload- IVF were then stopped. Neo was restarted to support MAPs. On POD 1, neo weaned off at 3 AM, then turned back on at 5:30 AM to support BP, O2 sats were at high 90s-100 on 50% face tent. His UOP decreasing in AM to <20 cc/hr. Albumin 250 x 1. And then he had adequate UOP. He was taking adequate POs at this time and restarted home atorvastatin. Neo was decreased to 0.2. His respiratory status improved but still c/o significant pain with respiration and movement. On POD 2 he was started on lopressor for tachycardia. His foley dc'd on this day. One chest tube was removed and cxr showed no pneumothorax. Tobramycin was added for double pseudomonas coverage and his zosyn dose was increased. On POD 3 sputum cultures were growing out e.coli and the Tobramycin was dc'd after discussion w/ ID given improvement on CXR and no pseudomonas in cultures. Chest tube #3 was pulled on this day and cxr showed no pneumothorax. Also, his creatinine bumped up to 1.5 (concern for med toxicity). Shortly thereafter his cr decreased and stayed at 1.2. That night he had episode of desat to high 70's, improved to low 90's on 15L NRB. Repeat CXR shows no acute changes and it was likely a mucous plug. On POD 4 his pain regimen was adjusted with good results and he was placed on PO meds only- his PCA was d/c'd. His antibiotics were tailored and he was now on cetriaxone only. His POD 5 cxr was greatly improved, pain control better, and he was transferred to the floor. Thereafter he continued to improve each day. On POD 7, his final chest tube was removed and cxr showed no pneumothorax. He was gradually weaned off most oxygen and only required 1-2 L when ambulating. Pt was originally home on oxygen before preseting to the hospital. Neuro: Post-operatively, the patient received Morphine IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications- ms contin and oxycodone CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Occasional episodes of tachycardia were well treated with lopressor. BP needed to be maintained occasionally as described above. Pulmonary: The patient was eventually stable from a pulmonary standpoint; vital signs were routinely monitored. Occasional desaturations needed to be treated with a face mask and/or nasal cannula as described above. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#2. Intake and output were closely monitored. His appetite decreased during his hospitalization and was stimulated with Megestrol Acetate. ID: Post-operatively, the patient was started on IV vancomycin, zosyn, tobramycin and eventually switched to only ceftriaxone. He was discharged on 2 weeks of bactrim. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. Given his previous history of stroke, neurology was consulted and pt was put back on his home comadin dose prior to discharge. He was being bridged with lovenox and was set up with his PCP for close follow up. At the time of discharge on POD#9, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He continued to have decreased saturation while ambulating and was thus sent home on the same oxygen therapy that he came in with. PT cleared him to go home with out VNA and just suggested some PT follow up at home. Medications on Admission: Lipitor 80 mg daily, Advair Diskus 500 mcg-50 mcg [**Hospital1 **], Spiriva 18 mcg daily, Atenolol 100 mg daily, ProAir HFA 90 mcg QID prn, Nitroglycerin 0.4 mg prn, amlodipine 10 mg daily Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for breakthrough pain. Disp:*30 Tablet(s)* Refills:*0* 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-12**] Sprays Nasal QID (4 times a day) as needed for dryness. 7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 13. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg/ 0.7gm Subcutaneous twice a day for 1 weeks. Disp:*14 syringes* Refills:*0* 14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**6-17**] hours. Disp:*30 Tablet(s)* Refills:*2* 15. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) tablet PO DAILY (Daily). Disp:*30 tablet* Refills:*0* 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 17. Outpatient Lab Work Please check INR regularly and have your PCP adjust Warfarin (coumadin) dosage accordingly. INR checks every 2-3 days for first 1-2 weeks. Per PCP. 18. quetiapine 25 mg Tablet Sig: 0.5 (Half) Tablet PO every six (6) hours as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 19. Coumadin 6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 20. Home Oxygen Oxygen Pulse Dose for Portability: Continuous Oxygen 2 liters by nasal cannula. Dx: 1. SaO2 less than 88% room air.; 2. COPD; 3. S/p Right Middle and Lower Lobectomy. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Non-expanded right middle lobe Empyema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were re-admitted to the Thoracic surgery service on [**2172-11-21**] for a chronically collapsed right middle lobe. Please Call Dr. [**Name (NI) 76749**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough up blood tinge sputum for a few days) or chest pain -Incision develops drainage -Chest tube site: remove outer dressing and cover site with a bandaid until healed. -Should chest tube site begin to drain, cover with a clean dry dressing and changes as needed to keep site clean and dry Pain -Acetaminophen 650 every 6 hours as needed for pain -Oxycodone 5-10 mg every 4 hours as needed for pain Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision site -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily -You did well on room air while at rest but required oxygen while ambulating. Please use oxygen at home with ambulation or as needed for shortness of breath. Please take 1.5 pills of coumadin today after discharge for a total of 9mg per your PCP's office. Then resume your normal schedule of 6mg daily and adjust per their recommendations. They will contact you this week about necessary changes. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2172-12-15**] 9:00 Please arrive 30 minutes early for a chest x-ray before your visit. Completed by:[**2172-12-2**]

[ "401.9", "272.4", "414.01", "412", "511.89", "512.83", "162.3", "496", "V12.54", "510.9" ]

icd9cm

[ [ [] ] ]

[ "32.49", "34.51", "33.24" ]

icd9pcs

[ [ [] ] ]

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7197, 12035

283, 371

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2083, 7174

17013, 17247

1700, 1747

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Discharge summary

report+addendum

Admission Date: [**2178-9-17**] Discharge Date: Date of Birth: [**2120-6-4**] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 108131**] is a 58-year-old male with multiple medical problems including acquired immunodeficiency syndrome, chronic obstructive pulmonary disease, end-stage renal disease, hepatitis B and hepatitis C who is status post recent hospitalization for hypercarbic respiratory failure and ? COPD exacerbation which was managed in the Medical Intensive Care Unit with BiPAP. He was discharged to home. He presented to [**Hospital1 69**] Emergency Room on [**9-17**] with a chief complaint of increasing dyspnea and lethargy. In the Emergency Room his nonrebreather. His arterial blood gas at that time was pH of 7.12, PCO2 68, PO2 77. He was placed on BiPAP 12/6. A chest x-ray showed bibasilar patchy infiltrates, right greater than left, and he was started on levofloxacin and vancomycin for a presume pneumonia. He was transferred to the Medical Intensive Care Unit where he was managed with BiPAP and then weaned to nasal cannula. His vancomycin was discontinued, and he was continued on levofloxacin. He was transferred in stable condition to the floor. At the time of transfer, the patient had a chief complaint of epigastric discomfort and was requesting his usual pain medications. He denied shortness of breath or chest pain but did report occasional productive cough. PAST MEDICAL HISTORY: 1. Acquired immunodeficiency syndrome; last CD4 count 132, last viral load 15,000 in [**2178-7-25**]. 2. Human immunodeficiency virus cardiomyopathy; ejection fraction 40% in [**2178-1-22**] echocardiogram. 3. Chronic obstructive pulmonary disease with baseline oxygen requirement of 3 liters by nasal cannula. 4. History of pulmonary embolism and deep venous thrombosis. 5. Hepatitis B and hepatitis C. 6. History of multi-substance abuse. 7. End-stage renal disease, on hemodialysis two times a week. 8. Benign prostatic hypertrophy. 9. Hemorrhoids. 10. History of purified protein derivative positive; unclear whether he was treated for this. 11. History of pancreatitis secondary to gallstones versus sludge. 12. Depression. 13. History of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. MEDICATIONS ON ADMISSION: Medications at home were amiodarone 200 mg p.o. q.d., Protonix 40 mg p.o. q.d., Zoloft 50 mg p.o. q.d., lamivudine 20 mg p.o. q.d., stavudine 20 mg p.o. q.d., albuterol nebulizers, lactulose 30 cc p.o. t.i.d., Valium 5 mg p.o. t.i.d., Renagel 4 tablets p.o. q.i.d., multivitamin, methadone 50 mg p.o. q.d., Colace 100 mg p.o. b.i.d., Bactrim-DS three times per week, Lopressor 12.5 mg p.o. b.i.d., captopril 6.25 mg p.o. t.i.d., Fentanyl patch 100 mcg per hour q.72h., Percocet p.r.n. ALLERGIES: HALDOL causes rash. THORAZINE causes anaphylaxis. H2 BLOCKERS cause thrombocytopenia. CLINDAMYCIN, CODEINE, and STELAZINE cause rash. SOCIAL HISTORY: History of intravenous drug use and alcohol abuse. A 40-pack-year smoking history. Has been on methadone since [**2162**]. Lives with his wife. CODE STATUS: Full. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.3, heart rate 80, respirations 18, blood pressure 90/60, 95% on 4 liters. In general, he was in no apparent distress, alert and oriented times three. HEENT revealed pupils were equally round and reactive to light. Extraocular movements were intact. Neck had no jugular venous distention or lymphadenopathy. Lungs revealed crackles on the right one-half the way up, rhonchi at the left base. Cardiovascular had a regular rate and rhythm, distant heart sounds, a 2/6 systolic murmur maximal at the apex. No gallops. Abdomen was soft, nontender, and nondistended. Liver edge 3 cm below the costal margin. No splenomegaly. No masses. Normal active bowel sounds. Extremities had no edema, 1+ distal pulses. Neurologically, cranial nerves II through XII were intact. Pupils were symmetric but minimally reactive. Strength was [**2-26**] to [**3-28**] in the upper and lower extremities. LABORATORY VALUES ON PRESENTATION: White blood cell count 3.8, 75.8% neutrophils, 18.7% lymphocytes, hematocrit 36.4, platelets 107. Sodium 137, potassium 5.4, bicarbonate 25, BUN 40, creatinine 6, glucose 74. INR 1.2, PT 13.3. ALT 46, AST 29, alkaline phosphatase 164, total bilirubin 0.4. Calcium 8.2, phosphate 5.4, magnesium 1.9. Sputum revealed multiple polys, oropharyngeal flora. Sputum and blood cultures were negative. RADIOLOGY/IMAGING: Chest x-ray revealed bibasilar patchy opacities read as aspiration versus pneumonia. HOSPITAL COURSE: 1. INFECTIOUS DISEASE: Pneumonia. The patient was continued on levofloxacin on the floor, and his oxygen requirements improved. At the time of this dictation he was back to his baseline oxygen requirement of 3 liters by nasal cannula. Day one of levofloxacin was on [**9-17**]. 2. PULMONARY: Status post chronic obstructive pulmonary disease exacerbation. Respiratory care has been following the patient, and he has been receiving nebulizers p.r.n. as well as chest physical therapy. 3. CARDIOVASCULAR: Blood pressure remained somewhat low in the 90s and low 100s. He continued on amiodarone for his history of ectopy secondary to human immunodeficiency virus cardiomyopathy. He continued on captopril and Lopressor. 4. RENAL: The patient continued with hemodialysis and Renagel. 5. PAIN: The patient was on a baseline pain regimen of Fentanyl patch and methadone. We have added oxycodone p.r.n. for breakthrough pain. 6. HUMAN IMMUNODEFICIENCY VIRUS: The patient was taking lamivudine, stavudine, and Bactrim for prophylaxis. 7. PROPHYLAXIS: The patient continued on Protonix and subcutaneous heparin. 8. ORTHOPAEDIC: On [**9-19**], the patient fell on left hip while trying to get to the bathroom. X-ray revealed left intertrochanteric fracture. It was felt that he should go to the operating room for surgical correction given that his respiratory status would decline if he were to be bed ridden. His surgery has been delayed due to the fact that he was taken to the operating room at one point but refused at the last minute. A second attempt at surgery will occur on [**9-24**]. He has designated his wife as his health care proxy. Note: This is an interim Discharge Summary. Please see Discharge Summary addendum for completion of hospital course and discharge instructions. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Name8 (MD) 4925**] MEDQUIST36 D: [**2178-9-23**] 15:13 T: [**2178-9-25**] 09:17 JOB#: [**Job Number **] (cclist) Name: [**Known lastname 17675**], [**Known firstname **] J Unit No: [**Numeric Identifier 17676**] Admission Date: [**2178-9-17**] Discharge Date: [**2178-10-6**] Date of Birth: [**2120-6-4**] Sex: M Service: HOSPITAL COURSE: 1. Infectious Disease: The patient was continued on a two week course of Levaquin, which was discontinued on [**2178-10-2**]. Surveillance sputum cultures were sent and are pending at the time of discharge. Repeat chest x-ray on [**10-5**] showed improved clearing of right lower lobe and left lower lobe infiltrates. 2. Orthopedics: The patient went for a left dynamic hip screw placement on [**2178-9-24**], without complications. Staples are to be removed on [**2178-10-8**], and the patient is to follow-up with Dr. [**Last Name (STitle) 3266**] from Orthopedics the first week of [**Month (only) 768**]. 3. Pain control: The patient's pain medication regimen was modified to include Fentanyl patch 125 mcg q 72 hours, methadone 50 mg po q day, oxycodone 10 mg po tid, morphine sulfate 30 mg po q four hours prn pain. The patient's pain seemed to be fairly well controlled on this regimen. DISCHARGE STATUS: Stable. DISPOSITION: The patient going to [**Hospital1 **] for rehabilitation. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 3266**] from Orthopedics the first week of [**Month (only) 768**]. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Hypercarbic respiratory failure. 3. Status post left intertrochanteric hip fracture with open reduction and internal fixation of fracture. DISCHARGE MEDICATIONS: Amiodarone 200 mg po q day, Protonix 40 mg po q day, Zoloft 50 mg po q day, lamivudine 20 mg po q day, stavudine 20 mg po q day, Lactulose 30 cc po tid, Valium 5.0 mg po tid, Renagel four tablets po qid, multi-vitamin one tablet po q day, methadone 50 mg po q day, Colace 100 mg po bid, Bactrim double strength one tablet po three times a week on Tuesday, Thursday, and Saturday, Lopressor 12.5 mg po q day, Captopril 6.25 mg po tid, Fentanyl patch 125 mcg topical q 72 hours, oxycodone 10 mg po tid, morphine sulfate 30 mg po q four hours prn pain, aspirin 325 mg po q day, and Coumadin 1.0 mg po q HS. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6658**] Dictated By:[**Name8 (MD) 1212**] MEDQUIST36 D: [**2178-10-6**] 15:03 T: [**2178-10-8**] 22:58 JOB#: [**Job Number **]

[ "496", "585", "425.4", "042", "507.0", "820.21", "E888.9", "518.81", "707.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "79.35" ]

icd9pcs

[ [ [] ] ]

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2333, 2968

7021, 8167

129, 1434

1457, 2306

2985, 4644

53,534

121,545

5471

Discharge summary

report

Admission Date: [**2185-10-26**] Discharge Date: [**2185-11-6**] Date of Birth: [**2104-4-27**] Sex: M Service: MEDICINE Allergies: Percocet / Ciprofloxacin Attending:[**First Name3 (LF) 4588**] Chief Complaint: fever, hypoxia, shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: 81 yo M w/ hx of CAD (3 VD s/p multiple PCAs [see below] most recent w/ POBA to mid-RCA [**1-4**]), ischemic CM (systolic and diastolic, last EF 40% 2/10), Parkinsons Dz, DM2, HTN, Renal cell carcinoma (s/p L nephrectomy), TIA who presented from rehabilitation facility with 2 days low grade fever, deoxygenation and SOB. . Pt. was in USOH (deconditioned, fatigued, requiring 2L NC since arriving at [**Hospital **] rehab, see recent d/c summary [**2185-10-6**]) until 3 days PTA when he developed low grade fevers (99-100F), with worsening fatigue and cough productive of white sputum. He reported substernal dull CP w/o radiation or diaphoresis/nausea, but did not recall duration. His sx improved for one day, however, on day of admission in AM, he was noted to have worsening cough, increased RR and hypoxia to 86% on 2LNC. Due to this change he was sent to the ED for an evaluation. In the ED, initial vs were: T99 P80 BP150/72 R20 99% O2 sat on 4LNC. He was noted to require increasing oxygen to NRB, satting in high 90s. He was given ASA 325mg, Vancomycin 1g and CFTX 1g. Due to no improvement, further lab tests were obtained and were notable for BNP of ~ 30K (prior at 18K), troponin of 0.2 w/o CK elevation, a dirty UA and Na of 149. EKG was reported as unchanged from prior. His BP max was at 149, so he was started on nitro gtt, given 40mg IV lasix (300cc UOP). and transferred to the floor. . Pt. was admitted to [**Hospital1 18**] [**9-25**] - [**10-6**] for delirium (multifactorial), hypernatremia, yeast UTI treated with fluconazole, episodes of hypotension and bradycardia, and bilateral pleural effusions which were felt to be stable from prior admission. . Of note, he has had b/l pleural effusions since his admission for NSTEMI (medically managed) in [**2185-3-9**], which have progressed in size until this admission. He has never had a thoracentesis. . Re: home oxygen, this was started in rehab after d/c from [**Hospital1 18**] on [**10-6**]. Never fully investigated and used on prn basis. . Since discharge, he apparently also been diagnosed with recurrent UTIs, and treated with Levofloxacin x 5 days, finished on [**10-24**]. His Cx at [**Hospital1 18**] during prior admission were negative. On the floor, VS - 84 132/70 28 94% NRB. Pt. appeared fatigued, using accessory muscles, w/o complaints of CP, but c/o of SOB. Past Medical History: 1. Parkinson's Disease 2. Type 2 diabetes 3. Hypertension 4. CAD - PCI with DES to RCA and LAD in [**2179**], NSTEMI [**2185-3-9**] that was medicallly managed. Most recent Cath in [**12/2183**]: showed 3VD. PTCA (POBA) of the mid-RCA was performed. Stent placement was unsuccessful. Has ischemic cardiomyopathy with LVEF 25%. Has class II NYHA symptoms. 5. h/o Renal Cell Carcinoma - [**2170**], s/p partial left nephrectomy. Now with chronic kidney disease 6. h/o prostate cancer s/p radiation therapy 7. spinal stenosis 8. Cerebrovascular disease with TIA [**12/2183**] 9. Osteoporosis 10. h/o left hip fracture, s/p left hemiarthroplasty 11. h/o left foot TMA, by Dr. [**Last Name (STitle) 1391**] 12. Polyneuropathy and amyotrophy Social History: Patient was a concert pianist, per wife, prior to [**Name (NI) 216**] hospitalization was still taking students. Married to a retired ER nurse ([**Doctor First Name **]), needs help w/ most ADLs per OMR, but per wife walks w/ walker and able to feed/clothe self. He has two adult children. Quit smoking cigarettes in [**2160**]; 40 pack-year history of smoking. Family History: Father - MI at 55, DM. Rest unknown. Physical Exam: Physical Exam: Vitals: T= 98.1, BP 122/72, HR 72, RR 22, O2 sat: 99% 6L FM General: Eyes closed but opens to command and communicates w/ examiner congruently. Bradykinetic. Cachectic, malnourised appearing man. NAD. HEENT: Sclera anicteric, dry MM, oropharynx clear. Edentulous. Neck: supple, JVP not visualized well [**3-1**] pt not turning head. no LAD. Lungs: Mostly auscultated anteriorly and upper lobes posteriorly. CTABL, but decreased breath sounds. trace crackles bilaterally in lower lung fields. CV: Distant heart sounds. Regular rate, normal S1 + S2, II/VI systolic murumr in precordium, loudest near the apex. Abdomen: soft, non-tender, non-distended, bowel sounds present Back: sacral ulcer stage II. GU: foley Ext: warm, trace edema b/l, 1+ pulses. Left toes amputated. In compression distribution boots. Neuro: AOx3, but slow to asnwer. Mildly confused. He has flat facies. CNs: R pupil surgical, L reactive [**3-29**], EOMi, face symmetric, tongue midline, shoulder shrug intact. Motor: he is bradykinetic, there is mild cogwheeling at both biceps tendons. No drift, jaw tremor. No formal strength testing conducted, but was able move UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], w/ weakness at foot on L. . Pertinent Results: [**2185-10-26**] CBC: WBC-7.5# RBC-3.78* HGB-10.3* HCT-33.7* MCV-89 MCH-27.2 MCHC-30.5* RDW-16.2* . CE: CK-MB-3 cTropnT-0.20* proBNP-[**Numeric Identifier 22137**] CK(CPK)-36* [**2185-11-2**] CK-MB-3 cTropnT-0.15* . URINE: RBC-[**7-7**]* WBC-[**12-17**]* BACTERIA-MOD YEAST-NONE EPI-3-5 BLOOD-MOD NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM . %HbA1c-5.9 eAG-123 . . PT-14.1* PTT-35.8* INR(PT)-1.2* . . . . [**2185-11-5**] CBC WBC-4.8 RBC-3.53* Hgb-9.8* Hct-30.5* MCV-87 MCH-27.7 MCHC-32.0 RDW-15.8* Plt Ct-160 Glucose-148* UreaN-23* Creat-0.9 Na-143 K-4.0 Cl-102 HCO3-33* AnGap-12 . URINE URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-1 CastGr-1* CastHy-13* . . . BASELINE EKG Normal sinus rhythm. Left atrial abnormality. Intraventricular conduction delay. Probable left anterior fascicular block. Left ventricular hypertrophy with secondary ST-T wave abnormalities. Compared to the previous tracing of [**2185-10-26**] no diagnostic interval change. . Intervals Axes Rate PR QRS QT/QTc P QRS T 65 200 126 456/464 17 -42 142 . . . . MICROBIOLOGY . . **FINAL REPORT [**2185-10-30**]** URINE CULTURE (Final [**2185-10-30**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LINEZOLID------------- 1 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . . . . URINE CULTURE (Final [**2185-11-2**]): NO GROWTH. **FINAL REPORT [**2185-11-1**]* . . STOOL STUDIES CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2185-10-27**]): CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Blood CULTURE x2: Blood Culture, Routine (Final [**2185-11-1**]): NO GROWTH. . . . Imaging: CXR: . On Admission [**2185-10-26**]: Limited study due to positioning and low lung volumes. Bilateral moderate pleural effusion, which is larger on the left and are similar in appearance from prior study ([**2185-10-18**]). Perihilar haziness with mild upper zone vascular redistribution likely represents mild volume overload. Bibasilar opacifications are lilely atelectasis, but concomitant infectious process cannot be excluded. The cardiac contours are obscured by pleural effusions. The mediastinal and hilar contours are unchanged. No pneumothorax is seen. . on [**2185-11-2**] Moderate-to-large bilateral pleural effusions have decreased in amount from prior study. Right PICC remains in place. There are low lung volumes. Cardiac size cannot be evaluated. There is no pulmonary edema. Bibasilar opacities consistent with atelectasis, left greater than right, have improved. Brief Hospital Course: 81 yo M w/ hx of CAD, ischemic CM (systolic and diastolic, last EF 40% [**10/2185**]), Parkinsons Dz, DM2, HTN, Renal cell carcinoma (s/p L partial nephrectomy), TIA who presented from rehabilitation facility with hypoxic respiratory distress and worsening effusions. # Hypoxic respiratory distress: On initial presentation to the ICU, he required oxygen supplementation with NRB. After a few hours with diruesis, patient denied any shortness of breath satting in the high 90s on 2L NC (which was falling off and mostly is on RA). His SOB was thought to be most likely due to CHF exacerbation, both systolic and diastolic components. His repeat echo from [**10-27**] originally showed worsening LV fxn of 25%, but an cardiology addendum in his chart stated no change from prior EF of 40% from his echo in 2/[**2185**]. However, there was also a component of infection (HCAP), with worsening pleural effusions since his MI in [**3-9**] (never been tapped) w/ resultant atelectasis and demand ischemia given elevated troponin. His baseline was w/o significant changes from prior, so troponins were thought to be a slow "leak" in the setting of worsening CHF. Mr. [**Known lastname 22136**] was changed to 0.5mg Bumex daily with metolazone for synergy and received several doses in the ICU. His SOB resolved enough for him to be transferred to the general medical floors. On the medical floors, he did not require any diuresis, and actually received soft fluid boluses a few times to maintain IVV in the setting of poor PO intake. His HCAP was treated with an 8 day course of Vancomycin (trough levels remained in the 20's by HD8), and a documented 5 day course of cefepime (due to possible poor clearing of medication, may have had physiological longer dose). He also concurrently received IV Flagyl for C.DIff/possible aspiration PNA. Due to poor PO intake/aspiration, he inconsistently received his cardiac medications, including a statin, BB, [**Last Name (un) **], and ASA. By time of discharge, he was receiving statin, bb, [**Last Name (un) **] PO and ASA PR. . # Parkinson's Disease. Mr. [**Known lastname 22138**] Sinemet regimen was difficult to continue in the setting of poor PO intake. He continued to develop exacerbations of his Parkinsonism, with profound bradykinesias and poor communication. His PO sinement was changed to dissolvable form, and he improved after three days of dosing with spontaneous speech and extremity movement. Most likely due to inconsistent absorption of PO Sinemet in the setting of aspiration. His outpatient neurologist was attempted to be [**Name (NI) 653**], but was unavailable throughout the course of Mr. [**Known lastname 22138**] hospitalizaton. No formal neurology consult was pursued given improvement with dissolvable Sinemet. . #Positive C. diff: Started IV Flagyl on [**2185-10-26**]. Instructed to continue until 10 days from last antibiotic use ([**2185-11-11**]). Diarrhea subsided by the time of discharge. His PICC was placed [**11-2**] for continued antibiotics, which will end [**11-11**]. If he is taking reliable PO, he may be transitioned to PO flagyl 500mg q8hr. His PICC may be taken out following completion of his antibiotic course. . #Enterococcal UTI: Urine culture from [**2185-10-28**] grew enterococcus sensitive to ampicillin at 10,000-100,000 organisms. He was treated with a protracted 6 day course of ampicillin/amoxicillin due to concerns excess antibiotics were worsening his mental status. He had repeat urine culture on [**11-1**] which reported no growth. . # Nutrition: Due to worsening bradykineasias, Mr. [**Known lastname 22136**] had a difficult time tolerating PO intake. He had complications of aspiration and required respiratory therapy nasopharyngeal/tracheal suction. He had several swallow evaluations, which ultimately suggested NPO status given his VERY HIGH RISK of aspiration. The [**Hospital **] health care proxy (HCP) declined the placement of feeding tube, and asked to pursue PO feeds despite aspiration risk, understanding the risks of feeding complications including airway obstruction, pneumonia, and death. He was placed on a guarded pureed solids diet, with straw delivered thin liquids and scandi shakes for caloric supplementation, oral care q 4 hours, 1:1 aspiration feeding, aspiration precautions, and vigilant PO suctioning/post prandial suctioning. Additinally, all his non-essential PO medications were discontinued, and only continued to receive his BB, [**Last Name (un) **], Statin, ASA, Sinemet, and Flagyl. . # Code Status: During the course of his hospitalization, Mr. [**Known lastname 22138**] HCP changed code status several times. The family ultimately understood that placing a pt. DNR/DNI does not change the quality of care that is delivered, but the interventions that are pursued in the event of a fatal arrhythmia or cardiac arrest. By the time of discharge, Mr. [**Known lastname 22136**] was placed DNR/DNI. . #CHF: Respiratory distress resolved with initial diuresis in the ICU, and did not require further diuresis on the floor. Although latest echo saw worsening EF from 40-25%, repeat analysis shows consistent EF of 40% with addendum to the previous read placed in the patient's chart. He was inconsistently delivered his cardiac medications in the setting of poor PO intake, but was ultimatley discharged to receive his beta blocker was and [**Last Name (un) **]. . # Type 2 diabetes. His lantus was stopped in the context of minimal PO intake. He was continued on an ISS with adequate control of his FSG 150-220. # Hypertension. Will continue his beta blocker and valsartan. Had intermittent episodes of hypertension throughout the hospitalization, but mostly ranged 110's-140's/50's-80's in the setting of inconsistent PO medication delivery. . # CAD. 3VD, s/p PCI with DES to RCA and LAD in [**2179**], POBA RCA in [**2183**], NSTEMI [**2185-3-9**] that was medically managed. Continued on his beta blocker, statin, aspirin. If taking limited PO, would give priority to his cardiac meds, and can give PR aspirin if necessary. Had some intermittent chest pain without EKG changes. Given SL nitro prn. Medications on Admission: Medications (Rehab): - Acetaminophen 650 mg PO prn - Insulin Lantus 10 U HS - Insulin SS - Aspirin 81 mg - Ascorbic Acid 500 mg PO BID - Multivitamins 1 TAB PO DAILY - Bisacodyl 10 mg PO DAILY:PRN constipation - Carbidopa-Levodopa (25-100) PO/NG Q8AM - Carbidopa-Levodopa CR (50-200) PO BID - Senna 1 TAB [**Hospital1 **]:PRN - Calcium Carbonate 600 mg [**Hospital1 **] - Simvastatin 20 mg DAILY - Tamsulosin 0.4 mg PO HS - Cyanocobalamin 500 mcg IM QTUES - Valsartan 120 mg PO DAILY - Lopressor 25mg Q6H - Docusate Sodium 100 mg PO BID - Vitamin D 1000 UNIT PO DAILY - Zinc Sulfate 220 mg PO DAILY - MOM, fleet enema - Ativan 0.25mg HS Discharge Medications: 1. carbidopa-levodopa 25-100 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO daily (): Please give midday. 2. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: Five Hundred (500) mcg Injection QTUES (every Tuesday). 3. carbidopa-levodopa 25-100 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO BID (2 times a day): Please give in the AM and PM. 4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 5. valsartan 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for wheezing/sob. 8. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 9. insulin lispro 100 unit/mL Solution Sig: As Directed Subcutaneous ASDIR (AS DIRECTED): Please follow supplied sliding scale. 10. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): Day1=[**10-26**]. Will complete course [**11-11**]. [**Month (only) 116**] transition to PO if taking reliably. 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. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 14. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 15. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day as needed for volume overload. 16. metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for volume overload: please give 30min prior to bumex. 17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: please give in lieu of PR ASA if taking PO well. 18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): For DVT prophylaxis while patient is in bed. 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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 4 grams in a 24 hour period. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Primary diagnoses: Acute congestive heart failure exacerbation (systolic HF) Health care associated pneumonia . Secondary diagnoses: Parkinson's Disease Type II Diabetes Spinal Stenosis History of transient ischemic attack osteoporosis polyneuropathy/amyotrophy Coronary artery disease Hypertension Clostridium difficile colitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 22136**], You were admitted to the hospital with confusion and weakness. You were found to have increasing cough, low grade fevers, and worsening oxygen needs as well as rapid respiration rates. Because of your respiratory distress, you were admitted to the intensive care unit. There you received oxygen supplementation and antibiotics for a possible pneumonia. You were also treated for a possible mild urinary tract infection. Additionally, you were given some diuretics to help urinate off excess fluid. Your symptoms were ultimately thought to be due to a congestive heart failure exacerbation. Your respiratory status improved enough for you to go to the general medical floors. Due to antibiotic use, you developed a diarrheal illness known as C.Diff, and were treated with an IV antibiotic known as "Flagyl". In the hospital, you were very lethargic and slow-to-move (bradykinetic). You had a hard time tolerating food, water, and pills by mouth, and wound up inhaling some of these contents into your lungs (aspiration). This caused you to have a hard time breathing, requiring daily suctioning and oxygen supplementation. Many of your oral medications were discontinued, and you were placed only on essential medications for your Parkinson's Disease as well as your heart medications. Your bradykinesia improved using dissolvable Sinemet (Parkinson's medication). You were evaluated by a SWALLOW specialist who said you were at very high risk of aspiration, and recommended nothing by mouth. However, your health care proxy and you requested to try foods, as a feeding tube was not wanted, understanding the VERY HIGH risk of aspiration and the complications associated with it. You were able to somewhat tolerate liquid with a straw and small amounts of pureed foods with some aspiration of these contents, requiring oral suction. Your mental status improved and you were communicating well with your family and medical staff. You remained afebrile and able to breath comfortably on room air. It was determined that your congestive heart failure exacerbation and possible infections had resolved, and you were transferred to a rehabilitation facility for further care. Many of your oral medications were discontinued while you were in the hospital. These discontinued medications include ascorbic acid, multivitamin, senna, calcium, colace, vitamind D, and zinc. Your current up-to-date medication list is provided with your discharge paperwork. Other changes to your medications are listed below: - START IV FLAGYL (500mg every 8 hours): continue taking up to and including [**2185-11-11**]. - CHANGE Aspirin to 325 mg daily - CHANGE Sinemet to 2 tablets in the morning and evening and 1 tablet at lunch - CHANGE Lopressor (metoprolol tartrate) to 12.5 mg twice a day - STOP Lantus, but continue your insulin sliding scale - STOP Ativan - We also ADDED nitroglycerine as needed for chest pain, albuterol nebs as needed for shortness of breath or wheezing, zofran for nausea, and heparin injections to prevent blood clot formation. - We ADDED bumetanide and metolazone as needed for fluid overload. During your hospitalization, your code status was officially changed and documented to DO NOT RESUSCITATE/DO NOT INTUBATE. This status can be changed at any time by you or your health care proxy in the event that you are not capable of making your own decisions. It has been a pleasure taking care of you [**Known firstname **]! Followup Instructions: You can follow up with your primary care doctor when you are ready to schedule an appointment. For appointments, please contact [**Name (NI) **] [**Name (NI) **] at ([**Telephone/Fax (1) 6846**].

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

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47394

Discharge summary

report

Admission Date: [**2174-8-3**] Discharge Date: [**2174-8-9**] Date of Birth: [**2099-1-6**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Left-sided weakness Major Surgical or Invasive Procedure: Placement of ventriculostomy drain Intubation History of Present Illness: History obtained from daughter and medical records The pt is a 75 year-old man with a history of HTN, atrial fibrrillation on coumadin, hyperlipidemia, type 2 diabetes mellitus, CAD s/p CABG, CHF, COPD, and CRI who presented from home with left-sided weakness. The pt's daughter reports that she was at parent's house until about 10pm on the evening of admission. Pt was at his baseline, and having no problems. Daughter went home (across the street) and was called by her mother ~5 minutes later that pt had fallen to floor. She returned to their house and found pt on floor, unable to get up. She tried to help him, but he "was dead weight" and he said he was having trouble moving his legs (both of them). He said that he "didn't feel well" and daughter noticed that he seemed to have trouble breathing. She also noticed that he was pale, was leaning to the left and was drooling. She called 911. After their arrival, pt developed "projectile vomiting". Per EMS, he also had vomiting in ambulance and may have aspirated. On arrival in ED, SBP 200s, and pt seemed somewhat sleepy and inattentive. He complained of pain in his stomach and "feeling lousy." Denied headache. He had no gag reflex, and was intubated for airway protection with lidocaine, vecuronium, fentanyl, succinylcholine, and etomidate. The pt's daughter reported no recent illnesses. Unable to obtain other ROS due to intubation. Past Medical History: 1. Hypertension 2. Atrial fibrillation on coumadin, previously on amiodarone 3. CAD, s/p CABG x4 "years ago" 4. DM2, complicated by peripheral neuropathy in his feet 5. COPD and bronchiectasis 6. Hypercholesterolemia 7. Congestive heart failure 8. Peripheral vascular disease 9. Chronic renal insufficiency, baseline creat 1.7-2.2 10. Hypothyroidism secondary to amiodarone 11. s/p cholecystectomy Social History: The pt lives with wife who is "sick" per daughter. Quit tobacco in [**2164**], has >100 pack-yr history. No alcohol use. Family History: The pt's father suffered an MI at age 60. Physical Exam: Vitals -T not taken BP 176/74 HR 80 . RR Initially 12, now on vent General: Appears stated age HEENT: NC/AT Sclera anicteric Lungs: Clear to auscultation bilaterally CV: RRR, nl S1, S2, no murmur. Abd: Soft, nontender, normoactive bowel sounds Extr: No edema, warm and well perfused . Neurologic Examination: Done in the few minutes prior to intubation Mental Status: Awake, somewhat inattentive, oriented to name, age, [**Hospital **] hospital. No dysarthria noted though minimal speech before intubation. Followed axial commands. . Cranial Nerves: Eyes somewhat roving. Blinks to threat on right but not left. Pupils equally round and minimally reactive to light, 4 to 3.5 mm bilaterally. Unable to visualize fundi due to roving eye movements. Extraocular movements roving, and do cross midline. No gag reflex. . Motor: Right arm and leg move to command. Some movement of left fingers and toes but does not hold up left arm or leg against gravity . Sensation: Minimal withdrawal of all limbs to noxious, though right better than left . Reflexes: Left toe up, right toe down . Unable to assess coordination and gait. Pertinent Results: Labs on admission: [**2174-8-2**] 11:40PM BLOOD WBC-4.7 RBC-4.35* Hgb-12.7* Hct-34.8* MCV-80* MCH-29.3 MCHC-36.6* RDW-16.5* Plt Ct-124* [**2174-8-2**] 11:40PM BLOOD PT-23.7* PTT-31.2 INR(PT)-3.7 [**2174-8-3**] 04:03AM BLOOD Glucose-343* UreaN-60* Creat-2.0* Na-139 K-4.2 Cl-103 HCO3-24 AnGap-16 [**2174-8-3**] 04:03AM BLOOD Calcium-8.0* Phos-3.9 Mg-1.5* Cholest-147 [**2174-8-3**] 04:03AM BLOOD Triglyc-280* HDL-22 CHOL/HD-6.7 LDLcalc-69 [**2174-8-3**] 04:03AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE CT head on admission: FINDINGS: There is extensive intraventricular hemorrhage seen in the lateral ventricles extending through the third ventricle into the fourth ventricle. Hydrocephalus is seen. Right lateral ventricle is larger than the left, measuring 3 cm in width. Areas of low attenuation are seen in the periventricular white matter of both cerebral hemispheres, and linear low density areas in the cerebellar hemispheres, likely representing chronic microvascular infarction. There is no evidence of brain herniation. There is no evidence of acute infarction. There is no shift of normally midline structures. There is probable moderate brain atrophy. The surrounding soft- tissue and osseous structures are unremarkable. IMPRESSION: Extensive intraventricular hemorrhage along with hydrocephalus. CT head [**2174-8-3**]: NON-CONTRAST HEAD CT: The right intraparenchymal hemorrhage is again visualized; it appears to arise from the right thalamus. It is not significantly changed in size or appearance. Again seen is associated edema in the right cerebral hemisphere. There is now layering intraventricular blood in the lateral, third, and fourth ventricles. There is interval development of a small (2 mm wide) low density fluid collection along the left frontal and parietal cerebral convexity surface. No new regions of intraparenchymal hemorrhage are identified. There is no acute major vascular territorial infarct. Osseous and soft tissues structures are unchanged. IMPRESSION: Interval development of small (2 mm) left cerebral convexity subdural fluid collection, likely a hygroma. Otherwise, no significant interval change in extensive intraventricular and right thalamic hemorrhage. Brief Hospital Course: 1. Right basal ganglia hemorrhage: The CT scan on admsission demonstrated a large basal ganglia bleed on the right side with significant intraventricular extension. Shortly after admission, a ventriculostomy drain was placed by the neurosurgery service. tPA was injected into the drain in an attempt to dissolve the intraventricular clot. A head CT was performed on hospital day two which revealed increase in size in the area of bleed and intraventricular extension. The pt's mental status waxed and waned over the cousre of the first four hospital days. Although he never opened his eyes to command or to pain, he would intermittently grasp an examiner's hand on command. The ventricular pressure was titrated by the neurosurgery service in an attempt to wean and remove the drain. However, the pt. did not tolerate this well when the drain was placed above 10cm of H2O. By the time of hospital day six, the pt. stopped following any commands and began to clinically deteriorate. A family meeting was held on hospital day 7 with the pt's daughter, [**Name (NI) 41356**], the pt's sister and [**Name2 (NI) 802**], and members of the neurology, neurosurgery and intensive care unit teams. At that time, the decision was made to withdraw support, extubate the pt and shift the goals of care to comfort measures. Shortly after extubation, the pt passed away with family members at his bedside. Medications on Admission: ASA 325mg po daily levoxyl 125mcg po daily isordil 10mg po tid atenolol 25mg po daily glyburide 5mg po bid hydralazine 10mg po tid ranitidine 150mg po bid lasix 40mg po daily coumadin 5mg po qSuTRFSa/2.5mg qMW MVI one tablet daily hydroxyzine 25mg po qhs albuterol prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: -intracerebral hemorrhage with intraventricular spread Discharge Condition: Deceased. Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "99.10", "96.04", "96.72", "38.91", "38.93", "02.2" ]

icd9pcs

[ [ [] ] ]

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5821, 7225

332, 380

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7744, 7842

2390, 2433

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4947, 5798

4114, 4938

2816, 2982

2757, 2801

1835, 2234

2250, 2374

42,009

147,209

39933

Discharge summary

report

Admission Date: [**2110-11-18**] Discharge Date: [**2110-12-12**] Date of Birth: [**2065-11-19**] Sex: M Service: MEDICINE Allergies: Erythromycin / IV Dye, Iodine Containing / Haldol Attending:[**First Name3 (LF) 633**] Chief Complaint: Fever, tachypnea Major Surgical or Invasive Procedure: NG tube placement femoral line placement History of Present Illness: Patient only able to provide limited history; details below taken from records on transfer, medical record, and history obtained in emergency room. Patient is a 44M with PMH of mental retardation, seizure disorder, [**Last Name (un) 3696**] syndrome, autism and recurrent aspiration pneumonias presenting with fever and tachycardia. Patient was recently admitted to [**Hospital1 18**] from an OSH for evaluation of mental status changes in the setting of [**Last Name (un) 3696**] and an aspiration pneumonia. He was treated with Vancomycin and Zosyn from [**Date range (1) 87807**]. His respiratory status was back to baseline and his mental status was improving at the time of discharge on [**2110-11-14**]. On the day of admission, patient was noted at his outside facility to be tachypneic to 32 with a HR=130 and oxygen saturation of 90% on room air. For these reasons he was transferred to the emergency room. On arrival vital signs were significant for T=101.6, HR=140 151/98, 96% on 4L. Exam was notable for rales on left and abdominal distention but no abdominal pain. Preliminary read of the CXR showed no clear focal consolidation but suggestion of a possible consolidation on the left, with low lung volumes. Also seen were dilated bowel loops, but without fluid levels and similar to prior X-rays. Initial labs were significant for WBC=16.8. Patient received Vancomycin, Flagyl, Tylenol, and 2-3L of IVF. HR improved in that setting to the 110's. He was then transferred to the general medicine service. ROS: All other systems reviewed and negative except as noted above. Past Medical History: Autism [**Last Name (un) 3696**] Seizure disorder Recurrent aspiration pneumonias Hypertension Asthma Schizoaffective disorder GERD Social History: Per prior records, patient is independent with ADL's at baseline, lives in a group home. Family History: Patient unable to report. Physical Exam: VS: T=99.4 BP=128/80 HR=115 RR=18 O2 Sat=97% on 4L Gen: Awake, alert, NAD HEENT: NCAT, EOMI, anicteric CV: RR, no m/r/g Pulm: Crackles bilaterally; bowel sounds audible Abd: Soft, distended, high-pitched bowel sounds throughout, non-tender Ext: No edema or calf tenderness Psych: Smiling, responding to questions, dysarthric Pertinent Results: CT ABD/PELVIS ([**2110-11-19**]): 1. Markedly dilated colon with no evidence for mechanical obstruction or stricture; significant stool burden in the rectum and cecum, most compatible with fecal impaction as there is no bowel wall thickening or pneumatosis. Differential considerations include moderate obstruction due to stool but pseudo-obstruction is suspected. 2. Foley balloon inflated within the urethra. 3. Mild bibasilar pulmonary consolidations which may represent atelectasis, but aspiration or infection cannot be excluded. CT ABD/PELVIS ([**2110-11-28**]): 1. No evidence of retroperitoneal hemorrhage. 2. Hyperdensity in the right colon may represent accidental ingestion of metallic foreign body as it seems to dense for metallic salts in pills;correlate with clinical or treatment history. 3. Bilateral pulmonary ground-glass opacifications again noted, relatively stable since [**2110-11-19**] and may represent aspiration/pneumonia, however, alveolar hemorrhage or edema cannot be completely excluded and should be considered in the correct clinical setting. 4. Calcified prostate noted. UNILAT UP EXT VEINS US LEFT IMPRESSION: Deep venous thrombosis seen within the left axillary vein extending to the basilic vein. . [**2110-12-3**] KUB-FINDINGS: One portable abdominal radiograph shows unchanged air-filled loops of colon. The study is again noted to be slightly underpenetrated. There is stable dilation of the likely mobile redundant cecum in a more anatomically appropriate postion comparted to prior. There is no evidence of free air or pneumatosis. Osseous structures appear unremarkable. IMPRESSION: Essentially unchanged distended cecum . CXR [**12-1**]-IMPRESSION: AP chest compared to [**11-30**]: New region of vague opacification in the right mid lung could represent early aspiration. No free subdiaphragmatic gas. Mild-to-moderate cardiomegaly has increased. No pneumothorax. . Head CT [**12-11**]-FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift of normally midline structures. There is no major vascular territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Ventricles and sulci are mildly prominent, indicating volume loss. Suprasellar and basilar cisterns are patent. There is mucosal thickening and aerosolized secretions within the frontal and bilateral maxillary sinuses. A few ethmoidal air cells are opacified. Layering fluid within the maxillary sinuses may indicate ongoing inflammation. Mastoid air cells are well aerated. Globes and soft tissues are unremarkable. . IMPRESSION: 1. No acute intracranial process, including hemorrhage or infarct. 2. Mild cerebral volume loss. 3. Moderate paranasal sinus disease. . EKG [**12-11**]-Sinus tachycardia. Delayed precordial R wave transition. Compared to the previous tracing of [**2110-11-22**] there is variation in precordial lead placement. No diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 107 152 64 312/394 29 0 -1 . BLood cultures were all negative. C.diff negative x6 . [**2110-12-11**] 8:48 am URINE Source: Catheter. **FINAL REPORT [**2110-12-12**]** URINE CULTURE (Final [**2110-12-12**]): NO GROWTH. Brief Hospital Course: 44 y/oM with PMH of MR, schizoaffective d/o, seizure d/o, recent admission for [**Last Name (un) **] Syndrome c/b delerium and aspiration PNA who was initially readmitted to the hospital with presumed aspiration pneumonitis. . In brief, the patient was initially admitted on [**11-18**] with tachycardia, hypoxia and abdominal distension. Initial evaluation revealed leukocytosis to 20, dilated bowel loops, electrolyte abnormalities, and pulmonary consolidations. His presentation was felt to be consistent with aspiration pneumonitis and an exacerbation of his [**Last Name (un) 3696**] syndrome and he was treated conservatively with monitoring serial KUB and an aggressive bowel regimen. He was also started empirically on IV vanco (stopped on [**11-19**]) and PO vanco/ flagyl for presumed cdiff, but this eventually returned negative. . Of note, his hospital course was c/b traumatic foley insertion on [**11-20**] causing gross hematuria. Urology was consulted and recommended watchful waiting with placement of a coude foley catheter. Hospital course also c/b slow development of thrombocytopenia with platelets trending from 248 on admission to a nadir of 97. Evaluation was with HIT antibody was negative and PPI, flagyl were discontinued due to concern that this could be a medication side effect. . On the evening of presentation, patient developed hypotension to 80/60, tachycardia to 160s and fever to 103 and was noted to have approx 1 cp blood surrounding his penis. Stat labs were obtained and showed a Hct of 18 from 27. He was bolused with IVF (approx 2L), emergency blood was hung at bedside, zosyn x 1 was given. Transfer to unit was initiated for further resuscitation and hemodynamic monitoring. A 22Fr Coude foley catheter was placed urgently, with resulting hemostasis. There was no further bleeding noted. . At the time of transfer to the ICU, his BP was 80/50s with tachycardia to the 150's and elevated lactate in the setting of fever and frank hemorrhage. Etiology was unclear: evolving sepsis vs hypotension from hemorrhage. CXR showed possible aspiration pneumonia vs. pneumonitis. Placed on empiric meropenem, iv flagyl, iv vancomycin, and po vancomycin as pt was having diarrhea. Rec'd 2 U emergency transfusion. Electroylte abnormalites with hypokalemia in the low 2's as well as potential hemodynamic instability prompted sterile placement of right femoral line for rapid electrolyte repletion. Pt. stabilized and femoral line was removed. Was aggressively fluid repleted, and also given additional transfusions of PRBC's. Po vanco and Iv flagyl were discontinued after c.diff negative x3. Continued IV vancomycin 1000mg IV q12hr and meropenem 500 IV q6hr were continued, and he completed 8 days of empiric therapy for HAP. Last day [**12-4**] . During this time, there was concern for evolving severe sepsis given hypotension and elevated lactate. Possible sources included HAP from possible aspiration or an intra-abdominal process such as c.diff with dilated colon, diarrhea/loose stool and recent broad spectrum abx. Elevated coags on admission to ICU concerning for DIC. Started abx's per above. As pt was thrombocytopenic with fevers, DIC labs were checked for possible HUS, but came back negative. He became afebrile with above treatment, and his platelet count improved. HAP treatment completed during admission. . # Hematuria: secondary to traumatic foley placement with prostatic urethral tear. Resolved with placement of a 22fr Coude foley catheter. Pt had development of tea-colored urine [**12-11**] that resolved with clear urine in the foley and [**12-12**] with clear urine in foley. Urology came to evaluate the patient and foley flushed without difficulty there was no hematuria or clots seen. Given that foley had been in place for 2 weeks, urology recommended, DC foley and voiding trial. Pt was able to urinate after foley removal and no hematuria was noted. Recommend follow up with Urology 1-2 weeks after discharge. . # LUE DVT: During the admission, he was noted to develop a significantly swollen left arm. Ultrasound confirmed a non-occlusive DVT in his axillary vein, and a totally occluded basilic vein. Notably, the patient did NOT have a line (eg PICC) in the left arm, so the cause of his DVT is not clear. The risk-benefit of anticoagulation in this patient with recent bleeding episodes was considered, and anticoagulation was discussed with Urology, who felt that with a foley in place he is a low bleed risk. His recent hematuria was not felt to be a contraindication for anticoagulation. His recent GI bleed was felt due to erosive esophagitis, which is being aggressively treated with ppi and sucralfate, and GI bleeding appeared to have resolved. Therefore, he was started on a cautious heparin drip, with transition to warfarin. Considering his history of bleeding, would recommend treating with warfarin for short term/such as one month, with reevaluation for discontinuation of anticoagulation at that time. Pt with supertherapeutic INR up to 5.6, now 3.1. Would hold dose tonight, check INR tomorrow and consider resuming coumadin at 1mg. Goal is [**2-5**] INR but would prefer close to 2 given the above. . # Ogilvies Syndrome: profound colonic dilitation on x-ray in setting of known ogilvies thought to be due to fecal impaction, hypokalemia. Followed by GI on floor with serial KUB's and aggressive bowel regimen resulting in copious loose stool on admission. Empirically started on C.Diff coverage per above, but was negative x 3 so d/c'd. Colonic dilatiation appeared to be stable via KUB. It is important to make sure that pt continues to have at least daily bowel movements, and that he does not become constipated. . #?coffee ground emesis upon initial admission-some concern of this in notes. Pt had not had any further episodes during this admission. GI evaluated the patient for Ogilvies syndrome as above. There is report of patient having "erosive esophagitis" at OSH and pt was placed on [**Hospital1 **] PPI. He will need an EGD as an outpatient after colonic issues and acute issues pertinent to this hospitalization have resolved. Pt noted to be guaiac negative with stable hematocrits aside from gross hematuria as above. . # Schizoaffective d/o, MR: He was followed by Psychiatry, who assisted with management of his periods of agitation. Recommend maintaining sleep-weak cycle as possible, judicious use of anti-psychotics given recent hx of tardive dyskinesia. Consider need for 1:1 sitter. His agitation was treated with ativan and seroquel with benefit. Patient was also often redirectable, by taking him for walks. Pt did become agitated [**12-10**] evening and did suffer a fall. Head CT was negative for acute injury. - seoquel 25-50 mg hs prn or ativan 0.25 mg q6hr prn per Psychiatry - add seroquel 25 mg [**Hospital1 **] prn agitation per Psych . # Seizure d/o: stable, continued lamictal . Erosive esophagitis - continued sucralfate for erosive gastritis - changed IV pantoprazole to lansoprazole Medications on Admission: 1. Quetiapine 100mg PO QHS 2. Lorazepam 0.5mg PO Q6H PRN agitation. 3. Nexium 20mg PO BID 4. Keppra 750mg PO BID 5. Lactulose 20g PO BID PRN constipation: titrate to [**2-5**] bowel movements per day. 6. Sucralfate 1g PO QID 7. Acetaminophen 325-650mg PO Q6H PRN pain or fever. 8. Advair Diskus 250-50 1 Inhalation twice a day. 9. Niacin 500mg PO at bedtime. 10. MVI PO once a day. 11. Singulair 10mg PO once a day. 12. Miconazole nitrate 2 % Powder Topical [**Hospital1 **] 13. Hydrocortisone Topical 14. Flonase 50 mcg/Actuation Spray at bedtime: once in each nostril. 15. Albuterol sulfate 90 mcg 1 Inhalation PRN shortness of breath or wheezing. 16. Calcium carbonate 500 mg (1,250 mg) Tablet, [**1-4**] Tablet, Chewables PO twice a day: 1000mg (2 tablets) in AM, and 500mg (1 tablet) in PM. 17. Prochlorperazine 10mg IM QID PRN Nausea Discharge Medications: 1. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: 15-30 MLs PO QID (4 times a day) as needed for dyspepsia. 3. quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia/agitation. 4. Ativan 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every six (6) hours as needed for agitation. 5. terbinafine 1 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day). 7. niacin 500 mg Capsule, Sustained Release [**Hospital1 **]: One (1) Capsule, Sustained Release PO BID (2 times a day). 8. levetiracetam 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). 9. montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 11. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 12. Advair Diskus 250-50 mcg/dose Disk with Device [**Hospital1 **]: One (1) Inhalation twice a day. 13. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 14. Flonase 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Nasal once a day. 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: One (1) Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 16. lactulose 10 gram/15 mL Solution [**Hospital1 **]: One (1) PO once a day as needed for constipation. 17. quetiapine 25 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day) as needed for insomnia/agitation. 18. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation: prn. 19. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed for constip. 20. warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM: to start [**12-13**] after checking INR. 21. Calcium 500 500 mg (1,250 mg) Tablet [**Month/Year (2) **]: 2 tabs qam, 1 tab qpm Tablets PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: # Abdominal distension - [**Last Name (un) 3696**] Syndrome # Thrombocytopenia # Urinary retention # Hematemesis # aspiration/healthcare associated pneumonia # Acute blood loss anemia # Hematuria # Erosive esophagitis # schizoaffective d/o Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted fever and a fast heart rate. During this stay you were treated for abdominal distension, low platelet counts (thrombocytopenia), urinary retention, bloody vomitus, aspiration/healthcare associated pneumonia, anemia, and hematuria (blood from penis). Your fever and pneumonia appear to have resolved. You were evaluated by the urology service and a foley catheter was placed. You no longer had any bleeding and your foley catheter was removed. You were able to urine without difficulty. You were also evaluated by the gastroeintestinal and psychiatric services. . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Once you are nearing discharge from rehab, please have them schedule an appointment with your primary care provider. Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2110-12-17**] at 8:00 AM With: UROLOGY UNIT [**Telephone/Fax (1) 164**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93", "96.07" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2181-7-12**] Discharge Date: [**2181-7-17**] Date of Birth: [**2126-6-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: right flank pain Major Surgical or Invasive Procedure: right sided thoracocentesis (-2200 mL fluid) History of Present Illness: 55 YO female with metastatic adenocarcinoma with unknown primary on C2D1 gemcitabine/irinotecan and with malignant pleural effusions presented to [**Hospital1 18**] ED with severe R flank pain, radiating to chest. Patient reports pain was [**9-19**] in severity. She was otherwise asymptomatic, denying shortness of breath or coughing at presentation. She experienced R flank pain previously for which she had applied a fentanyl patch with adequate pain control. Of note, she has known lytic bone lesions to the R pelvis. She reports that she had not applied the fentanyl patch to the R flank recently as pain control had improved. . The patient's cancer initially presented as syncope and further work-up revealed pericardial/pleural effusion [**2181-5-10**]. The pleural fluid revealed metastatic adenocarcinoma and the pericardial fluid a well-differentiated mucinous adenocarcinoma. The patient has had 3 recent admissions: on [**5-16**] for dyspnea and [**6-6**] and [**6-14**] for dizziness/syncope. On admission [**6-6**], the patient had pericardiocentesis and balloon pericardiotomy with removal of 520 cc of bloody fluid. [**Month/Year (2) **] on [**6-4**] showed stable loculated pericardial effusion. [**Month/Year (2) **] [**6-11**] (EF>55%) suggestive of pericardial constriction, although unchanged in size since prior admission. . During admission on [**6-14**], cardiology team saw the patient and recommended trial of low dose beta blocker for rate control; a pericardial window was not performed because the effusion was determined to be stable and symptoms thought to be related to dehydration and tachycardia. Subsequent CT of the torso did not reveal a primary source but did reveal bony lytic lesions in the right ischium and bilateral ilia concerning for metastatic disease. She also underwent an upper and lower endoscopy without evidence of a primary lesion. Considering pericardial and pleural fluid pathology, a subtle gastric or pancreatico/biliary tumor was suspected and the patient was started on gemcitabine/irinotecan. Her last dose of chemotherapy was yesterday 8/2 per patient. Chemotherapy was begun on [**2181-6-15**]. . Pt. presented to ED with tachycardia above baseline in 130s to 140s. Patient has h/o resting tachycardia 115-120. Electrocardiogram in the ED showed sinus tachycardia unchanged from prior. Radiography showed reaccumulation of pulmonary edema and CT of the chest showed no acute changes. A therapeutic thoracentesis was performed of 2200 mL of dark maroon right pleural fluid. In addition, after the procedure, the patient complained of increased shortness of breath increased from baseline, patient's O2 saturation was in the 90s. The patient was administered Lasix (40 mg X1) in the ED with subsequent improvement of respiratory function. In ED patient was administered vancomycin 1 g, ondasetron 2 mg twice, and 4 doses of morphine sulfate 4 mg. Patient was admitt-ed to ICU for pain control and management of tachycardia in setting of pleural effusions. Past Medical History: - Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in [**2162**]. - GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age 50, normal pap's per patient - Hypertension. - History of mild asthma, inhalers not used for several years. - normal mammogram less than one year ago. - normal colonoscopy 2/[**2178**]. - recent pericardial effusion/tamponade - right pleural effusion - large common femoral DVT - adenocarcinoma of unclear primary Social History: She works as a nursing assistant. Lives with her husband, who keeps very early hours, working at the [**Location (un) **] food market. Children are 18 and 19. Family History: Her father died of stomach cancer at age 72. Mother died of colon cancer at age 63. She is the 10th of 13 children. She has lost 3 siblings to motor vehicle accidents. Physical Exam: Gen: NAD HEENT: Sclera anicteric. PERRL, EOMI. No oral lesions Neck: Supple CV: Tachycardic, regular, no M/R/G. Chest: Bilaterally decreased LL BS L>R to [**12-13**] way up. R sided ronchi. ABD: Soft, NND. No HSM or tenderness. Soft subcutaneous firm mobile nodule in midepigastrium (at site of Lovenox injection sites per patient). Ext: No cyanosis or edema Neuro: non-focal, CN II-XII grossly intact, moves all extremities well Skin: no rash or petechiae noted Pertinent Results: [**2181-7-11**] 11:40AM GRAN CT-1260* [**2181-7-11**] 11:40AM PLT COUNT-521* [**2181-7-11**] 11:40AM WBC-2.7* RBC-4.04* HGB-13.2 HCT-37.9 MCV-94 MCH-32.5* MCHC-34.7 RDW-17.4* [**2181-7-12**] 12:17PM LACTATE-1.7 [**2181-7-12**] 12:22PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2181-7-12**] 12:22PM ALT(SGPT)-98* AST(SGOT)-52* CK(CPK)-63 ALK PHOS-148* AMYLASE-30 TOT BILI-0.8 [**2181-7-12**] 12:22PM LIPASE-74* [**2181-7-12**] 12:22PM GLUCOSE-119* UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16 . C.dif - negative Blood and urine cx: no growth . CXR ([**7-11**]): IMPRESSION: Increased size of now large right pleural effusion and minimally increased now moderate left pleural effusion. . Chest CT ([**7-12**]) IMPRESSION: 1. Diffuse peribronchovascular opacity with air bronchograms involving the right middle and right lower lobes post thoracentesis. Given the rapid evolution of this process, findings likely represent pulmonary edema. Pulmonary hemorrhage or multifocal pneumonia is less likely. Close interval radiographic follow up recommended. 2. Large left pleural effusion with adjacent compressive atelectasis. 3. Minimal pericardial fluid. 4. No pneumothorax or reaccumulation of the right pleural effusion. CXR ([**7-15**]): IMPRESSION: 1. Unchanged moderate left-sided pleural effusion. 2. Patchy opacities at the right lung base have cleared since the prior examination, likely representing pulmonary edema given its rapid improvement; mild persistent residual pulmonary edema. Brief Hospital Course: The patient is a 55 y/o woman with metastatic adenocarcinoma of unknown primary (likely discrete gastric or pancreaticobiliary ca) admitted with tachycardia in the setting of malignant pericardial effusions and uncontrolled pain. . # Malignant Effusion - The patient presented for outpatient therapeutic thoracocentesis [**7-12**] (done for worsening SOB) with removal of 2200 mL R sided fluid, followed by excruciating pain at thoracotomy site. The dyspnea after her procedure was likely a result of reexpansion edema, which was reflected on her chest X-ray. She was initially treated in the intensive care unit with oxygen therapy as well as IV Lasix and closely monitored. No infectious etiology was identified. It was decided that thoracentesis was not warranted as her pleural effusion was significantly smaller after the procedure. Her respiratory distress rapidly improved with diuresis and she was soon back to baseline (requires home O2). . # Mucinous adenocarcinoma of unknown primary: The patient began chemotherapy on [**2181-6-15**] with Gemzar and CPT-11 for metastatic disease. She did not experience significant nausea during hospitalization, but continued to have diarrhea related to her chemotherapy which was treated with Lomotil. . # DVT/PE - She is s/p IVC filter placement on [**2181-5-30**] s/p DVT of common femoral. She was continued on lovenox therapy. . # Pain - Patient had known lytic lesions, with high risk of pathologic fracture. Bilateral hip xray on [**6-12**] demonstrated no progression of known metastatic lesions. Orthopedics were consulted on prior admisson and believe chemotherapy should proceed prior to any radiation therapy to the hip. Also with pain at site of thoracentesis. She was treated with home fentanyl 25mcg patch for pain control, home lidocaine patch with morphine for breakthrough pain Medications on Admission: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every 6-8 hours as needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Nausea. 7. Megace Oral 40 mg/mL Suspension Sig: Ten (10) mL PO once a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every [**3-16**] hours as needed for diarrhea. 11. Nebulizer for home use Please provide one nebulizer and associated equipment. 12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer treatment Inhalation every six (6) hours. Disp:*120 mL* Refills:*2* 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer treatment Inhalation every six (6) hours. Disp:*120 mL* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: 1.) Malignant pleural effusion 2.) Mucinous adenocarcinoma of unknown primary Discharge Condition: fair Discharge Instructions: You were in the hospital because of pain and difficulty breathing after your thoracocentesis (or pleural fluid drainage). You were given medications to help get fluid off of your lungs and pain medications. When you leave the hospital, continue to take all medications as prescribed and keep all health care appointments. If you feel worsening shortness of breath, chest pain, fever, chills, abdominal pain or if your condition worsens in any way, seek immediate medical attention. Followup Instructions: You have the following appointments with Dr.[**Name (NI) 8949**] office on [**7-25**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13145**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-7-25**] 10:00

[ "E933.1", "199.1", "787.91", "401.9", "197.2", "198.5" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

10356, 10434

6444, 8289

332, 378

10556, 10563

4809, 6421

11094, 11612

4140, 4309

9055, 10333

10455, 10535

8315, 9032

10587, 11071

4324, 4790

276, 294

406, 3440

3462, 3947

3963, 4124

5,389

168,705

9205

Discharge summary

report

Admission Date: [**2134-7-5**] Discharge Date: [**2134-7-10**] Date of Birth: [**2052-11-16**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: headache Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 31624**] is an 81-year-old right-handed man with PMH significant for mitral valve replacement and CAD s/p stenting presents with acute onset headache. He reports that he awoke at 2am c/o dull headache, localized to the right parietal region. He felt nauseous (per call-in, he denies). He took a taxi into the hospital and was given tylenol in the ED with improvement of the headache. He denies weakness, numbness, tingling, gait abnormalities, change in vision, difficulty performing daily tasks, change in speech, memory problems, difficulty concentrating, chest pain, dyspnea, abdominal pain, vomiting, bowel/bladder symptoms, fevers, chills, night sweats, weight loss, anorexia, or change in energy. He has had occasional "pain in [his] head from time to time" recently, unsure if just a mild headache or similar to his current headache. Past Medical History: Aortic Stenosis s/p Aortic valve replacement [**3-/2132**] with porcine valve s/p Pneumonia [**2130**] s/p Bilat. Inguinal hernia repair s/p Deviated septum repair s/p Tonsillectomy s/p Bilat. saphenous vein stripping CAD s/p stenting [**3-/2132**] Social History: No tobacco, very rare and limited alcohol, no drug use. Widowed, used to work as a research physicist at [**University/College **]. HCP - [**Name (NI) **] and [**Name (NI) 31626**] [**Name (NI) 31627**] (sister-in-law and brother-in-law) in [**Name (NI) 31628**], CT (does not know phone or street #). Full code. Family History: No coagulopathy, aneurysms, stroke. No known cardiopulmonary disease. His parents lived until they reached ages greater than 90. Physical Exam: VS: T 98.2, HR 58, BP 127/54, RR 14, SaO2 97%/RA Genl: NAD, lying in bed HEENT: NCAT, MMM, OP clear Neck: no bruits, radiating murmur CV: RRR, nl S1, S2, II/VI systolic murmur Chest: CTAB Abd: soft, NTND, BS+ Ext: warm and dry Neurologic examination: Mental status: Awake and [**Name (NI) 3584**], cooperative with exam, normal affect. Oriented to person, place (from a list, cannot find name "[**Hospital3 **]", and year, but not month ("[**Month (only) **]"). Speech is fluent with normal comprehension and repetition; naming intact except hammock (can get with phonemic cue). No dysarthria. [**Location (un) **] intact except misses the first word of every sentence - corrects when cued with finger in front of sentence. Registers [**1-16**], recalls 0/3 in 5 minutes (1 with syntactic cue, 2 others from list). No right-left confusion. No evidence of apraxia or visual neglect. In line bisection, lines are bisected correctly but misses the lines in his left superior visual field. Can identify an "A" made out of small "B"'s. Describes cookie jar picture initially as a woman at a bathroom sink with stockingshanging out, but describes the left side of the picture correctly and then identifies it as in a kitchen. Cranial Nerves: Pupils equally round and minimally reactive to light, 4mm bilaterally. Visual fields are notable for left homonymous hemianopia, notable with visualization of red stimulus, worse with left eye. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, cold sensation throughout, and position sense at big toes, decreased vibration at toes bilaterally. No extinction to DSS. Identifies nickel in right hand as a quarter, identifies dime in left hand as a button. Able to say the nickel is heavier. Decreased graphesthesia bilaterally, with 1/3 numbers identified correctly on right and [**12-19**] on left. Able to point to the correct touched spot on arm but overshoots the arm (especially when using the left hand to identify spot on right hand). Reflexes: 2+ and symmetric throughout. Toes downgoing bilaterally. Coordination: finger-nose-finger, finger-to-nose, fine finger movements, and [**Doctor First Name **] normal. Gait: Narrow based, steady. Romberg -> sway, no fall. Pertinent Results: Labs: WBC-5.5 RBC-3.77* HGB-12.2* HCT-35.3* MCV-94 MCH-32.3* MCHC-34.5 RDW-14.0 PLT COUNT-145* PT-13.1 PTT-28.3 INR(PT)-1.1 GLUCOSE-93 UREA N-27* CREAT-1.5* SODIUM-139 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13 GLUCOSE-90 UREA N-22* CREAT-1.4* SODIUM-137 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12 CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.1 CK(CPK)-134 CK-MB-5 cTropnT-<0.01 Imaging: Head CT: 1. Acute right parieto-occipital intraparenchymal hemorrhage with mild surrounding edema but no significant midline shift. There is associated intraventricular and subarachnoid hemorrhage. Differential diagnosis includes amyloid, hemorrhagic primary or metastatic lesion, or AVM. 2. Chronic appearing sinus disease involving the left maxillary sinus. MRI/MRA Head: 1. Right posterotemporal/occipital intraparenchymal hematoma with adjacent subarachnoid hemorrhage and intraventricular blood within the occipital horns of the lateral ventricles bilaterally. 2. No underlying enhancing lesions or vascular malformations are seen. 3. Superficial siderosis of the right frontal lobe. CT Torso: 1. No site of possible malignancy was identified. 2. Multiple simple cysts of both kidneys. 3. Fibrotic changes of both lung apices are noted. 4. Fecal impaction noted. ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2132-1-22**], a bioprosthetic aortic valve is now present. Mild bileaflet mitral valve prolapse is now appreciated. The severity of mitral regurgitation is unchanged. Estimated pulmonary artery systolic pressures are higher. No vegetations are visualized on the valves. If clinically indicated, a TEE may better assess for prosthetic valve endocarditis. Brief Hospital Course: Mr. [**Known lastname 31624**] is an 81-year-old man with a history of CAD and aortic valve relacement who presented with a headache and was found to have a right parieto-occipital hemorrhage. His hospital course was as follows: 1. Neuro: Intraparenchymal hemorrhage. This was seen on CT and a repeat CT was stable. MRI showed superficial siderosis, suggesting amyloid angiopathy as the etiology. A CT torso was negative for malignancy. He was admitted to the Neuro ICU for close observation and blood pressure control. His MAP stayed under 130 and he was called out to the floor. He was continued on an insulin sliding scale and Tylenol to maintain euglycemia and euthermia. He was not given anti-epileptics as they would not be indicated unless he had a seizure. 2. CAD. He had his beta blocker increased to 25 [**Hospital1 **] for better BP control. His statin was increased to 40 following an LDL result of 121. Aspirin was held until his follow-up Neurology appointment. 3. Full code 4. Dispo: He was evaluated by PT and OT; OT felt he would benefit from rehab. Medications on Admission: metoprolol 25mg daily simvastatin 20mg daily NO aspirin or coumadin All: NKDA Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: 1. Intraparenchymal hemorrhage, right parieto-temporal Secondary: 1. Coronary artery disease Discharge Condition: Good condition, ambulating and eating independently. Neuro exam notable for disorientation, impaired attention, impaired recall; 4/5 strength in left deltoid, triceps, wrist extension; VF defect in left upper quadrant. Otherwise normal. Discharge Instructions: You have been evalauted for a headache. You were found to have a hemorrhage in your brain. This has impacted your cognitive function. You have had your Lopressor and Zocor increased to better control your blood pressure and cholesterol. Please take all medications as directed and keep all follow-up appointments. If you develop new vision changes, difficulty swallowing, difficulty speaking, facial droop, dizziness, seizure activity, specific muscle weakness, loss of sensation, chest pain, shortness of breath, palpitations, or any other symptom that is concerning to you, please call your PCP or your neurologist or go to the nearest hospital emergency department. Followup Instructions: You will be called to set up an appointment with Dr. [**Last Name (STitle) **] in Neuro-Ophthalmology. Please call your PCP ([**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 250**]) to schedule an appointment in [**11-17**] weeks. You have the following appointments scheduled: 1. NEUROLOGY Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2134-8-9**] 2:00 2. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2134-9-20**] 11:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2134-7-10**]

[ "V45.82", "277.39", "V42.2", "401.9", "414.01", "272.0", "431" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8867, 8937

7194, 8266

326, 333

9084, 9323

4782, 5190

10041, 10819

1847, 1977

8396, 8844

8958, 9063

8292, 8373

9347, 10018

1992, 2224

277, 288

361, 1227

3238, 4763

5199, 7171

2263, 3222

2248, 2248

1249, 1500

1516, 1831

57,599

182,505

38066

Discharge summary

report

Admission Date: [**2108-11-26**] Discharge Date: [**2108-12-17**] Date of Birth: [**2059-8-24**] Sex: F Service: CARDIOTHORACIC Allergies: Topamax / Percocet / Tizanidine / Lyrica / Tramadol / Methocarbamol / Naproxen / Gabapentin / Sulfa (Sulfonamide Antibiotics) / Cefazolin / Albuterol Attending:[**First Name3 (LF) 5790**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**2108-11-29**]: Flexible bronchscopy with trach change [**Last Name (un) 295**] TTS fixed flange 110 mm [**2108-11-29**]: Flexible bronchoscopy [**2108-11-28**]: Bronchoscopy with bronchoalveolar lavage, revision of tracheostomy site and tracheostomy change, thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, and left main stem bronchus bronchoplasty with mesh. [**2108-11-26**]: Flexible Bronchoscopy History of Present Illness: 49 y/o with severe TBM followed by thoracics and IP. She was seen at pre-admission testing this am in preperation for an upcoming right thoracotomy and tracheobronchoplasty. While there she developed acute respiratory distress in the setting of increased secretions x 1 day. Suction was attempted with removal of a mucous plug, but her symptoms continued and she was urgently transfered to the ED. . She reports episodes of stridor yesterday and 5am today which are typical for her day to day exacerbations. No change in her dyspnea, or change in suctioning needs. Reports some brown sputum with "old blood" this week and yellow sputum, no change in quanitity from normal. No F/C/NS. She reports her standard chronic lower back pain with raiation to BL buttox. She also has occasional palpations and chest tightness with dyspnea. . She reports difficulty with hyperglyemia with random glucoses of 278-423 this month. She has been taking her lantus, but has not been compliant with the novolog SS given the unexpected death of her father. [**Name (NI) **] change in diet. . In the ED, initial vs were: T98.2 P 101 BP 122/94 R 20 O2 sat 100%. She was aggressively suctioned with removal of secretions. She had ongoing dyspnea and underwent bronchoscopy by IP which showed no further plugging. Patient was given Ipratropium and xopenex neb, 2mg midazolam and 75mcg fentanyl (with bronch), dilaudid 2mg PO and 2mg IV, and 10 U of regular insulin SC. BG initially 378 with an AG of 20. Lactate was 4.2 but improved to 2.4 with hydration. Labs showed mild leukocytosis and transaminitis. CXR without acute process. EKG without ischemic changes. VS prior to transfer 98.1 98 18 134/75 98% ra fbs 217. Noted to desat to 90-92% while sleeping. . On the floor, she complains of her chronic back pain. . Most recently admitted [**2108-9-17**] to [**2108-9-28**] with successful trial of a Y-stent with significant relief of pulmonary symptoms. Course was prolonged for management of chronic pain and depression / anxiety with the help of psych. . On [**2108-10-23**] she underwent a flexible bronchoscopy with therapeutic aspiration of thick secretions surrounding the [**Location (un) **] T tube. She is scheduled to undergo right thoracotomy and tracheobronchoplasty for her TBM in two days. Past Medical History: -Severe TBL at both mainstem bronchi and bronchus intermedius, s/p both metal and silicone stents (unsuccessful [**1-2**] inflammation requiring intubation during stent removal [**6-9**]), s/p Trache/PEG [**6-9**]. - Recent MSSA VAP and PNA x3 in recent years -Osteopenia/osteoarthritis -Chronic pain -Type II DM -Diabetic neuropathy -Depression -Fibromyalgia -Herpes -Hiatal hernia -Hypertension -Hypothyroidism -IBS -GI bleed -nephrolithiasis -Irregular heart rhythm -NASH (w/up Hepatitis serologies, Fe studies, alpha-1-antitrypsin neg). -PTSD -Agoraphobia -GERD -Latent TB - INH course stopped (with ID input) [**1-2**] - transaminitis -Carpal tunnel -S/P appendectomy -S/P C-section -S/P cholecystectomy -S/P hysterectomy -S/P R oophorectomy -S/P L ovarian cystectomy -S/P shoulder surgery x4 -S/P L breast ductal excision -S/P liver biopsy x2 Social History: - Lives in VT w/ husband and mom. - Tobacco history: none, has used medical marijuana in the past. - ETOH: allergic (hives) - Illicit drugs: none Family History: Family just died from leukemia and ICH s/p fall. CAD - grandfather [**Name (NI) **] CA, CVA, DM. Physical Exam: Vitals: T:98.1 BP: 155/95 P: 100 R: 22 O2: 100 RA, Wt 195.8lb, BG 198 General: Alert, oriented, no acute distress, able to speak in full sentences. no accessory muscle use. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, T tube in place and caped Lungs: diffuse rhonchi. no wheeze CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild RUQ tenderness without rebound or gaurding, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal. CN intact. A+Ox3 Pertinent Results: [**2108-11-26**] 11:00AM PT-12.9 PTT-21.5* INR(PT)-1.1 [**2108-11-26**] 11:00AM PLT COUNT-309# [**2108-11-26**] 11:00AM NEUTS-58.1 LYMPHS-30.8 MONOS-3.2 EOS-5.8* BASOS-2.1* [**2108-11-26**] 11:00AM WBC-12.8*# RBC-5.32# HGB-14.6# HCT-44.0 MCV-83 MCH-27.5 MCHC-33.3 RDW-14.1 [**2108-11-26**] 11:00AM %HbA1c-9.4* eAG-223* [**2108-11-26**] 11:00AM ALBUMIN-5.1 [**2108-11-26**] 11:00AM ALT(SGPT)-139* AST(SGOT)-182* LD(LDH)-373* ALK PHOS-281* TOT BILI-0.2 [**2108-11-26**] 11:00AM GLUCOSE-378* UREA N-10 CREAT-0.7 SODIUM-134 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-20* ANION GAP-25* [**2108-11-26**] 11:07AM LACTATE-4.2* K+-4.3 [**2108-11-26**] 12:55PM URINE RBC-0-2 WBC-[**2-2**] BACTERIA-FEW YEAST-NONE EPI-[**2-2**] [**2108-11-26**] 12:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2108-11-26**] 12:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.044* [**2108-11-26**] 12:55PM URINE UCG-NEGATIVE [**2108-11-26**] 01:32PM GLUCOSE-225* LACTATE-2.4* K+-3.8 [**2108-11-26**] 01:32PM TYPE-[**Last Name (un) **] PO2-61* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 [**2108-11-27**] 06:10AM BLOOD WBC-7.2 RBC-4.35 Hgb-11.7* Hct-36.1 MCV-83 MCH-27.0 MCHC-32.5 RDW-13.9 Plt Ct-215 [**2108-11-27**] 06:10AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-141 K-3.6 Cl-102 HCO3-29 AnGap-14 [**2108-11-27**] 06:46AM BLOOD Lactate-1.8 [**2108-11-27**] 06:46AM BLOOD Type-[**Last Name (un) **] pO2-36* pCO2-49* pH-7.40 calTCO2-31* Base XS-3 . [**2108-11-26**]: CXR: The cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. Mild left basilar atelectasis. No pneumonia. IMPRESSION: No acute cardiothoracic process. Brief Hospital Course: Assessment and Plan: 49 y/o with TBM and anxiety with anticipated right thoracotomy and tracheobronchoplasty presents with acute respiratory distress relieved with suctioning. . # Acute respiratory distress: Based on the acute onset, presences of T tube and relief with suctioning mucous plugging is the most likely explanation for acute respiratory distress. Per ED s/o Bronchoscopy without other acute findings. The patients significant anxiety is also likely contributing. She was treated with ipratropium nebs, xopenex nebs (pt has "allergy" to albuterol), mucomyst nebs, oxygen prn (pt uses [**1-5**] L during the day at home), and frequent suctioning with RT. After the mucous plug was removed her acute symptoms resolved. On hospital day 2, the patient was scheduled for a tracheobronchoplasty via a right thoracotomy. The patient was admitted into the surgical ICU on hospital day 3 after her trancheo bronchoplasty. She was initially sedated with propofol because her neuromuscular blockade was not reversed in the OR. She was started on a short course of antibiotics with Levaquin due to increased tan sputum secretions. . # DM II - Blood glucose presistently in high 200s to 400s for few weeks. Alc 9.4. However the patient admits to non-compliance with novolog sliding scale, and does not seem to strictly modify her diet. AG on admission likely explained by lactic acidosis. She was started on an insulin gtt on hospital day 3 after she was transferred to the intensive care unit post-operatively. The AG closed within 24hrs. Her blood glucose drastically improved with initiation of the sliding scale novolog. A nutrition consult was obtained for DM teaching. We obtained a consult from [**Last Name (un) **] to manage her elevated blood sugars. We titrated your lantus dose daily and increased your insulin sliding scale. . # TBM: Severe, followed by IP and thoracic surgery. Per report from ED bronch performed in the ED showed stable TBM. Pt scheduled for right thoracotomy and tracheobronchoplasty on wednesday. Postoperatively, she was weaned off the vent to CPAP in the intensive care unit. She required pulmonary hygeine and VAP care. She had a portex tracheostomy exchanged at the bedside by IP to a #7 [**Last Name (un) **] and received trach care as needed. She also received 2 bronchoscopies on hospital day 3. The patient was continued on CPAP on HD 4. We continued to trend her ABGs and suctioned as needed. Her chest tube was discontinued on HD7 and the chest x-ray showed no signs of a pneumothorax. However, she had a chest x-ray that showed a right middle lobe infiltrate and she was started on a short course of Levaquin (approximately 7 days). Her respiratory status remained stable after her chest tube was pulled and antibiotics were started. She was started on a trach mask on HD 7 on 70% and her FiO2 was weaned. She was transferred to the floor on hospital day 9. She had her tracheostomy evaluated by interventional pulmonology who recommended downsizing her trach from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] to a portex 6. She tolerated the change in her tracheostomy tube. She continued to have some secretions, but improved with nebulizer treatment. She was evaluated by speech and swallow during her admission and they completed a trial with a Passy Muir speaking valve. . # Lactic acidosis: 4.2 on arrival, improved to 2.4 with 1 L IVF and bronch, 1.8 on HD 1. Likely [**1-2**] resp distress and hypoxia. No f/c/s, CXR clear, no signs of infection (mild leukocytosis likely from stress rxn, resolved by HD 1). ABG prior to transfer not acidotic. . # Transaminitis: At baseline levels on admission. Carries dx of NASH. Appears to have had w/u at [**University/College **] and Central [**Hospital 84990**] hospital (h/o liver bx x2). W/u at [**Hospital1 **] includes Hep B and C serologies, Fe studies. Slightly high alpha-1 antrypsin. No record of IgG, [**Doctor First Name **], AMA. . # Psych: significant anxiety and depression: continued fluoxetine and xanax. SW was consulted. During her stay in the ICU, the patient had fluctuating mental status and psychiatry evaluated her in the unit. She had visual hallucinations and was very anxious about not being able to breath despite having O2 sats in the high 90s and a normal respiratory rate. recommended continuing zyprexa, prozac and klonoopin. They encouraged the maintain sleep/wake cycle as often as possible. . # Chronic pain: The patient received an epidural pre-operatively. Her epidural was discontinued on [**11-30**]. She was continued on dilaudid 2mg QID prn and we titrated her dilaudid to 2-8mg q3hr prn pain. We consulted the chronic pain service on [**12-16**] to discuss persistent rib pain and they recommended starting a lidocaine patch and resuming her home dose of oxycontin on discharge. . # Nutritional status: The patient was treated with tube feeds per nutrition on [**12-1**] to provide nutrition. Her tube feeds were with Nutren Pulmonary at 75 cc/hr, which would promote her nutrition. Her tubefeeds were discontinued after she was transferred to the floor. The patient was able to tolerate PO intake with no difficulties. . Code: Full (discussed with patient) . Emergency Contact: HCP: [**First Name8 (NamePattern2) 84991**] [**Name (NI) **] Relationship: daughter [**Telephone/Fax (1) 84992**]. [**Name (NI) **] (husband) [**Telephone/Fax (1) 84993**]. . Medications on Admission: acyclovir 400mg PO daily amitriptyline 100mg PO daily amlodipine 5mg daily clonazepam 1mg PO TID fluoxetine 80mg PO daily hydromorphone 2mg PO QID Lantus 58 units qhs Novolog SS, (takes 17 units for BG 400) ipratropium neb q6h kapidex 60mg PO daily levothryoxine 25mcg PO daily mucomyst 2ml of 20% inhaled [**Hospital1 **] Viactiv PO BID docusate 100mg PO BID Mucinex 1200 TAB PO BID senna 2 tab [**Hospital1 **] . Allergies: Albuterol - shaking / seizures Cefazolin Gabapentin - swelling Lyrica - severe constipation Methocarbamol - swelling Naproxen - swelling Percocet (Oxycodone Hcl/Acetaminophen) - vomiting Sulfa (Sulfonamide Antibiotics) Tizanidine - swelling Topamax - swelling Tramadol Discharge Medications: 1. amlodipine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. fluoxetine 40 mg Capsule [**Hospital1 **]: Two (2) Capsule PO once a day. 3. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO BID (2 times a day). 4. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 6. acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime) as needed for anxiety/agitation: [**Month (only) 116**] take and additional dose in the morning if agitated. Disp:*60 Tablet(s)* Refills:*0* 8. guaifenesin 600 mg Tablet Sustained Release [**Month (only) **]: One (1) Tablet Sustained Release PO twice a day as needed for thick secretions. Disp:*30 Tablet Sustained Release(s)* Refills:*1* 9. clonazepam 1 mg Tablet [**Month (only) **]: One (1) Tablet PO at bedtime. 10. acetaminophen 500 mg Tablet [**Month (only) **]: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever. 11. clonazepam 0.5 mg Tablet [**Month (only) **]: One (1) Tablet PO BID (2 times a day). 12. hydromorphone 2 mg Tablet [**Month (only) **]: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. 13. docusate sodium 100 mg Capsule [**Month (only) **]: One (1) Capsule PO BID (2 times a day). 14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 15. ranitidine HCl 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 16. Trach collar Cool mist humidified trach collar. Please dispense two 17. Home Oxygen supplementation Please dispense home oxygen supplementation and supplies. Please give [**1-3**] liter flow continuously. Respiratory diagnosis: Tracheobronchomalacia 18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (3) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 19. hydromorphone 2 mg Tablet [**Month/Day (3) **]: 1-4 Tablets PO Q3H (every 3 hours) as needed for pain for 2 weeks. Disp:*90 Tablet(s)* Refills:*0* 20. Trach Supplies #6 uncuffed, nonfenestrated Portex trache tube. Please dispense two 21. insulin glargine 100 unit/mL Solution [**Month/Day (3) **]: One (1) dose Subcutaneous at bedtime: as listed in sliding scale. 22. insulin regular human Injection Discharge Disposition: Home With Service Facility: Central [**Hospital 3914**] Home Health & Hospice Discharge Diagnosis: - trachobronchialmalacia s/p - Latent TB on INH and pyridoxine currently - HTN - DM type 2 - NASH - Hyperlipidemia - Hypothyroidism - Osteopenia - Osteoarthritis - Hiatal Hernia - Carpal Tunnel - IBS - GI bleed - Hemorrhoids - Kidney stones (4 in last 10 years) - PNA (x 3, all in last 7 years) - Chronic Pain - Herpes - Depression - Fibromyalgia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **] [**Known lastname **], It was a pleasure taking care of you during your hospitalization. You were admitted for surgical management for a medical condition known as tracheobronchomalacia. You tolerated the procedure well and are now ready to return home. Please call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101.5 or chills or shakes -Increased shortnss of breath, cough or chest pain -Incision develops drainage, redness or swelling. You may shower but no tub bathing. While taking narcotics for pain, take stool softeners and no driving. Walk several times per day. Use passey muir valve to speak, but take off while sleeping. While sleeping use humidified trach collar set up as you already have at home. Suction only if unable to cough up secretions. Followup Instructions: Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] for your appointment. You will see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in 2 weeks with a chest xray prior to your appointment.

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Discharge summary

report

Admission Date: [**2112-10-28**] Discharge Date: [**2112-11-23**] Date of Birth: [**2045-4-16**] Sex: F Service: SURGERY Allergies: Bactrim / Macrobid / Cortisone / Codeine / Vancomycin Attending:[**First Name3 (LF) 473**] Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: [**10-28**]: ERCP [**11-15**]: Percutaneous dilational tracheostomy with bronchoscopic guidance History of Present Illness: The patient is a 67 y.o. F with h/o breast cancer s/p lumpectomy, gallstones who presents with epigastric pain and nausea. + emesis and dry heaves. She presented to an OSH where the abdominal CT scan demonstrated diffuse new inflammatory changes surrounding the head of the pancreas with fluid tracking along the anterior pararenal fascia- c/w acute pancreatitis. Study was limited [**3-12**] to absence of IVc contrast thus +Gallstones in the GB but GB unremarkable. Pain is similar to a presumed attack of biliary colic that she had 2 years ago which resolved without medical intervention. She was given zosyn 4.5 gm IV, protonix 40 mg IV, zofran 4 mg IV, dilaudid 1 mg IV x 2 along with pepcid 20 mg IV x T, benadryl 25 mg IV x T. She was then transferred to [**Hospital1 18**] for ERCP. In the [**Hospital1 18**] ED she was given dilaudid 1 mg IV x 1. ROS GEN: no fevers, chills, + chronic night sweats since menopause, no fatigue, 10 lb weight gain [**3-12**] to dietary indiscretion HEENT: no vision changes, tinnitus, loss of hearing, no dysphagia headache, sinus tenderness, rhinorrhea or congestion. CV: no chest pain RESP: no cough, no shortness of breath, no orthopnea, PND GI: + epigastric pain with radiation to b/l lower abdominal quadrants. + nausea, +vomiting/dry heaves no diarrhea, no constipation, GU: no dysuria, hematuria, hesitancy, or change in frequency, change in bladder habits, vaginal discharge SKIN: no rashes, lesions, pressure ulcers NEURO: no weakness, paresthesias, numbness, headaches, dizziness MUSCULOSKELETAL: no arthralgias, myalgias PSYCH: No sadness or hallucinations. All other review of systems negative. Past Medical History: L breast- invasive ductal carcinoma, grade [**3-13**] with DCIS. ER positive PR negative- [**2110-8-9**] hypercholesterolemia hypothyroidism osteopenia arthritis. multiple UTIs PSH: - Excision of a R breast benign mass - disk surgery on her back in [**2080**] - laser eye surgery for her glaucoma Social History: She smoked socially in her 20s and drinks less than five drinks per week. She is not working outside of her home. She lives at home with her husband who has multiple myeloma and is currently undergoing treatment. He seems to have failed a novel therapy and is due to be seen at [**Company 2860**] on Monday. She admits to being quite worried about him. Family History: breast cancer Aunt (age 64), GM (Age 55), mother at (age 64) Physical Exam: VS Tm = 98.0 P = 87, BP = 104/58 RR = 16 O2Sat = 92% RA GENERAL: Obese female who appear her stated age. She is currently in a great deal of abdominal pain. Nourishment: Good Grooming: Fair. Mentation: Alert, oriented, good historian. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, markedly diminished bowel sounds. + epigastric tenderness. No rebound or guarding. Rectal deferred given patient's discomfort. Genitourinary:WNL Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Appropriate affect and despite her pain level she has appropriate brightening. Pertinent Results: [**2112-10-28**] 12:25AM GLUCOSE-157* UREA N-19 CREAT-0.8 SODIUM-141 POTASSIUM-5.6* CHLORIDE-106 TOTAL CO2-27 ANION GAP-14 [**2112-10-28**] 12:25AM estGFR-Using this [**2112-10-28**] 12:25AM ALT(SGPT)-48* AST(SGOT)-71* ALK PHOS-40 TOT BILI-1.0 [**2112-10-28**] 12:25AM LIPASE-4335* [**2112-10-28**] 12:25AM WBC-17.5*# RBC-4.25 HGB-13.4 HCT-40.5 MCV-95 MCH-31.5 MCHC-33.1 RDW-13.0 [**2112-10-28**] 12:25AM NEUTS-94.7* LYMPHS-2.9* MONOS-1.9* EOS-0.2 BASOS-0.2 [**2112-10-28**] 12:25AM PLT COUNT-199 [**2112-10-28**] 12:25AM PT-13.2 PTT-21.8* INR(PT)-1.1 ECG: SR Prolonged QTC OSH: WBC = 20 K HCT = 38 amylase = 4219 Lipase >3000 U/A neg leuk esterace, negative nitrites, MICRO: [**10-28**] UCx(final): no growth [**10-29**] BCx: no growth [**10-29**] UCx(final): no growth [**10-29**] MRSA screen(final): negative [**10-29**] Sputum cx(final): 2+ GNR, sparse growth [**10-31**] BCx: no growth [**10-31**] Sputum cx(final): 2+ GPC pairs; sparse growth [**10-31**] MRSA screen(final): negative [**11-3**] blood cx no growth [**11-3**] sputum: no growth [**11-4**] sputum: no organisms [**11-4**] urine: negative [**11-4**] blood cx: no growth [**11-5**] blood cx: no growth [**11-7**] IV catheter Tip No growth [**11-11**] Sputum Contaminated [**11-11**] blood culture - GPC in clusters x 2 bottles, unclear if central line [**11-11**] urine negative [**11-13**] bcx - no growth [**11-13**] sputum - no orgs [**11-19**] sputum - GPC pairs and cluster [**11-20**] BAL - no microorganisms, PMNS. Ucx -VRE UTI sensitive to zyvox IMAGING: [**10-28**] ERCP: Sludge and small stone fragments were extracted. There is no evidence of biliary stricture or ductal dilatation. Filling defects within the gallbladder consistent with stones/sludge [**10-29**] CT: Basilar atelectasis and pleural effusion bilaterally. Moderate amount of fluid in peritoneal cavity, strandings in fat surrounding the pancreas and other organs and adynamic ileus are findings compatible with pancreatitis. No free air. [**10-31**] CXR: left-sided pleural effusion, basilar atelectasis [**11-2**] CXR: NG tube tip passes below the diaphragm, most likely terminating in the stomach. No interval change bibasilar atelectasis [**11-4**] CTA prelim: Interval worsening of peripancreatic inflammatory stranding without evidence yet of pancreatitis-related complication. No definite focal fluid collection observed. Anasarca with small left greater than right pleural effusions. Cholelithiasis with biliary stent in place. [**11-7**] CXR: Increasing left basilar atelectasis. Minimally improving right basilar atelectasis. [**11-13**] CXR: No interval change in ET tube is persistently low with tip 1.7 cm above the carina. Bibasilar atelectasis with small pleural bilateral effusions are unchanged. [**11-14**] CXR: Endotracheal tube seen with tip approximately 3 cm above the carina. Nasogastric tube coursing over the stomach, tip incompletely imaged. Cardiac and mediastinal contours are unchanged. Persistent retrocardiac opacity and bilateral pleural effusions, not significantly changed from prior, however, do appear increasing since studies performed in [**2112-10-10**]. [**11-15**] - CXR post-trach: no pneumomediastinum or PTX. The lung volumes are somewhat improved though there is persistent obscuration of the hemidiaphragms consistent with effusion and atelectasis. [**11-15**] - CT abd w/ contrast: . Interval evolution of known pancreatitis, with hypo-enhancement in the region of the pancreatic head, and slight increase in parapancreatic fluid collections which have become more loculated in appearance, extending superior to the pancreas as well as inferior to the pancreas, and extending inferiorly along Gerota's fascia and the left paracolic gutter. 2. Biliary stent in place. 3. Interval slight decrease in parahepatic free fluid and increase in pelvic free fluid. 4. Interval increase in now small-to-moderate sized bilateral pleural effusions, with related compressive atelectasis in the visualized lung bases. [**11-18**] CXR: Since [**11-15**], left lower lobe consolidation with complete collapse and left pleural effusion increased. Right basilar opacity also increased. Mild volume overload is present. [**11-19**] CXR: Indwelling devices are unchanged in position. Improvement in recently described volume overload with minimal perihilar edema remaining. No substantial change in left retrocardiac opacity and adjacent moderate left pleural effusion, but right pleural effusion has decreased in size. [**11-20**] CXR: Interval increase in the left lower lobe atelectasis most likely completely atelectatic by now. Otherwise unchanged [**11-21**] Portable Abdomen: Dobhoff tube lies in the stomach. CBD plastic stent overlies right upper quadrant of the abdomen. There are no dilated loops of small or large bowel, without evidence of obstruction or ileus. There is no supine evidence of free intraperitoneal air or pneumatosis. ASSESSMENT AND PLAN: 67F gallstone pancreatitis s/p ERCP, sphincterotomy, stent, intubated for respiratory decompensation Brief Hospital Course: The patient is a 67 y.o. F with h/o gall stones, breast cancer s/p lumpectomy with radiation now on tamoxifen, who presents with presumable gallstone pancreatitis. ISSUES: 1) acute gallstone pancreatitis - Per micromedix: A retrospective cohort study of 703 postmenopausal women diagnosed with invasive breast cancer revealed adjuvant tamoxifen therapy is related to a risk in gallstone formation which is most evident after 3 years of treatment. Of the 703 patients, 457 received tamoxifen while 246 had not. After a mean follow-up of 4.6 years, the incidence of gallstone formation in tamoxifen-treated patients was 37% compared to 2% in patients not receiving tamoxifen (p less than 0.0001) (Akin et [**Doctor Last Name **], [**2107**]). 2) respiratory decompensation/failure s/p tracheostomy 3) presumed VAP 4) maculopapular abdominal rash - suspected drug rash, resolving 5) VRE UTI sensitive to zyvox . CHIEF COMPLAINT: gallstone pancreatitis . EVENTS: [**10-28**] Transferred from OSH for ERCP for presumed gallstone pancreatitis. ERCP performed. [**10-29**] increasing abdominal pain o/n, hypotension treated with multiple 1L boluses, KUB at 6am shows ?free air under diaphragm. To TICU, intubated NGT, PO/IV contrast AB CT, Right IJ triple lumen placed, [**10-31**] esophageal balloon placed - PEEP increased to 24, T=102.3 - sent Bld,Urine,Sputum Cx, changed abx to vanco/zosyn, on TPN, bladder pressure peaked at 28 [**11-1**] insulin drip started due to elevated BS [**11-2**] Lasix gtt began with slow success; rising white count [**11-3**] decreasing PEEP [**11-4**] CTA abdomen [**11-5**]: some meds changed to PO, increasing fever and wbcs, continuing to diurese. [**11-6**] TPN, albumin [**Hospital1 **] w/lasix gtt, PEEP at 8 [**11-7**] RIJ d/c'd left subclavian CVL placed, transfused 2 uPRBC [**11-9**] - tolerating CPAP well, daily SBTs, diuresed >3L, Hct holding after transfusion [**11-10**] - tolerating PS well, SBT @6am, diuresing 1-2L net, albumin added to hydration regimen, clonidine patch aadded to improve BP control; [**2112-11-11**]. Overnight spiked 102, pancx. [**11-11**] failed SBT in AM Pt with persistent rash in groin extending onto flank. [**11-12**] RSBI 44 but failed SBT again, continue weaning; Worsening lower abdominal maculopapular rash, with blistering over mons, and progression to back and bilateral flanks. Spiked T 102, recultured. [**11-13**]- Failed SBT again, attempted to continue wean; still persists on CPAP/PS 5+10, cultures pending, continued rash spread seems to be atopic in nature, RSBI+SBT in AM, treated with benadryl for continued rash [**11-14**]-failed SBT again today and was extubated transiently. As patient was agitated, she was given propofol for sedation. [**11-15**] - trach @ bedside today, then started weaning. Gen [**Doctor First Name **] ordered CT abd w/ contrast to eval for interval change. [**11-18**] - neuro status waxing and [**Doctor Last Name 688**], weaned off fent gtt, started on fent patch + oxycodone PO, slowly weaned off benzo (ativan 0.5mg q8hrs x 2 days, then q12hrs, then qdaily, then off). [**11-19**] - concern for increased secretions and clinical discomfort on ventilator [**Doctor Last Name **] concern for infectious process; CXR shows interval infiltrate from [**11-15**], pt started on Linezolid/Zosyn [**11-20**] - Had bronchoscopy. Had one episode of emesis: 15 cc's of yellowish emesis, nonbloody, nonbilious, following coughing episode. Given zofran. Further attempts to wean ativan and fentanyl and replace with propofol. [**11-21**] - BAL from [**11-20**] no growth. VRE UTI sensitive to zyvox. Foley changed. Low grade temps during the day. On TCM >12 hours until pt complains of fatigue, placed back on CPAP 5/5/35% @ MN for rest, plan for longer TCM [**11-22**]. Neuro status much improved, AAO x 3, answering questions appropriately. [**11-22**] - rehab screen to be pursued, Dobhoff placed, started on a clonidine patch for persistent hypertension, failed speech and swallow - to be re-evaluated over next two days; remained off ventilator all night [**11-23**]: NEUROLOGIC: Neuro checks Q: 4h Pain: oxycodone PO ATC, fent patch 25mcg/hr, IV dilaudid prn breakthrough Sedation/Benzo withdrawal tx: ativan and haldol prn, on SL zyprexa [**Hospital1 **], clonidine patch, pt much more alert. . CARDIOVASCULAR: HD stable. On lopressor 75mg tid PO. Still remains tachycardic with stable BP. PULMONARY: - s/p trach [**11-15**]. Initially tolerated TCM x 48 hours but subsequently needed vent support. Again on TCM trials. - continue nebs/Combivent treatment . GI / ABD: Abdomen exam improving TF started [**11-19**], at goal, TPN stopped. Monitor for residuals. . NUTRITION: On TF. . RENAL: Foley, follow UOP, to maintain euvolemia. . HEMATOLOGY: Hct stable. . ENDOCRINE: - Insulin SS for labile blood sugars secondary to pancreatic inflammation - Hypothyroid - TSH 3.0 on [**11-20**], maintain levoxyl 25mcg PO. ID: - VRE UTI - on zyvox for a 14 day course - BAL negative, zosyn d/c'ed after discussion with primary team. . LINES/TUBES/DRAINS: right radial aline inserted [**11-20**], LSC CVL triple lumen, PIV x 1, trach, Foley, Dobhoff Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - [**2-10**] Tablet(s) by mouth once a day LEVOTHYROXINE [LEVOXYL] - (Prescribed by Other Provider) - 50 mcg Tablet - 1 Tablet(s) by mouth once a day TAMOXIFEN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day TRIMETHOPRIM - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider; OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CALCIUM + VITAMIN D - (Prescribed by Other Provider; OTC) - 600 mg (1,500 mg)-200 unit Tablet - 2 Tablet(s) by mouth once a day GLUCOSAMINE-CHONDROITIN - (Prescribed by Other Provider; OTC) - Dosage uncertain MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 4. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4H:PRN 5. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 6. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q6H (every 6 hours) as needed. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal PRN (as needed) as needed for constipation. 8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 11. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for anxiety. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 13. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. 18. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 19. Insulin Regimen Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale: Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-50mg/dL 4 oz. Juice 51-150mg/dL 0 Units 151-200mg/dL 2 Units 201-250mg/dL 4 Units 251-300mg/dL 6 Units 301-350mg/dL 8 Units 351-400mg/dL 10 Units > 400mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] and [**Last Name (un) **] Discharge Diagnosis: Gallstone Pancreatitis, Acute Respiratory Failure & Ventilator Dependence Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications on discharge from rehab and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2113-8-9**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20428**], MD Phone:[**Telephone/Fax (1) 20429**] Date/Time:[**2113-8-9**] 10:30 Completed by:[**2112-11-23**]

[ "577.0", "E930.8", "V16.3", "V46.11", "599.0", "486", "244.9", "E879.8", "V09.0", "272.0", "511.9", "275.41", "275.3", "V15.3", "716.90", "V13.02", "518.0", "518.81", "574.20", "V10.3", "733.90", "365.9", "999.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "33.24", "51.85", "96.72", "96.04", "99.15", "99.04", "51.87", "42.92", "96.6", "43.11", "31.1", "93.90" ]

icd9pcs

[ [ [] ] ]

17515, 17585

9265, 10177

330, 428

17703, 17712

4178, 9242

19075, 19361

2828, 2890

15338, 17492

17606, 17682

14453, 15315

17736, 19052

3848, 4159

2905, 3752

10194, 14427

456, 2116

3767, 3831

2138, 2439

2455, 2812