ChanBeDu/relevant_section_length · Datasets at Hugging Face

49,496

112,342

36626

Discharge summary

report

Admission Date: [**2124-2-29**] Discharge Date: [**2124-3-29**] Date of Birth: [**2055-8-23**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 9598**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: s/p central line placement x 2 (HD catheter) History of Present Illness: Mr. [**Known lastname 2795**] is a 68 yo with met renal cell carc admitted on [**2124-2-29**] for week 2 of high dose IL-2 therapy. His last dose was complicated by shock requiring dopamine and brief atrial fibrillation, spontaneously reverting back when dopamine was changed to neo. His current course was given from [**2-29**] to [**3-4**] and has been complicated by nausea/vomiting, encephalopathy, diarrhea, rigors, and desquamation, but also by hypotension in the 70s systolic requiring neo for 90 min on [**3-2**] and restarted again on [**3-5**], ARF with decreasing UOP (355 total cc's on [**3-5**], none on [**3-4**], + ~ 14L LOC but without detailed recording of his UOP), and progressive metabolic acidosis despite bicarb infusion. Vancomycin was started empirically in the setting of severe dermatitis, and he has been on prophylactic cipro throughout his stay. His last dose 9am on [**3-4**]. His Cr has risen progressively from 1.9 on admission to 6.6 on the evening of transfer. Because of his progressive renal failure, dopamine was added to improve renal perfusion. He was also transiently in afib. His Tmax during his stay has been 99.5 on [**3-1**] with no other elevated temps, though he has been intermittently around 95F. . REVIEW OF SYSTEMS: (+)ve: as per HPI (-)ve: chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness Past Medical History: metastatic renal cell carcinoma, s/p nephrectomy. metastatic to lung, adrenal gland, brain. s/p cyberknife [**12-19**]. Bleeding ulcers HTN Hyperlipidemia GERD Diverticulosis Migraines Barrett's esophagus Anemia with folate deficiency Appendectomy in [**2076**] Hemorrhoidectomy [**2094**] Back surgery in [**2113**] Vasectomy Social History: He is a chief of police in [**Location (un) 82875**] Police. He is married and he is seen with his wife today. [**Name2 (NI) **] has two adult children. He does not smoke. He has about five to eight glasses of bourbon weekly. Family History: No history of any kidney cancer, but his mother had ovarian cancer, no obvious signs of Burkitt lymphoma, who is now healthy. Physical Exam: 97.8 119 105/44 16 100%2L . PHYSICAL EXAM GENERAL: dry and desquamated HEENT: Normocephalic, atraumatic. conjunctival erythema. No scleral icterus. PERRLA/EOMI but tracks slowly and incompletely. mucous membranes dry. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. 2/6 SEM in RUSB, rubs or [**Last Name (un) 549**]. JVP=flat LUNGS: CTAB, good air movement biaterally anteriorly. ABDOMEN: hypoABS. Soft, NT, ND. No HSM EXTREMITIES: diffuse [**3-15**]+edema, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: diffuse erythema and desquamation. skin breakdown on grown and buttocks. NEURO: A&Ox3 though with difficulty with word finding. Appropriate. CN 2-12 intact. Preserved sensation throughout. [**6-14**] strength throughout. Gait assessment deferred PSYCH: Listens and responds to questions appropriately . Pertinent Results: [**2124-2-29**] 09:49AM PT-13.9* PTT-21.6* INR(PT)-1.2* [**2124-2-29**] 09:49AM PLT COUNT-386# [**2124-2-29**] 09:49AM WBC-8.0 RBC-3.21* HGB-9.5* HCT-29.3* MCV-91 MCH-29.6 MCHC-32.4 RDW-13.9 [**2124-2-29**] 09:49AM ALBUMIN-3.4* CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-2.0 [**2124-2-29**] 09:49AM ALT(SGPT)-19 AST(SGOT)-21 LD(LDH)-169 CK(CPK)-55 TOT BILI-0.6 [**2124-2-29**] 09:49AM estGFR-Using this [**2124-2-29**] 09:49AM GLUCOSE-121* UREA N-17 CREAT-1.6*# SODIUM-144 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-25 ANION GAP-11 [**2124-3-24**] hand x-ray No previous images. The distal [**Hospital1 **] and adjacent soft tissues are essentially within normal limits on the images presented. No evidence of erosions or dystrophic calcification. [**2124-3-23**] CT abd/pelvis 1. Small bowel dilation without a clear transition point to suggest mechanical obstruction. A 7 cm segment of small bowel wall thickening may represent ischemia, infection, or inflammation. A repeated CT with i.v. contrast may help evaluate the transit of oral contrast as well as the mesenteric vasculature 2. Nasogastric tube just passed the gastroesophageal junction. Consider reposition of nasogastric tube in the body of the stomach. 3. Metastatic disease, incompletely evaluated on this non-contrast study. 4. Bibasilar consolidative opacity concerning for pneumonia 5. Florid colonic diverticulosis without evidence of diverticulitis. 6. Decrease in size of right adrenal nodule suggestive of response to therapy. 7. Extensive therosclerotis including coronary artery, abdominal aorta and mesenteric vessels. [**2124-3-23**] MRI head 1. Near-complete interval resolution of the enhancing lesion within the left anterior temporal lobe. Only minimal residual enhancement and FLAIR signal hyperintensity persist. No new enhancing lesions are identified. TTE [**2124-3-6**]: The left atrium is elongated. 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. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. TTE [**2124-3-8**]: IMPRESSION: small pericardial effusion located mostly posterior to the left ventricle. There is minimal fluid anterior to the right ventricle. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, which can be consistent with impaired ventricular filling but is more likely due to the irregularity of the heart rate. There is no frank tamponade seen. Normal biventricular function. No evidence of endocarditis although the valves are not well seen. Compared with the prior study (images reviewed) of [**2124-3-6**], this is a limited study. The valves are not well seen. The patient remains tachycardic but is now in atrial fibrillation. The size of the pericardial effusion is similar Renal Ultrasound [**2124-3-6**]: 1. No hydronephrosis of the right kidney. Left kidney is surgically absent. CXR [**2124-3-6**]: Lung volumes are lower, pulmonary vasculature more engorged, and distended mediastinal veins, unchanged, pointing toward volume overload or cardiac decompensation. A more focal opacity at the left lung base laterally would be better evaluated after hemodynamic status is optimized. It could be a small region of infection or infarction, pleural effusion, or transient atelectasis. Heart is top normal size, though increased since yesterday. Right subclavian line ends in the upper SVC. No pneumothorax. CT head/chest non-con [**2124-3-7**]: Slightly decreased vasogenic edema in region of known left temporal lobe metastasis. 1. Extensive new strikingly peripheral/subpleural ground-glass opacities with a slight upper lobe predominance is highly suggestive of drug-induced toxicity (likely IL-2 drug-induced eosinophilic lung disease). The more confluent lower lobe opacities are most suggestive of atelectasis, although infection cannot be excluded by imaging. 2. Persistent findings suggestive of vascular engorgement with mild interstitial edema and small bilateral pleural effusions. 3. No significant interval change to some of the previously noted metastatic lesions with many of the previously noted foci obscured by the new lung parenchymal opacities. Slight enlargement of prevascular lymph nodes can be seen in the setting of underlying pulmonary edema/elevated CVP. CXR [**2124-3-8**]: FINDINGS: As compared to the previous examination, a new central venous access line has been inserted over the left anterior jugular vein. The tip of the line projects over the upper SVC. There is no evidence of complication, notably no pneumothorax. The other monitoring and support devices are in unchanged position. Also unchanged is the size of the cardiac silhouette and the bilateral multifocal parenchymal opacities. The retrocardiac opacity could have minimally increased in the interval. Lower Extremity U/S: IMPRESSION: No evidence of DVT in either lower extremity. Left peroneal vein not well visualized. BAL: Bronchial lavage, right mid lobe: NEGATIVE FOR MALIGNANT CELLS. Bronchial epithelial cells, pulmonary macrophages, and neutrophils; no viral inclusions noted. CXR [**2124-3-11**]: Tip of the endotracheal tube is no less than 48 mm from the carina, standard placement for patient of this size. Diffuse infiltrative pulmonary abnormality, more pronounced in the perihilar right lung has progressed could by virtue of asymmetry be pneumonia rather than pulmonary edema, although pulmonary vascular congestion is present. The heart is moderately enlarged. Moderate right pleural effusion is stable. Right jugular line ends in the low SVC, left jugular line in the mid SVC, nasogastric tube passes below the diaphragm and out of view. Mediastinal widening in the right lower paratracheal station is due to a combination of adenopathy and venous engorgement. Portable Abdomen [**2124-3-10**]: FINDINGS: Supine AP abdomen radiograph demonstrates a nasogastric tube following a normal course and terminating in the distal stomach. There is no evidence of pneumoperitoneum. The bowel gas shadow appears unremarkable [**2124-3-6**] 7:08 am URINE Source: Catheter. **FINAL REPORT [**2124-3-8**]** URINE CULTURE (Final [**2124-3-8**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML [**2124-3-7**] 4:21 pm URINE Source: Catheter. **FINAL REPORT [**2124-3-8**]** URINE CULTURE (Final [**2124-3-8**]): NO GROWTH DIRECT INFLUENZA A ANTIGEN TEST (Final [**2124-3-7**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2124-3-7**]): Negative for Influenza B. [**2124-3-8**] 4:22 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2124-3-10**]** FECAL CULTURE (Final [**2124-3-9**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2124-3-10**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2124-3-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2124-3-9**] 10:09 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2124-3-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2124-3-11**]): ~1000/ML Commensal Respiratory Flora. POTASSIUM HYDROXIDE PREPARATION (Final [**2124-3-9**]): 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). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2124-3-9**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. [**2124-3-9**] 10:09 am Rapid Respiratory Viral Screen & Culture **FINAL REPORT [**2124-3-11**]** Respiratory Viral Culture (Final [**2124-3-11**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2124-3-9**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. [**2124-3-9**] 12:11 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2124-3-9**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2124-3-11**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2124-3-6**] 2:29 am BLOOD CULTURE Source: Line-R SCTL -> MSRA (+) [**2124-3-10**]: VRE blood culture from a-line [**2124-3-11**], [**2124-3-12**] blood cultures pending Brief Hospital Course: #. Shock: Felt initially most likely due to sepsis and he was covered broadly with antibiotics. Initially broadened antibiotics to vanc/levo/cefepime to cover above sources. Goal CVP was [**9-21**], MAP > 65. Initial central venous O2 saturation was 91%. Patient was transferred from floor to ICU on dopamine and neo; dopamine was converted to levophed. Pulsus was normal at 5. Echocardiogram as above, largely unremarkable. Hypotension persisted and was thought to be septic in etiology with IL-2 distributive physiology contributing. Shock was refractory to fluid boluses; received normal saline and water with bicarb given renal failure. Blood cultures eventually grew out MRSA, successive cultures negative until [**2124-3-10**], with [**2124-3-10**] culture growing vancomycin-resistant Enterococcus. During this time, patient was actually weaned off pressors. The right subclavian triple lumen was removed and a right internal jugular triple lumen was placed. Goals of care were discussed with family, who requested continued aggressive treatment. Linezolid replaced vancomycin for VRE bacteremia. The patient's pressures stabilized and pressors were discontinued. He did not have further hypotension after transfer to the oncology floor. # MRSA/VRE bacteremia: S/p line removals; Patient completed 15 day course of linezolid. Also added Meropenem on [**3-24**] given MS decline and asterixis. Antibiotics were d/c'd on [**3-25**] and patient has been stable, afebrile without leukocytosis since. Repeat blood and urine cultures have been negative. # partial/early SBO: On [**3-25**] patient developed worsening abdominal distention and confusion. This early SBO was likely due to narcotics though concerning that is ongoing and limiting nutrition. MRI head with improved findings. An NGT was placed for 24 hours and the patient's MS cleared as did his SBO. There was initially some concern for messenteric ischemia given guiaic positive stool, known necrotic fingers and subsequent CT abd findings, so GI and surgery were consulted. Patient however soon improved clinically so further work-up with colonoscopy was not done. He was able to tolerate a regular diet for 48H prior to discharge. A PICC had been placed for access and for ability to start TPN if needed, however TPN was never started. # Anemia: likely multifactorial due to poor nutrition, acute nutrition, and marrow suppression. Patient is also FOB+ s/p 2U PRBC since [**3-17**]. then another 1U [**3-24**]. He was continued on iron, folate and B12 on [**3-27**]. Mr. [**Known lastname 2795**] did have guiaic positive stools during admission which should be followed-up by gastroenterology as an outpatient. # gangrene: [**3-14**] pressors, shock as below. Patient was treated with wound care and transitioned to a fentanyl patch with breakthrough morphine for pain. # thrombocytopenia: Resolved. Likely due to myelosuppression. # coagulopathy: Patient was supplemented with vitamin K X3 days to decrease his INR. # Respiratory failure- Patient was intubated electively in setting of persistent hypervolemia and renal failure. Maintained on minimal ventilatory support during dialysis. Patient received antibiotic coverage for aspiration pneumonia. The patient was extubated on [**2124-3-15**] and continued to improve significantly. The patient was called out to the OMED floor team for further managment. #. ARF: IL-2 mediated ARF most likely, however prerenal or postrenal etiology also possible. K wnl, phos elevated though stable from last draw. Patient likely had IL-2 induced renal injury, with possible ischemic acute tubular necrosis. Despite aggressive fluids, renal function did not improve. Patient was showing signs of uremia and hypervolemia, and continuous [**Last Name (un) **]-venous hemodialysis was started following intubation and placement of HD line. On the last days of admission he did not require diuresis and continued to auto-diurese with a creatinine of 1.1-1.3. He was not continued on his anti-hypertensives as his SBPs were 130-140. Mr. [**Known lastname 2795**] should have his renal function checked as an outpatient in the next 1-2 weeks. If there are concerns with worsening kidney function as an oupatient, he should be followed by renal. # Atrial fibrillation with rapid ventricular response- Occurred on morning of [**2124-3-7**]. Became more hypotensive, received two attempts at DC cardioversion, transient sinus rhythm restored, then converted back into a. fib. Amiodarone load and drip was started. Converted to sinus rhythm day later, maintained on amio drip. Cardiac enzymes were flat, lower extremity ultrasound negative for DVT. Repeat TTE showed no right heart strain. The amiodarone drip was discontinued and the patient remained in normal sinus rhythm. #. HA/MS changes: Known metastatic disease to brain and IL-2 can cause swelling. He is AOx3, though slightly agitated. Clinical picture not c/w meningitis/encephalitis and most likely toxic-metabolic. CT head showed slight improvement in metastatic disease, less vasogenic edema. Lumbar puncture was deferred given intracranial mass. As patient stayed on the oncology floor his mental status gradually returned to [**Location 213**]. He can have a formal neurocognitive outpatient work-up if deemed necessary by his PCP. # skin/eye/mucous membrane breakdown: Patient developed significant skin breakdown, particularly on his fingertips likely due to pressors and IL-2. He was evaluated by plastic surgery and hand x-ray found no need for intervention. He was continued on: nystatin, miconazole, benadryl, sarna, Hydrocerin, HydrOXYzine, eye drops, Gelclair. #. RCC: finished week 2 of IL-2. Maintained contact with outpatient oncologist. CODE STATUS: Full (confirmed) Medications on Admission: MEDICATIONS upon transfer: Hydrocerin 1 Appl TP QID:PRN dry skin 50 mEq Sodium Bicarbonate/1000 ml D5 1/2 NS Continuous at 75 ml/hr HydrOXYzine 25-50 mg PO/NG Q6H:PRN pruritis Lorazepam 0.5-1 mg PO/IV Q4H:PRN Acetaminophen 975 mg PO Q6H prn Meperidine 25-50 mg IV Q2H:PRN Rigors Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN Morphine Sulfate 1-2 mg IV Q2H:PRN pain Ciprofloxacin HCl 250 mg PO/NG Q24H Pantoprazole 40 mg PO Q24H DOPamine 4 mcg/kg/min IV DRIP Phenylephrine 1 mcg/kg/min IV DRIP DiphenhydrAMINE 25-50 mg PO/IV Q6H:PRN pruritis Diphenoxylate-Atropine [**2-12**] TAB PO PRN after each loose stool Prochlorperazine 10 mg PO/IV Q6H:PRN nausea/vomiting Erythromycin *NF* 5 mg/g OU TID Sarna Lotion 1 Appl TP QID:PRN pruritus Gabapentin 100 mg PO/NG TID pruritus Gelclair 15 mL ORAL TID:PRN mucositis *Stopped* Aldesleukin 47.4 Million Units IV Q8H on Days 1, 2, 3, 4 and 5. . Home Medications: lipitor 20mg diltiazem 240mg [**Hospital1 **] folate 1mg qday protonix 40mg qday triamterene/hydrochlorothiazide 75/50mg qday valsartan 320mg qday vit C 1g qday citrucel 1g [**Hospital1 **] cyanocobalamin 1g sc monthly Discharge Medications: 1. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection once a month: next due [**4-24**]. 5. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 6. Diphenhydramine HCl 25 mg Capsule Sig: [**2-12**] Capsules PO Q6H (every 6 hours) as needed for pruritis. Disp:*60 Capsule(s)* Refills:*0* 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea/vomiting, insomnia or anxiety. Disp:*30 Tablet(s)* Refills:*0* 8. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for dry skin. Disp:*QS 1 month* Refills:*0* 9. Oral Wound Care Products Gel in Packet Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed for mucositis. Disp:*QS 1 month* Refills:*0* 10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pruritis. Disp:*60 Tablet(s)* Refills:*0* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. Disp:*QS 1 month* Refills:*2* 12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: do note take more than 4 grams per day. Disp:*120 Tablet(s)* Refills:*0* 13. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): remove previous patch before applying. Do not drive while using this. Disp:*20 Patch 72 hr(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) pkt PO DAILY (Daily) as needed for constipation. Disp:*60 pkt* Refills:*2* 19. 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:*2* 20. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital **] health care Discharge Diagnosis: Primary: Metastatic RCCA - s/p C1W2 HD IL-2 therapy Secondary: VRE/MRSA sepsis acute renal failure, resolved SBO, resolved peripheral necrosis of digits acute mental status changes, resolved Discharge Condition: Alert, oriented, ambulatory Discharge Instructions: You were admitted to [**Hospital1 69**] for IL-2 therapy for your Renal Cell Carcinoma. While you were here you had a very complicated hospital course. -You developed bacteria in your blood and you were treated with antibiotics for MRSA and VRE. You have finished your courses of antibiotics and your blood cultures have been normal. -You had a UTI with e-coli and you were treated with antibiotics. Your urine cultures have since been normal. -You needed dialysis. Your kidney function has since improved and your creatinine was 1.2 at discharge. This should be monitored closely and you should see a renal doctor if it worsens. -You were in the intensive care unit and you were intubated for confusion. This improved. You should ask Dr. [**Last Name (STitle) **] if neurocognitive evaluation is needed. -You had necrosis (damage) to your fingertips from some of the medications in the ICU. Plastic surgery saw you and your finger tips started to improve. -You also had skin damage to your sacrum (above your buttocks) from the IL-2. The VNA services should help you change these dressings. While you were here some of your medications were changed. You should CONTINUE taking: lipitor 20mg folate 1mg qday protonix 40mg qday vit C 1g qday cyanocobalamin 1g sc monthly (you received this on [**3-27**]) You should STOP taking: citrucel 1g [**Hospital1 **] diltiazem 240mg [**Hospital1 **] triamterene/hydrochlorothiazide 75/50mg qday valsartan 320mg qday You should START taking: Benadryl, hydroxyzine, camphor-methol, petrolatum-mineral oil as needed for itching Lorazepam as needed for nausea, vomiting or anxiety (do not drive or drink alcohol while taking this) oral care and wound care products tylenol as needed for pain ferrous gluconate twice a day fentanyl patch every 72 hours (do not drive or drink alcohol while taking this) morphine as needed for pain (do not drive or drink alcohol while taking this) You should take senna and colace every day to prevent constipation and take miralax and bisacodyl if you become constipated. Notify [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, at ([**Telephone/Fax (1) 82663**] for fever, chills, shortness of breath, or inability to take oral fluids Followup Instructions: You have the following appointment's with Dr. [**Last Name (STitle) 1729**], [**Telephone/Fax (1) 22**]. [**2124-4-25**] 02:00p XCT (TCC) [**Apartment Address(1) **]: Catscan appointment [**Hospital6 29**], [**Location (un) **] [**2124-5-2**] 02:30p [**Doctor Last Name **],TUESDAY BIOLOGICS SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Dr. [**Last Name (STitle) 82876**] [**Doctor First Name 82877**] PCP [**Telephone/Fax (1) 82878**] [**4-3**] at 2:15pm We will fax a copy of your discharge paperwork to Dr. [**Last Name (STitle) **]. Visiting Nursing: [**Telephone/Fax (1) 82879**] [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]

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icd9cm

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117,883

1828+1829

Discharge summary

report+report

Admission Date: [**2157-6-11**] Discharge Date: [**2157-6-18**] Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 783**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]F diastolic CHF (EF 55%), CAD, CRI, Afib who presented to ED in acute respiratory distress. Most recently hospitalized at [**Hospital1 2177**] for nausea/vomiting/dehydration, then received IVF putting patient into acute CHF, requiring intubation in [**Month (only) 547**] this year. <BR> Otherwise, USOH until this week, when she began to complain of some mild difficulty breathing. Was felt by her PCP to have COPD exacerbation and increased baseline prednisone dose of 5QOD to 30mg QD two days prior to admission. Seen by PCP at home who continued to feel this was "bronchitis" - unclear if [**Name (NI) **] prescribed at this point. Did well through evening prior to admission (apparently prepared a meal for 5 people), then at 1AM on day of admission, began to have acute shortness of breath. Was given nebs and supplemental O2 by home health aide. <BR> After 1.5 hours, did not improve, and was brought by ambulance to [**Hospital1 18**] ED, found to have systolic BP in 230s, low grade temp 100.2. Given Lasix, nitroglycerin, found to have ABG of 7.03/89/334 on BiPAP, and consequently was intubated (Etomidate/Rocuronium). Nitro was initially to 333mcg at 0430, then downtitrated as SBP came down to 122-> was found to be agitated while intubated and given Versed 2mg-> subequently SBP down to 40/palp. Started on Dopamine 20mcg/kg with improvement of BP to 97/44. Given total of 5 liter NS. and urine output 930cc over ED stay. Otherwise, given vanco/levo/flagyl, decadron 6. Past Medical History: -CHF- ECHO [**12-12**] EF 50-55% with mild MR [**First Name (Titles) **] [**Last Name (Titles) 10225**] -Coronary Artery Disease, LAD stent [**5-13**] -Paroxysmal Atrial Fibrillation -Asthma -s/p thyroid sx -Diverticulitis -Hypercholesterolemia -Right Hip Fracture -History of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears -Chronic Renal Insufficiency Social History: -Lives in apartment with 24 hour home care. Able to walk with walker at home, but uses wheelchair when leaving the house. Daughter is main caregiver in terms of administering medications. Ambulates with a walker. Smoked in her teens but none since. Rare EtOH use. Family History: Non-contributory Physical Exam: GENERAL: Intubated, but awake, NAD. HEENT: PERRL, EOMI, OMMM. NECK: JVP , Supple, no LAD. CARDIOVASCULAR: S1, S2, reg, LUNGS: Anterior exam- clear, but basilar rales. ABDOMEN: Active bowel sounds, Soft, NT, ND EXTREMITIES: Warm, no CCE. NEURO: Awake, and alert, able to mouth words in response to questions. Moving all four. Pertinent Results: [**2157-6-11**] 04:53AM LACTATE-3.0* [**2157-6-11**] 05:00AM PT-11.0 PTT-21.6* INR(PT)-0.9 [**2157-6-11**] 05:00AM WBC-26.3*# RBC-4.52# HGB-13.6# HCT-41.3# MCV-91 MCH-30.0 MCHC-32.9 RDW-14.3 [**2157-6-11**] 05:00AM NEUTS-72* BANDS-18* LYMPHS-6* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 [**2157-6-11**] 05:00AM cTropnT-<0.01 [**2157-6-11**] 05:00AM CK(CPK)-77 [**2157-6-12**] 04:09AM BLOOD WBC-11.8* RBC-4.09* Hgb-12.2 Hct-38.0 MCV-93 MCH-29.7 MCHC-32.0 RDW-14.9 Plt Ct-315 [**2157-6-18**] 06:00AM BLOOD WBC-10.1 RBC-4.31 Hgb-12.6 Hct-38.2 MCV-89 MCH-29.2 MCHC-32.9 RDW-15.2 Plt Ct-318 [**2157-6-18**] 06:00AM BLOOD Glucose-98 UreaN-53* Creat-1.8* Na-143 K-3.9 Cl-104 HCO3-28 AnGap-15 [**2157-6-14**] 04:11AM BLOOD Glucose-156* UreaN-59* Creat-2.1* Na-142 K-3.6 Cl-110* HCO3-22 AnGap-14 [**2157-6-12**] 04:09AM BLOOD Glucose-103 UreaN-47* Creat-2.2* Na-141 K-4.4 Cl-106 HCO3-22 AnGap-17 [**2157-6-11**] 02:44PM BLOOD Cortsol-22.4* [**2157-6-17**] 04:30AM BLOOD Vanco-14.9* Brief Hospital Course: [**Age over 90 **]F diastolic dysfunction, CRI, COPD/Asthma, here w/ respiratory failure and hypotension. * HYPERCARBIC RESP FAILURE: Multifactorial, due to MRSA pneumonia and COPD flare, with likely CHF due to flash pulmonary edema due to hypertensive urgency and large volume resuscitation in the ED given sepsis protocol. Pt was intubated in the ED given her hypercarbia with a pCO2 of 89 on admission. Pt improved her ventilation and oxygenation while intubated after treatment with IV Vanco, steroids and azithromycin. Pt was extubated on HD#3 and did well post-extubation. Her steroids were tapered to fairly quick PO prednisone taper given the findings of her cosyntropin test which showed a brisk adrenal response. Her nebulizer treatments were continued as needed and steroid was tapered off. Pt was discharged to finish 14d-course vancomycin for MRSA pneumonia. However, by a mistake, a VNA arrangement was not confirmed at her time of discharge on [**6-18**]. Pt was discharged without a VNA arrangement for vanc administration/PICC care and did not receive a dose of vancomycin prior to discharge. The pt returned to the hospital the next day for vancomycin. Vancomycin 1g was given on [**6-19**] and was discharged home again after receiving vancomycin. . * Hypotension/hypertension: Pt intially hypertensive in the ED to 230s, and was aggressively treated with NTG gtt, and became hypotensive in the ED and with suspected infectious etiology, was placed on sepsis protocol, and had a CVL placed in the ED and received large volume resuscitation. Likely represented aspect of hypovolemia along with element of sepsis along with aggressive iatrogenesis with her IV NTG gtt(her MVo2 remained >70% and cardiogenic shock was thought unlikely). Pt was placed on levophed in the ED to help maintain her MAP >65, which was weaned after HD#2 as her BPs allowed. She became hypertensive after her sepsis had corrected and her antihypertensive regimen was reinitiated with metoprolol 75mg TID, hydralazine and imdur. However, given she only had mild MR, no systolic dysfunction on [**Month/Year (2) **], and inconvenient hydralazine dose frequency, hydralazine and imdur were discontinued. . * CRI: At her baseline with good UOP. . #. CAD: s/p stenting in [**2153**]. Continued asa, lipitor, BB. . #. h/o PAF: Continued BB, not coumadin candidate given h/o falls and diverticular bleeds. . # Hypothyroidism: Continued synthroid 88mc qday. * FEN: NPO while intubated. After extubation, started diet as tolerated to cardiac diet. . * ACCESS: RIJ placed in ED - no checklist. Was removed and L subclavian was placed in the ICU. This was removed once her inital sepsis resolved. . * Prophylaxis: SQH, PPI, bowel regimen. Because pt gets constipated easily, pt wanted mag citrate rx at the time of 2nd discharge. . * CODE: Full . * Comm: Daughter [**First Name4 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 10235**] H, [**Telephone/Fax (1) 10236**] C Medications on Admission: Protonix 40 Synthroid 88 Senna Metoprolol 50 TID Albuterol SLNTG 0.3 Lactulose Dulcolax Aspirin EC 325 Nystatin Advair Colchicine 0.6 QOD Prednisone 5 QOD Aranesp 40 Iron 325 Lipitor 20 Colace Lasix 80 QD MVI Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. Disp:*qs for 1month * Refills:*0* 11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other day. 12. Ferrous Sulfate 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. Disp:*qs 7 days* Refills:*0* 16. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. PICC care PICC care per CCS protocol 18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day) as needed for joint pain. 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:*qs 2 weeks* Refills:*0* 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. Disp:*qs 2 weeks* Refills:*0* 21. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*2* 22. Aranesp 40 mcg/0.4 mL Syringe Sig: One (1) syringe Injection every other week. 23. Senna 187 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnoses: Congestive heart failure exacerbation Pneumonia Chronic obstructive pulmonary disease exacerbation Secondary diagnoses: Coronary artery disease Chronic renal insufficiency Discharge Condition: Stable Discharge Instructions: Return to emergency department or call your primary care physician if you develop fevers, chills, worsening cough, chest pain, shortness of breath, or any other worrisome symptoms. Take medications as instructed and Dr. [**Last Name (STitle) 10237**] will come see you at home. Followup Instructions: Dr. [**Last Name (STitle) **] will come to your house and see you next week. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Admission Date: [**2157-6-19**] Discharge Date: [**2157-6-19**] Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 783**] Chief Complaint: see d/c summary on [**2157-6-18**] Major Surgical or Invasive Procedure: None Brief Hospital Course: See discharge summery on [**2157-6-18**] for details. Because pt did not have VNA arranged for vancomycin injection at home, pt came and received vancomycin 1g and was discharged with proper VNA arrangement. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Pneumonia Discharge Condition: Stable Discharge Instructions: Return to emergency department or call your primary care physician if you develop fevers, chills, worsening cough, chest pain, shortness of breath, or any other worrisome symptoms. Take medications as instructed and Dr. [**Last Name (STitle) **] will come see you at home. Followup Instructions: Dr. [**Last Name (STitle) **] will come to your house and see you next week. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "428.30", "458.29", "518.81", "482.41", "276.0", "427.31", "428.0", "272.4", "403.91", "V45.82", "274.9", "491.21", "V09.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "00.17", "38.91", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

10826, 10878

10594, 10803

10564, 10571

10932, 10941

2903, 3897

11263, 11473

2524, 2542

7159, 9405

10899, 10911

6926, 7136

10965, 11240

2557, 2884

9645, 9699

10490, 10526

309, 1823

1845, 2225

2241, 2508

23,829

151,928

4849

Discharge summary

report

Admission Date: [**2174-12-22**] Discharge Date: [**2174-12-29**] Date of Birth: [**2105-3-31**] Sex: F Service: MEDICINE Allergies: Reglan / Bee Sting Kit Attending:[**First Name3 (LF) 4219**] Chief Complaint: presented to hospital for c/o BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 69 y/o female with ESRD last dialysis [**12-21**], HTN, GERD, DM type II who presents with BRBPR initially 2 months ago that she thought was vaginal bleeding but was told by OB/gyn that she was having rectal bleeding. Patient BRBPR resolved and she was scheduled for c-scope after the holidays until day of admission when she had and another large bowel movement of BRBPR. When patient arrived in the ED she had another BM with BRBPR. Patient denies pain, never had colonoscopy before. Patient was then admitted to MICU where she was observed o/n, was noted to be hemodynamically stable and did not require any blood transfusions. MICU course c/b altered mental status which was thought to be due to fatigue. Mentation cleared shortly and no further workup was done. She had HD prior to transfer to [**Hospital Ward Name 12837**]. Upon arrival patient had 2 episodes of hematochezia (200cc, 100cc), patient denied having any pain. Hematochezia was maroon colored and had clots. No formed stool. Past Medical History: ESRD on HD MWF Anemia on epo w/ HD DMII HTN GERD Depression Hypothyroidism PVD s/p metatarsal amputation RLE [**12-25**] s/p Right TMA debridmant [**7-28**] Rt. AKA Social History: prior to stay at rehabiltiation center since rt. bka, patient lived with husband former [**Name2 (NI) 1818**], denies ETOH or drug use Family History: non-contributory Physical Exam: On admission to MICU PE: T 97.3 HR 61 BP 176/53 RR 16 O2Sat 100 % RA Gen: NAD Heent: PERRL, EOMI, sclera anicteric, MMM, OP clear Lungs: + bibasilar crackles Cardiac: [**Name2 (NI) 8450**] S1/S2 no murmurs Abdomen: soft, NTND NABS Ext: R AKA; trace edema on LLE; L femoral cortis Neuro: AAOx3 On admission to floor: Vitals: T: 97.5, BP: 122/49, HR: 66, R: 18, Sats 94% on 2 L NC GEN: NAD, pleasant female. HEENT: NC/AT, EOMI, PERRL, MMM, o/p clear, Neck: Right EJ iv CV: [**Name2 (NI) 8450**], no m/r/g, normal s1/s2. Chest: right chest HD catheter: c/d/i. PULM: crackles at bases b/l, o/w no rhonchi or wheezes. ABD: round, obese, NABS, soft, NT/ND. Rectal: no visible external hemorrhoids, maroon colored stool oozing out of rectum. Ext: right AKA, left: DP/PT 1+, trace edema in leg. Left hallux with gauze and mild erythema. No femoral cordis. Neuro: AxOx3. CN II-XII grossly intact. moves all extremities. Pertinent Results: [**2174-12-22**] 09:00AM BLOOD WBC-6.7 RBC-3.08* Hgb-10.6* Hct-34.5* MCV-112*# MCH-34.4* MCHC-30.7* RDW-19.6* Plt Ct-206 [**2174-12-23**] 04:02AM BLOOD WBC-5.8 RBC-2.89* Hgb-10.1* Hct-32.7* MCV-113* MCH-34.9* MCHC-30.8* RDW-20.9* Plt Ct-138* [**2174-12-23**] 04:06PM BLOOD WBC-5.9 RBC-2.98* Hgb-10.3* Hct-33.8* MCV-113* MCH-34.5* MCHC-30.4* RDW-20.9* Plt Ct-199 [**2174-12-24**] 02:11AM BLOOD WBC-6.8 RBC-2.64* Hgb-9.3* Hct-29.0* MCV-110* MCH-35.1* MCHC-31.9 RDW-19.8* Plt Ct-189 [**2174-12-28**] 07:55AM BLOOD WBC-5.6 RBC-2.72* Hgb-9.3* Hct-30.5* MCV-112* MCH-34.3* MCHC-30.7* RDW-19.4* Plt Ct-225 [**2174-12-22**] 09:00AM BLOOD PT-14.2* PTT-30.2 INR(PT)-1.4 [**2174-12-22**] 09:00AM BLOOD Plt Ct-206 [**2174-12-28**] 07:55AM BLOOD PT-13.8* PTT-30.6 INR(PT)-1.3 [**2174-12-28**] 07:55AM BLOOD Plt Ct-225 [**2174-12-22**] 09:00AM BLOOD Glucose-54* UreaN-42* Creat-6.8*# Na-141 K-5.0 Cl-97 HCO3-29 AnGap-20 [**2174-12-23**] 04:02AM BLOOD Glucose-57* UreaN-42* Creat-6.8* Na-143 K-4.5 Cl-101 HCO3-29 AnGap-18 [**2174-12-24**] 10:05AM BLOOD Glucose-63* UreaN-27* Creat-6.1* Na-141 K-4.4 Cl-99 HCO3-27 AnGap-19 [**2174-12-24**] 02:27PM BLOOD Glucose-65* UreaN-29* Creat-6.5* Na-141 K-4.9 Cl-101 HCO3-29 AnGap-16 [**2174-12-26**] 06:35AM BLOOD Glucose-66* UreaN-52* Creat-8.9*# Na-138 K-6.1* Cl-96 HCO3-27 AnGap-21* [**2174-12-27**] 06:25PM BLOOD Glucose-70 UreaN-33* Creat-6.9*# Na-140 K-5.4* Cl-100 HCO3-26 AnGap-19 [**2174-12-28**] 07:55AM BLOOD Glucose-83 UreaN-39* Creat-8.2*# Na-140 K-5.7* Cl-100 HCO3-25 AnGap-21* [**2174-12-23**] 04:02AM BLOOD Calcium-8.9 Phos-6.0* Mg-2.0 [**2174-12-24**] 10:05AM BLOOD Calcium-8.8 Phos-5.1* Mg-1.6 [**2174-12-24**] 02:27PM BLOOD Calcium-9.1 Phos-4.9* Mg-1.7 [**2174-12-28**] 07:55AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0 [**2174-12-23**] 04:02AM BLOOD VitB12-1385* Folate-GREATER TH [**2174-12-23**] 04:02AM BLOOD TSH-2.5 Bleeding Scan - Postive findings of bleeding within the right upper quadrant, most likely within the duodenum. Brief Hospital Course: The patient is a 69 yo F with DM2, ESRD on HD, HTN, Hypothyrodism and neuropathy who presents with intermittent hematochezia for 2 days. 1. Hematochezia - The patient was admitted with GI bleeding which was thought likely a diverticular bleed given current clinical scenario, though AMV, internal hemorrhoids or right sided colonic bleed could also be considered. Given the patients persistent bleed GI was consulted who recommended a tagged RBC scan to help determine bleeding site. The scan showed bleeding within the right upper quadrant, most likely within the duodenum. The patient received 1 unit PRBC. An upper endoscopy was performed and only showed mild ulcer unlikely responsible for bleeding, thus they proceded with a colonoscopy. A colonoscopy revealed diverticulosis of the colon, blood in the colon, and a polyp on the ileo-cecal valve. They felt the bleed was likely diverticular in nature. They did not biopsy the polyp given the patients recent bleed. She was scheduled for a repeat colnoscopy in 6 months. The patient bleed stopped and her hct stabalized. Physical therapy worked with the patient and cleared her for discharge home. 2. ESRD - The patient was continued on MWF dilaysis. 3. Hypertension - The patient was admitted on metoprolol 75 [**Hospital1 **]. Because of her renal disease, she was started on losartan 50QD and her betablocker dose was decreased to 25mg [**Hospital1 **]. They can both be titrated up by her PCP. Medications on Admission: 1. Gabapentin 200 mg PO BID 2. Senna 3. Quetiapine Fumarate 12.5 mg PO BID 4. Bisacodyl 5. Epoetin Alfa 20,000 unit [**Unit Number **]. Paroxetine HCl 20 mg PO DAILY 7. Lansoprazole 30 mg Delayed Release PO DAILY 8. Levothyroxine Sodium 125 mcg PO DAILY 9. Folic Acid 1 mg PO DAILY 10. Amiodarone HCl 200 mg DAILY 11. Atorvastatin Calcium 20 mg PO daily 12. Docusate Sodium 13. Aspirin 81 mg Tablet 14. B Complex-Vitamin C-Folic Acid 1 mg daily 15. Metoprolol Tartrate 75 mg PO BID 16. Acetaminophen 325 mg prn 17. Calcium Acetate 667 mg Tablet PO TID W/MEALS 18. Ascorbic Acid 500 mg PO DAILY 19. Psyllium 1.7 g Wafer PO DAILY 20. Hydrocodone-Acetaminophen 5-500 mg PO Q6H prn 21. Insulin NPH 50units am and 12U pm Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): take dose after dialysis. 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for constipation. 14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. Psyllium 1.7 g Wafer Sig: One (1) PO once a day. 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 18. Losartan 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Lower GI Bleed Discharge Condition: Stable, hct stable at 30. Vital signs stable. Dilaysis done on day of discharge. Discharge Instructions: --Please return to the ER immediately if any more GI bleeding. --Please take all medications as prescribed. You will need to have a repeat colonoscopy in 6 months because they were unable to remove a polyp because of the blood in your colon. I have scheduled you for an appointment in [**Month (only) 205**]. The nurse will call you with instructions a week prior to the appointment. --Please resume you MWF outpatient dialysis as you were prior to admission. --Now that you are eating please resume your home insulin regimen. -- We decreased the dose of your metoprolol and added a new drug (losartan) to control your BP. Please take the new doses and medications. All other medications should stay the same. Followup Instructions: ** We have scheduled you for a repeat colonoscopy for [**2175-7-4**]. Because of your medical issues, we would like to admit you to the hospital for admission inorder to prep you for the study. You will be admitted to the hospital on [**2175-7-3**]. Someone from the hospital will contact prior to that date. Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2175-7-4**] 10:00 Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 2986**] Date/Time:[**2175-7-4**] 10:00 **Please make an appointment with your Primary Care doctor (Dr. [**Last Name (STitle) 18998**] [**Telephone/Fax (1) 20264**]) in the next 1-2 weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

[ "250.00", "440.20", "285.29", "530.81", "311", "403.91", "244.9", "455.0", "531.40", "211.1", "285.1", "585.6", "562.12", "211.3", "355.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

8371, 8430

4680, 6147

321, 335

8489, 8574

2687, 4657

9337, 10138

1721, 1739

6915, 8348

8451, 8468

6173, 6892

8598, 9314

1754, 2668

246, 283

363, 1363

1385, 1552

1568, 1705

14,903

167,666

26533

Discharge summary

report

Admission Date: [**2194-12-1**] Discharge Date: [**2194-12-16**] Date of Birth: [**2121-6-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Linezolid Attending:[**First Name3 (LF) 2159**] Chief Complaint: N/V, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Pt. is a 73 y/o female with a hx of PVD s/p endarterectomy and bypass c/b recurrent R [**First Name3 (LF) 18371**] infections who presents with N/V x 1 week. History of wound infection dates back to early [**9-27**]. At that time treated with Vanco and Zosyn (~ 2 weeks) with Pseudomonas cultured from the wound. Admitted to [**Hospital1 18**] on [**9-28**] with recurrent infection, wound grew MRSA. On [**9-29**] started Vanc, Gent, Flagyl. On [**10-2**] underwent R fem-DP bypass. Discharged to rehab on [**10-8**] on Vanco only. Readmitted [**10-10**] for recurrent infection- underwent debridement and d'ced on Vanco and Zosyn. Readmitted on [**10-24**] with recurrent wound infection. Wound cultre grew only pan-sensitive Kelbsiella and Enterobacter. Initial antibiotics were Levo, Vanco, and Zosyn. Wound debrided [**10-25**], [**10-30**], [**11-3**]. MR [**First Name (Titles) **] [**Last Name (Titles) 18371**] showed 30 cm fluid collection, no evidence of osteomyelitis. Pt was d'ced on [**11-6**] on Levaquin and Linezolid. . Pt. reports that for ~1 week she has been having N/V/odynophagia. Unable to tolerate POs. Tolerating some liquids. Lso having watery diarrhea x 3 days, no abd pain. R leg pain much improved. . On admission pt. found to be anemic and hypoglycemic. She was transfused 3 U PRBCs, and hematology, endocrinology, and ID were consulted. Past Medical History: RA on prednisone since [**7-28**] HTN GERD Osteoporosis Anemia of Chronic disease h/o ATN SFA-DP bypass ([**10-27**]) R saphenous vein to CFA angioplasty R femoral endarterectomy R arm prosthesis Social History: 165 pack years, quit 15 years ago, living at home with VNA, no EtOH, no illicits Family History: Esophageal [**Name (NI) **] sister Physical Exam: T 98.4 HR 54 BP 135/27 RR 16 alert and oriented x 3, NAD tachycardic, no murmers CTA, distant breath sounds abd soft, NT, slightly distended R groin C/d/i, vac in place R LE warm, DP biphasic, PT biphasic, ulcer is clear, no drainage LLE DP palpable UE: petechiae Pertinent Results: Admission Labs: [**2194-12-1**] 03:40PM RET AUT-0.2* [**2194-12-1**] 03:40PM D-DIMER-805* [**2194-12-1**] 03:40PM PT-12.6 PTT-21.7* INR(PT)-1.1 [**2194-12-1**] 03:40PM PLT SMR-VERY LOW PLT COUNT-65*# [**2194-12-1**] 03:40PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2194-12-1**] 03:40PM NEUTS-44* BANDS-26* LYMPHS-22 MONOS-5 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2194-12-1**] 03:40PM WBC-5.0# RBC-2.42*# HGB-6.9*# HCT-20.1*# MCV-83# MCH-28.7 MCHC-34.6 RDW-13.7 [**2194-12-1**] 03:40PM HAPTOGLOB-217* [**2194-12-1**] 03:40PM ALBUMIN-3.5 URIC ACID-10.3* [**2194-12-1**] 03:40PM CK-MB-NotDone cTropnT-0.12* CK(CPK)-20* [**2194-12-1**] 03:40PM LIPASE-17 [**2194-12-1**] 03:40PM ALT(SGPT)-7 AST(SGOT)-7 LD(LDH)-145 ALK PHOS-60 AMYLASE-41 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [**2194-12-1**] 03:40PM GLUCOSE-179* UREA N-24* CREAT-1.2* SODIUM-139 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-16* ANION GAP-21* [**2194-12-1**] 03:47PM GLUCOSE-187* K+-3.4* [**2194-12-1**] 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2194-12-1**] 07:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2194-12-1**] 11:50PM FIBRINOGE-173 [**2194-12-1**] 11:50PM PT-12.7 PTT-22.2 INR(PT)-1.1 [**2194-12-1**] 11:50PM WBC-3.8* RBC-3.50*# HGB-10.1*# HCT-27.9*# MCV-80* MCH-28.8 MCHC-36.2* RDW-16.2* PLT COUNT-42* [**2194-12-1**] 11:50PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-1.4* [**2194-12-1**] 11:50PM CK-MB-NotDone cTropnT-0.16* CK(CPK)-32 . Admission XR Abd: No evidence of free air or obstruction . Admission CXR: The heart size is normal. The mediastinal and hilar contours are normal. The lungs are clear, without vascular congestion or consolidation. No pleural effusion or pneumothorax. Right humerus prosthesis is unchanged in appearance. The right PICC line has been removed in the interim. The bones are demineralized. . CT Head: 1) No evidence of acute intracranial hemorrhage. 2) Mild ventriculomegaly, of unclear clinical significance. 3) Chronic small vessel ischemic changes without CT evidence to suggest acute major vascular territorial infarction . TTE The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Resting regional wall motion abnormalities include inferior and inferolateral akinesis with mildly aneurysmal basal segments. Overall left ventricular systolic function is mildly impaired. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . MR [**Year/Month/Day **]: Direct comparison with prior examination dated [**2194-10-29**]. As before, there is a narrow, lobulated and contiguous fluid collection which tracks along the lateral aspect of the sartorius muscle, from the level of the mid iliac bone to the distal femoral diaphysis, covering approximately 30 cm craniocaudad dimension. The fluid collection is somewhat decreased in the transverse and AP dimension since the prior examination. The fluid tracking along the medial aspect of the right sartorius muscle has decreased in amount and distribution, yet remains present more distally. The more proximal aspect of the fluid collection extends to the level of the wound within the anteromedial aspect of the right [**Year (4 digits) 18371**]. As contrast was not administered, surrounding enhancement cannot be assessed. No new discrete fluid collection is seen. There remains diffuse subcutaneous edema along bilateral flanks, adjacent to the gluteal muscles. Soft tissue edema is seen along the medial aspect of the groin bilaterally, within subcutaneous soft tissues, as well as adjacent to the adductor muscles and gracilis muscles bilaterally. . There is no marrow edema, or hip joint effusion. No fluid collection is seen within the left [**Year (4 digits) 18371**]. . There is a 13-mm hyperintense focus on STIR images seen within the right adnexum, which could represent a small ovarian cyst. Moderate amount of urine is seen within the bladder. . IMPRESSION: Persistent yet decreased fluid collection tracking along the right sartorius muscle extending over a 30-cm segment craniocaudad dimension. Study is limited due to the lack of intravenous gadolinium . Brief Hospital Course: Pancytopenia: Heme/Onc consulted. Felt that pancytopenia was [**12-25**] Linezolid, which was d/ced on admission. HIT Ab was negative. Received 2 further U PRBCs for hct < 27 (slowly drifted down, likely [**12-25**] slow BM recovery and frequent phlebotomuy). Noted to be B12 deficient, received IM B12 in house. Counts slowly improved and were stable for several days prior to discharge. . Hypoglycemia: Endocrine consulted. Initial ddx included insulinoma, anti-insulin abs, adrenal insufficiency given chronic steroid use for RA, sepsis, or Levofloxacin effect. Infectious work-up was negative (multiple blood and urine cx negative, no PNA on CXR). [**Last Name (un) **] stim test was performed and was WNL. Levofloxacin was held. Endocrine team recommended a monitored fast, and checking glucose, insulin, cpeptide, and pro-insulin when FS documented below 70 to r/o insulinoma. When FS dropped below 70 this was attempted, howeer phlebotomy was not able to draw blood and pt. refused further attempts. FS improved with holding Levofloxacin, and a presumptive diagnosis of hypoglycemia [**12-25**] med effect from levofloxacin was made. . HTN: Continued Diltiazem, and Lasix at home doses, + Metoprolol in house as BP elevated . RA: Continued Prednisone at home doses . PVD/Wound infection: followed by Vascular service throughout hospitalization. MRI [**Month/Day (2) 18371**] was performed (see results above) and showed a decrease in sixe of the fluid collection. Abx were held throughout hospitalization with no clinical change in leg wound, no erythema or drainage. Vascular felt that the fluid collection was more c/w post-op change than with infection, and recommended f/u in 2 weeks for further skin grafting. . AMS: had some episodes in confusion in the hospital, which were thought to be toxic-metabolic encephalopathy for C diff infection (see below). Improved with treatment of infection. There was a question of underlying dementia, as pt. seemed to have problems with short term memory, and this should be further worked up on an outpatient basis. . C diff: Pt. developed diarrhea and leukocytosis in house, and stool was + for C diff. Started ub PO Flagyl with improvement in symptoms and leukocytosis. Medications on Admission: Levaquin 500 mg QD Diovan 160 daily Cardizem 240 daily Prednisone 7.5 QAM, 2.5 QPM Neurontin 300 mg [**Hospital1 **] Aspirin 325 daily Protonix 40 mg daily Tums Lasix 20 mg daily Linezolid 600 mg [**Hospital1 **] Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Disp:*25 Tablet(s)* Refills:*0* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Cardizem LA 240 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Cyanocobalamin 2,000 mcg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 11. Prednisone 2.5 mg Sig: one tab QAM, 3 tabs QPM Dispense: 120 (one-[**Age over 90 1375**]y) Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: C Diff Colitis Pancytopenia secondary to Linezolid, resolved Hypoglycemia secondary to Levaquin, resolved Peripheral Vascular Disease Hypertension Discharge Condition: Improved- without fever for several days Discharge Instructions: Please call your doctor or go to the ER if you have any further fevers, chills, diarrhea, abdominal pain, redness or pus around the wound in your right [**Name (NI) 18371**] or right foot, or any other symptoms that concern you. Please call Dr. [**Last Name (STitle) **] or go to the ER if your diarrhea comes back once you finish your antibiotic (Flagyl). Followup Instructions: Vascular Surgery: Dr. [**Last Name (STitle) 1391**], Wednesday, [**12-31**] at 11:00 office # [**Telephone/Fax (1) 1393**] Primary Care: You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**Last Name (LF) 2974**], [**12-19**] at 1:30. Please call [**Telephone/Fax (1) 250**] if you have any questions or need to reschedule. His office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] Center, on [**Initials (NamePattern4) 1388**] [**Last Name (NamePattern4) 5074**]. Dr. [**Last Name (STitle) **] should check a stool sample for C diff and check a CBC at that visit. Completed by:[**2195-4-27**]

[ "530.81", "714.0", "998.51", "584.9", "285.9", "284.8", "287.5", "008.45", "251.1", "401.9", "E930.8", "440.20", "276.50" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10728, 10799

7032, 9273

298, 305

10990, 11033

2385, 2385

11439, 12129

2050, 2086

9537, 10705

10820, 10969

9299, 9514

11057, 11416

2101, 2366

245, 260

333, 1717

4428, 7009

2402, 4419

1739, 1936

1952, 2034

55,337

110,520

37830

Discharge summary

report

Admission Date: [**2171-12-18**] Discharge Date: [**2172-1-26**] Date of Birth: [**2118-7-8**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2763**] Chief Complaint: SBP Major Surgical or Invasive Procedure: Paracentesis x 2, left IJ, right temp HD line, A-line x 3, Left PICC History of Present Illness: 53-year-old female with a history of alcohol abuse and cirrhosis status post liver and kidney transplant in [**11/2169**] who presented to [**Location (un) 12017**] with abdominal pain, vomiting and diarrhea, found to have SBP, and transferred to [**Hospital1 18**] for further management. She states the non-bloody/non-billous vomiting started Monday evening as well as the diarrhea. She states she drank a boost that exacerbated this. No fevers. She continued to have this intermittently overnight and awoke Tuesday morning with severe lower and left sided abdominal pain, 15/10, and constant and releived with dilaudid. In the OSH, her blood pressures were noted to be in the 80s with a lactate of 2.4. She was started on ceftriaxone and given 1.5 grams/kg of albumin. On day of transfer, other notable lab findings include a wbc of 19,900, INR: 1.7, and Cr of 2.0 (baseline around 1.5). . Of note, the patient was recently admitted to [**Hospital1 18**] on [**2172-11-16**] for acute renal failure due to volume overload, as well as an E. Coli UTI. Her Cr prior to d/c was 1.4. With the question of outflow obstruction vs. rejection in the outpatient a transjugular liver biopsy [**12-12**] was attempted, but failed due to diminutive right hepatic vein. There is also speculation from her Hepatologist that her worsening liver failure is due to recurrent EtOH use, and she admits to resuming EtOH use in the fall. . On arrival to the MICU, the patient is complaining of abdominal pain that has somewhat improved from initial presentation. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes Past Medical History: - Alcoholic cirrhosis c/b HRS. Dialysis dependent prior to transplant. - Status post orthotopic deceased liver-kidney transplant and splenectomy on [**2169-11-28**], c/b jejunostomy leak requiring exploratory laparotomy and small bowel resection. - [**2169-12-25**] right hepatic artery stent placement on asa/plavix - Hypothyroidism - Dyslipidemia - History of two enteroenterostomies and a small bowel obstruction s/p exploratory laparotomy with lysis of adhesions in 03/[**2169**]. - Osteoporosis LIVER HISTORY: - previously been on azathioprine, prednisone, and tacrolimus immunosuppresion. Azathioprine, previously DC'd due to hair loss in early [**2169**] and patient was, maintained on prednisone and tacrolimus, before switching to, tacro sole therapy. Patient recently restarted on azathioprine again in [**2171-8-24**]. Azathioprine dose decreased in mid [**Month (only) 1096**] for apparent concern of peripheral edema. Given concern of diarrhea, azathioprine was discontinued, and patient was maintained on tacrolimus sole therapy. Due to sole therapy, would target slightly higher goal of [**5-2**]. Continued atovaquone for PCP [**Name Initial (PRE) 1102**]. . Social History: - Tobacco: Denies - EtOH: Hx of heavy EtOH use. - Drugs: Denies - Home: Lives alone. Independent in ADL's. 2 grown children. - Work: Quit job at convenience store due to health issues. - She has two children ages 21 and 18, who live near her Family History: [**Name Initial (PRE) 6961**] are alive at ages 79 and 80 and in good health. She has four siblings, none of whom have any chronic illnesses Physical Exam: Physical Exam: Vitals: T:96.6 BP:89/53 P: 97 R: 15 O2: 95% 3L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP mid neck, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, rales at the bases Abdomen: Multiple surgical scars, distended, tender to deep palpation of LLQ, bowel sounds present, no organomegaly, no rebound GU: foley Ext: warm, well perfused, 2+ pulses, 1 + anasarca Neuro: 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, no asterixis Pertinent Results: Admission Labs: [**2171-12-18**] 03:46PM BLOOD WBC-15.6* RBC-2.28*# Hgb-6.7*# Hct-21.2*# MCV-93 MCH-29.5 MCHC-31.8 RDW-14.7 Plt Ct-266# [**2171-12-18**] 03:46PM BLOOD Neuts-86.2* Lymphs-10.2* Monos-2.6 Eos-0.6 Baso-0.4 [**2171-12-18**] 03:46PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-2+ Schisto-1+ Burr-1+ Stipple-1+ [**2171-12-18**] 03:46PM BLOOD PT-23.5* PTT-48.4* INR(PT)-2.2* [**2171-12-18**] 03:46PM BLOOD Fibrino-173*# [**2171-12-18**] 03:46PM BLOOD Glucose-101* UreaN-31* Creat-2.0* Na-132* K-4.3 Cl-101 HCO3-21* AnGap-14 [**2171-12-18**] 03:46PM BLOOD ALT-15 AST-32 AlkPhos-75 TotBili-0.3 [**2171-12-18**] 03:46PM BLOOD Albumin-3.0* Calcium-7.2* Phos-4.8*# Mg-1.3* Iron-30 [**2171-12-18**] 03:46PM BLOOD calTIBC-31* VitB12-1797* Folate-14.9 Hapto-70 Ferritn-296* TRF-24* [**2171-12-24**] 09:44AM BLOOD TSH-2.9 [**2171-12-19**] 02:29PM BLOOD Cortsol-36.2* [**2171-12-18**] 03:46PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2171-12-21**] 07:00PM BLOOD Vanco-14.8 [**2171-12-18**] 03:46PM BLOOD tacroFK-7.4 [**2171-12-18**] 04:26PM BLOOD Type-[**Last Name (un) **] pO2-27* pCO2-50* pH-7.25* calTCO2-23 Base XS--6 [**2171-12-18**] 04:26PM BLOOD Lactate-1.4 [**2171-12-19**] 03:25AM BLOOD freeCa-1.00* Imaging: CXR: FINDINGS: In comparison with the study of [**2170-3-5**], there are lower lung volumes. There is enlargement of the cardiac silhouette with diffuse bilateral pulmonary opacifications, most prominent in the central region, consistent with pulmonary edema. Poor definition of the left hemidiaphragm could reflect atelectasis and effusion. Although the radiographic abnormalities are most consistent with pulmonary edema, the possibility of supervening pneumonia would have to be considered in the appropriate clinical setting. . [**1-18**] CXR: CHF with pulmonary edema and bilateral effusions, together with bibasilar collapse and/or consolidation, similar in appearance to [**2172-1-15**]. [**Last Name (un) 1372**]-/orogastric tube as described. . [**2172-1-14**] 4:48 pm URINE Source: Catheter. **FINAL REPORT [**2172-1-16**]** URINE CULTURE (Final [**2172-1-16**]): MORGANELLA MORGANII. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII | AMIKACIN-------------- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 32 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 0.5 S NITROFURANTOIN-------- 256 R TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: 53-year-old female with a history of alcohol abuse and cirrhosis status post liver and kidney transplant in [**11/2169**] who presented to an outside hospital with abdominal pain and found to have SBP, and transferred to [**Hospital1 18**] for further management. . The patient was on the medical service for the first 27 days in the hospital before being transferred to the liver service. She was continued on daptomycin for VRE bacteremia, as well as ultrafiltration, lasix, and hemodialysis was continued to reduce volume as she remained oliguric. Supportive nutrition was continued through Dobhoff. On occasion she developed a rapid ventricular rate (atrial tachycardia) which responded to IV metoprolol. Her standing PO metoprolol was stopped, as her hypotension was limiting the amount of fluid removed at HD. She developed an increasing leukocytosis, and work-up revealed a UTI. She was initially treated with ceftriaxone, however leukocytosis continued to trend up and other work-up was negative so she was broadened to cefepime, which covered Morganella, the organism that eventually grew. She did not make any significant progress in her overall state, and a family meeting was planned given that she had been hospitalized for such a prolonged amount of time. However, on the 5th day of her time on the liver service, she triggered for tachypnea after returning from dialysis. Over the next 2-3 hours her mental status declined, her vitals became unstable, and it became clear she was going into septic shock. This decline happened very acutely, and she was quickly transferred to the MICU for further management. . In the MICU, the patient required intubation for airway protection and was initiated on broad antibiotic and antifungal coverage. Unfortunately, her septic shock was refractory to broad antibiotic/antifungal coverage and she required 2 pressors. She was also given a trial of CVVH to try to optimize her volume status. It became clear that her prognosis was grave as she was not able to wean off of her pressors over the week in the ICU. After a goals of care discussion with her husband and multiple family members including her daughter and son, it was decided that her care would be transitioned to comfort measures only on the evening of [**1-25**]. She was started on a morphine drip and extubated shortly thereafter. She passed away on [**2172-1-26**] at 9:05AM with her husband, daughter, and son at bedside. An autopsy was offered and declined by her husband/HCP. Medications on Admission: Medications: 1. atovaquone 1500 mg PO DAILY 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 4. Boniva 3 mg/3 mL Syringe Sig: Three (3) mg IV every 3 months. 5. levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY 7. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H 8. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID 9. aspirin 81 mg Tablet DAILY 10. calcium carbonate 500 mg calcium (1,250 mg) PO twice a day. 11. cholecalciferol (vitamin D3) 400 unit Tablet PO DAILY 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY 13. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY 15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itchiness. 20. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily 21. Levothyroxine 150 daily Discharge Medications: Patient expired Discharge Disposition: Extended Care Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

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icd9cm

[ [ [] ] ]

[ "96.04", "38.95", "50.13", "54.91", "38.97", "96.72", "96.6", "39.95", "38.91" ]

icd9pcs

[ [ [] ] ]

11234, 11249

7469, 9983

296, 366

11308, 11325

4607, 4607

11389, 11499

3809, 3951

11194, 11211

11270, 11287

10009, 11171

11349, 11366

3981, 4588

1959, 2334

253, 258

394, 1940

4624, 7446

2356, 3533

3549, 3793

27,000

141,960

31774

Discharge summary

report

Admission Date: [**2190-12-7**] Discharge Date: [**2190-12-21**] Date of Birth: [**2133-4-17**] Sex: F Service: MEDICINE Allergies: Quinolones / Clindamycin / Ciprofloxacin / Prilosec / Ensure Attending:[**First Name3 (LF) 477**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 57 F with pmhx diabetes mellitus, met adenocarcinoma to lungs, COPD, emphysema, recurrent UTIs, sarcoidosis was at Rehab since [**11-12**] after recent MRSA PNa, tx'd then found unresponsive in RF, tx'd to BW and started on dialysis, then moved to rehab at [**Hospital1 **], but spike fever sent to [**Hospital3 52206**], dx'd with pseudomonoas and MRSA, started on vanco and aztreonam. Finally tx'd to current [**Hospital 5503**] Rehab at rehab today was called for resp distress 132/75 92% P 96 RR 40-28, was given solumedrol, nebs, but worsened through the day, and was tx'd to OSH. . At OSH 101 141/63 32 91%NRB, abg 7.26/65/93 was given asa, vancomycin, 40mg solumedrol, lasix 80 IV, dilaudid and morphine, DDimer 3700. Apparently recenctly at [**Hospital 5503**] Rehab, last dialyzed on [**12-6**] with 2 kg taken off. . In our ED T 97 88 116/60 18 100% 15L Facemask, received nebs, also kayexalate for her K5.6, . She was tx to 11R but was noted to be tachypneic and in respiratory distress and was tx to the ICU. . In the ICU, she was using accessory muscle use, but could state she was SOB, but otherwise had minimal pain. Past Medical History: Onc Hx: Adenocarcinoma of Unknown origin (? GI/Cervical). The patient initially had presented in [**2188-12-9**] with vaginal bleeding her vagina. Her cervix was biopsied at Women and [**Hospital 60658**] Hospital that showed malignancy involving her cervix and was treated with external beam radiation therapy and brachytherapy. Her vaginal bleeding resolved, but in [**Month (only) 956**] [**2189**] CT and PET scans showed multiple pulmonary nodules which were biopsied and suggested metastatic carcinoma of likely gastrointestinal tract origin and in [**2189-8-8**] she was found to have residual disease involving her cervix. The patient then was seen at the [**Hospital6 8865**] where she was seen by both the gastrointestinal oncology team as well as the gynecological oncology team. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and gynecological oncology mentioned to the patient that she was not a candidate for surgical resection of her disease because of the wide spread metastases on her CT of the chest. The treatment of her metastatic malignancy of likely gastrointestinal origin began fall of [**2189**] and consisted of FOLFOX with Avastin to begin, followed by FOLFIRI with Avastin. In [**2190-3-11**], her treatment with FOLFIRI plus Avastin had to be held because she underwent toe amputations related to her diabetes mellitus. Tumor markers inc. CA [**82**] and CEA were rising, suggesting refractoriness to FOLFIRI, and she was switched to FOLFOX in in [**2190-4-8**], to which she responded favorably. In [**2190-7-9**], the patient noted recurrence of her bleeding vaginally, and the patient was seen by Dr. [**Last Name (STitle) **] of gynecology oncology who felt that there was no possible benefit that could be obtained from local therapy or surgical options regard to her pelvic involvement. In [**2190-10-9**], she started dialysis treatments; the etiology of her ESRD is unclear. [**Name2 (NI) **] chemotherapy has been held the last few months due to multiple admissions for pneumonia/COPD exacerbation. . Past medical history: COPD history of vocal cord polyp sarcoidosis type 2 diabetes mellitus Charcot's arthropathy diabetic retinopathy MRSA pneumonia [**7-15**] arthritis pseudogout end-stage renal disease adenocarcinoma of unknown primary with metastases. Toe amputation [**2189**] Social History: She lives at home with her sister and had worked as a switch board operator. The patient smoked for 43 years and quit about three years ago. She denies any alcohol exposure. Family History: Her sisters are healthy and her mother had [**Name2 (NI) 499**] cancer at the age of 62. Physical Exam: VS: 97.9, 130/60, 82, 14, 97% on cool NEB FM. Wt 157 lbs. GENERAL: Tired appearing caucasian female, with slight accessory muscle use and speaking in full sentences with difficulty. HEENT: Moist mucous membranes. NECK: JVP at 10 cm. COR: RR, normal rate, difficult to hear heart sounds over audible breath sounds. LUNGS: Bilateral rhonchi in both lungs diffusely with very little air movement and expiratory wheezes bilaterally. ABDOMEN: Normoactive bowel sounds, [**Name2 (NI) 499**] palpated with stool, mildly tender diffusely. EXTR: Trace edema to the mid-tibia, slightly more prominent on the left. Pertinent Results: Admission labs: [**2190-12-7**] 05:45PM WBC-10.6 RBC-3.44* HGB-9.7* HCT-30.8* MCV-90 MCH-28.3 MCHC-31.6 RDW-17.5* [**2190-12-7**] 05:45PM NEUTS-95* BANDS-0 LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2190-12-7**] 05:45PM PLT SMR-NORMAL PLT COUNT-341 [**2190-12-7**] 05:45PM PT-12.1 PTT-24.2 INR(PT)-1.0 [**2190-12-7**] 05:45PM GLUCOSE-109* UREA N-50* CREAT-4.0* SODIUM-135 POTASSIUM-5.6* CHLORIDE-94* TOTAL CO2-23 ANION GAP-24* [**2190-12-7**] 05:21PM TYPE-ART O2-100 O2 FLOW-15 PO2-144* PCO2-49* PH-7.33* TOTAL CO2-27 BASE XS-0 AADO2-544 REQ O2-87 [**2190-12-7**] 10:06PM TYPE-ART PO2-157* PCO2-44 PH-7.35 TOTAL CO2-25 BASE XS--1 INTUBATED-NOT INTUBA . Pertinent labs: [**2190-12-7**] 05:45PM BLOOD CK-MB-NotDone proBNP-9291* [**2190-12-7**] 05:45PM BLOOD CK(CPK)-30 [**2190-12-7**] 05:45PM BLOOD cTropnT-0.02* [**2190-12-8**] 03:54AM BLOOD CK(CPK)-25* [**2190-12-8**] 03:54AM BLOOD CK-MB-5 cTropnT-<0.01 [**2190-12-8**] 10:18AM BLOOD CK(CPK)-25* [**2190-12-8**] 10:18AM BLOOD CK-MB-5 cTropnT-0.01 . Imaging: CHEST (PORTABLE AP) [**2190-12-7**] IMPRESSION: Diffuse patchy parenchymal opacifcation with effusions without prior for comparison. Diagnostic considerations are extensive but include edema, multifocal pneumonia, sarcoid, and ARDS. Brief Hospital Course: 57 year old female with multiple medical problems including DM2, COPD, recent MRSA and pseudomonas pneumonia, and metastatic adenocarcinoma of unclear primary (cervical v. GI), who presented with increased dyspnea, attributed to COPD exacerbation and pneumonia. . 1. SOB: Pt was initially admitted to the ICU. She does have multiple contributing factors including COPD, MRSA pneumonia, HD-dependence, and presence of metastases in lung. ICU team also felt there was a significant component of anxiety as the dyspnea responded well to ativan and morphine. Also, her ABGs were not significantly abnormal, and she satted well on NC but insisted on having a face mask. It was not felt that she had a PE as LENIs were negative and there was no sig. RV strain on ECHO. Induced sputum was neg. for PCP but grew MRSA. She was treated with vancomycin and meropenem for 14 days for pneumonia. She was also treated with nebulizers and solumedrol and HD as needed for volume-overload. . 2. ESRD: Pt continued dialysis, calcium carbonate, lanthanum, and nephrocaps per Dialysis Team. . 3. Adenocarcinoma: Given pt's poor functional status, chemotherapy was held. Pt did report sig. pelvic pain. Radiation oncology was consulted and did not feel that the patient was a candidate for radiation therapy. Her pain was controlled with Fentanyl patch and dilaudid PCA. . 4. HTN: Labetalol was restarted in the ICU for SBP in 150-180's, and her BP responded well. . 5. DM II: Pt was placed on a ISS while in house. . Pt began to have worsening functional and mental status, and after discussion with her family, her goals of care were shifted to comfort. She died on [**2190-12-21**]. Medications on Admission: Fentanyl patch 125mcg. labetalol 50mg Daily Oxycontin 10mg [**Hospital1 **] prevacid 30mg daily renal caps 1 pd daily megace 200mg [**Hospital1 **] ativan 0m5 mg for bipap levaquin 250mg daily fdc' on [**11-19**] albuterol imipenem dc'd on [**11-27**] vancomycin dc'd [**11-27**] spiriva liderderm patch R upper back mucinex Dilaudid 4mg q2hrs prn dulcolax ativan 0.5mg qid prn aspirin 81mg Calcium Carbonate 1250 TID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Adenocarcinoma of unknown origin Pneumonia Chronic renal failure on hemodialysis Chronic obstructive pulmonary disease Diabetes mellitus type 2 Hypertension Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8311, 8320

6130, 7815

329, 343

8520, 8529

4832, 4832

8581, 8682

4102, 4192

8283, 8288

8341, 8499

7841, 8260

8553, 8558

4207, 4813

282, 291

371, 1516

4848, 5516

5532, 6107

3631, 3893

3909, 4086

30,909

172,900

32907

Discharge summary

report

Admission Date: [**2164-4-3**] Discharge Date: [**2164-4-11**] Date of Birth: [**2102-9-25**] Sex: M Service: SURGERY Allergies: Benadryl Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: [**2164-4-3**] - Thoracoabdominal esophagogastrectomy, jejunostomy tube placement and excision of lipoma of chest wall. History of Present Illness: his gentleman has esophageal cancer which is at least a T3 lesion, probably has positive nodes. He has been given neoadjuvant treatment. Now presents for surgical excision. Of note, since the patient is morbidly obese, weighing over 375 pounds, it was thought best to approach this through a thoracoabdominal incision given the patient's very difficult body habitus and relatively low-lying lesion. Past Medical History: T3N0 signet cell adenoca (s/p chemo & XRT), morbid obesity, GERD, +cigs, h/o etOH Social History: +cigs, h/o etOH Family History: no history of esphageal cancer Physical Exam: afebrile hemodynamically normal A+O x 3 NAD RRR no MRG appreciated CTAB no WRR morbid obesity, softly distended abdomen with an absence of tenderness mae [**4-9**] B le and ue Pertinent Results: [**2164-4-3**] 09:11PM TYPE-ART TEMP-36.4 PO2-138* PCO2-58* PH-7.28* TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA [**2164-4-3**] 09:11PM LACTATE-1.6 [**2164-4-3**] 09:06PM GLUCOSE-125* UREA N-23* CREAT-1.0 SODIUM-143 POTASSIUM-5.3* CHLORIDE-111* TOTAL CO2-25 ANION GAP-12 [**2164-4-3**] 09:06PM estGFR-Using this [**2164-4-3**] 09:06PM CALCIUM-7.8* PHOSPHATE-4.2 MAGNESIUM-1.6 [**2164-4-3**] 06:45PM TYPE-ART PO2-180* PCO2-52* PH-7.26* TOTAL CO2-24 BASE XS--4 [**2164-4-3**] 06:45PM LACTATE-1.5 [**2164-4-3**] 05:44PM TYPE-ART TEMP-36.4 O2 FLOW-10 PO2-153* PCO2-71* PH-7.19* TOTAL CO2-28 BASE XS--2 INTUBATED-NOT INTUBA [**2164-4-3**] 05:44PM LACTATE-1.9 [**2164-4-3**] 05:44PM freeCa-1.13 [**2164-4-3**] 05:28PM GLUCOSE-159* POTASSIUM-5.8* [**2164-4-3**] 05:28PM MAGNESIUM-1.7 [**2164-4-3**] 05:28PM HCT-35.7* [**2164-4-3**] 05:28PM HCT-35.7* [**2164-4-3**] 01:38PM TYPE-ART RATES-/16 TIDAL VOL-400 O2-100 PO2-168* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 AADO2-505 REQ O2-84 INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-ETT [**2164-4-3**] 01:38PM GLUCOSE-108* LACTATE-2.6* NA+-139 K+-5.0 CL--106 [**2164-4-3**] 01:38PM HGB-11.5* calcHCT-35 [**2164-4-3**] 01:38PM freeCa-1.09* [**2164-4-3**] 01:38PM HGB-11.5* calcHCT-35 [**2164-4-3**] 01:38PM freeCa-1.09* [**2164-4-3**] 12:20PM TYPE-ART PO2-87 PCO2-42 PH-7.39 TOTAL CO2-26 BASE XS-0 [**2164-4-3**] 12:20PM HGB-12.4* calcHCT-37 [**2164-4-3**] 12:20PM freeCa-1.09* [**2164-4-3**] 12:20PM freeCa-1.09* [**2164-4-3**] 10:26AM TYPE-ART RATES-/16 TIDAL VOL-400 O2-100 PO2-94 PCO2-48* PH-7.34* TOTAL CO2-27 BASE XS-0 AADO2-579 REQ O2-94 INTUBATED-INTUBATED VENT-CONTROLLED [**2164-4-3**] 10:26AM TYPE-ART RATES-/16 TIDAL VOL-400 O2-100 PO2-94 PCO2-48* PH-7.34* TOTAL CO2-27 BASE XS-0 AADO2-579 REQ O2-94 INTUBATED-INTUBATED VENT-CONTROLLED [**2164-4-3**] 10:26AM GLUCOSE-135* LACTATE-1.3 NA+-140 K+-5.2 CL--104 [**2164-4-3**] 10:26AM GLUCOSE-135* LACTATE-1.3 NA+-140 K+-5.2 CL--104 [**2164-4-3**] 10:26AM HGB-14.0 calcHCT-42 [**2164-4-3**] 10:26AM freeCa-1.09* [**2164-4-3**] 08:53AM HGB-13.7* calcHCT-41 [**2164-4-3**] 08:53AM HGB-13.7* calcHCT-41 [**2164-4-3**] 08:53AM freeCa-1.13 Brief Hospital Course: The patient was admitted with the HPI above and taken to the operating room by Dr. [**Last Name (STitle) **] on [**2164-4-3**] for Thoracoabdominal esophagogastrectomy, jejunostomy tube placement and excision of lipoma of chest wall with chest tube placement. The patient was monitored in the ICU until [**2164-4-6**] and returned to the floor, during which time the jejunostomy tube was used to feed the patient. By the third of [**Month (only) 116**] the patient was comfortable to transfer to the chair. By the fourth of [**Month (only) 116**] the patient had passed a swallow study and started on an oral diet. As the oral diet increased, the patient's j-tube feedings were reduced until he could tolerate an oral diet as his sole source of nutrtion. During the patients hospital course his chest tube was also removed, a situation which helped his ambulatory status extensively. By the end of the [**Hospital 228**] hospital course, he had returned to being able to tolerate a solely oral diet, ambulating at his baseline functional status, having his pain controlled on an oral pain regimen, and being able to manage himself at home. Based on the evaluation of the surgical team, the patient was stable to be discharged home. Medications on Admission: asa 325', zantac 150, MVI Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Phenol-Phenolate Sodium Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for sleep aid. 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 1 weeks. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Carcinoma of the esophagus status post neoadjuvant treatment. Morbid Obesity Discharge Condition: stable, tolerating post esophagogastrectomy oral diet, ambulating independently without difficulty, voiding independently without difficulty, tolerating an oral pain regimen Discharge Instructions: CRIMSON General d/c instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Leave the steri-strips on. They will fall off on their own, or be removed during your followup. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: You are to call Dr.[**Name (NI) 1482**] office for a follow-up appointment in [**12-7**] weeks. You are to call your primary care physician [**Name9 (PRE) 2678**] for [**Name Initial (PRE) **] post-surgical and post-hospitalization appointment. You are to continue your post esphagogastrectomy diet, as you were taught in the hospital.

[ "V85.4", "530.85", "214.8", "278.01", "151.0", "305.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.41", "43.5", "44.29", "46.39" ]

icd9pcs

[ [ [] ] ]

5744, 5750

3453, 4693

285, 407

5872, 6048

1233, 3430

7298, 7637

989, 1021

4769, 5721

5771, 5851

4719, 4746

6072, 6936

6951, 7275

1036, 1214

228, 247

435, 835

857, 940

956, 973

12,519

106,575

17962+17963

Discharge summary

report+report

Admission Date: [**2195-4-27**] Discharge Date: [**2195-5-15**] Date of Birth: [**2134-11-14**] Sex: F Service: ORTHOPEDIC HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old female with a history of scoliosis and spinal stenosis with degenerative disc changes with significant lateral listhesis of L2 and L3 who was seen in the past by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] who recommended the patient to consider anterior and posterior spinal fusion procedure. The patient was given information regarding this surgical intervention including risks and benefits, and opted for surgery, which was scheduled for the day of admission [**2195-4-27**]. PAST MEDICAL HISTORY: Hypertension, insulin dependent diabetes, thoracolumbar scoliosis 63 degrees with mild kyphosis at L2-L3 level. Stenosis at the same L2-L3 level with lateral disc protrusion at L3-L4 and degenerative changes of the facet joints at L4-L5-S1 bilaterally. PAST SURGICAL HISTORY: Knee surgery in [**2186**]. Appendectomy, colonoscopy. FAMILY HISTORY: Hypertension, cancer, diabetes and arthritis. ALLERGIES: Sulfa drugs, adhesive tape, Vicodin, Percocet and Cipro. PHYSICAL EXAMINATION ON PRESENTATION: Well developed, well nourished white female, was moving with severe discomfort to and from the examination table, complaining of pain in her lower back and severe limitation in axial rotation, flexion and extension and lateral side bending. The patient had evidence of thoracolumbar scoliosis. The patient stood deviated to the right. She had good strength in terms of hip flexion, abduction, adduction, knee extension, flexion, dorsiflexion and plantar flexion. She had a positive straight leg raise on the left side. She is clear to auscultation bilaterally. Heart normal S1 and S2 without murmur. Abdomen soft, nontender, nondistended. HOSPITAL COURSE: The patient underwent T10 to L4 anterior spinal fusion, partial vertebrectomy of L1, L2 and L3 and anterior allograft placement at L4-L5 with autograft on the day of admission [**2195-4-27**]. The surgery was done by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. Post surgery the patient was followed by the acute pain service and was managed on Dilaudid PCA. The patient was also followed by [**Last Name (un) **] Diabetes Center physicians for management of her brittle diabetes. The patient had been on an insulin pump prior to the operation. Postoperatively, the insulin pump was discontinued and the patient was placed on an insulin drip. The plan was to restart the insulin pump when the patient was ready for self management. During her first surgery the patient had a chest tube placed. In the posterior procedure, she had fusion of T10 to L5, with multiple thoracic and lumbar laminotomies, and segmental instrumentation application from T10 to L5 with autograft, osteotomy of L2 and L3, and had an epidural catheter placed. The description of the procedure may be found in the operative notes. Postoperatively, the patient was transferred to the Trauma CICU. She continued to be intubated and sedated. Postoperative day two the patient was intubated but alert. The patient was extubated on [**2195-5-4**] and continued to be on a face mask. The patient was on tube feeds and monitored by nutritional services. Pain was controlled with Dilaudid drip. The patient was managed on the PCA for pain control with Dilaudid . The pain control was monotored by the acute pain service. The Hemovac drain was removed on postoperative day six. The following day the Foley catheter was discontinued and the patient was transferred to the medical surgical floor from the Trauma CICU. Bilateral pneumoboots were continued for prophylaxis of deep venous thrombosis. The patient was intermittently after the second surgery and medical consult was requested. The confusion was attributed to the effect of analgesia, Dilaudid, which was discontinued on [**2195-5-9**]. The patient's mental status slowly improved. Along with improvement the patient brought her concern regarding visual loss. Both ophthalmology and neuro-ophthalmology consults were requested. The patient was seen by Dr. [**Last Name (STitle) 10030**] from neurology who found no evidence of cortical blindness but an ischemic optic neuropathy. MRI with angiography of the head and neck was obtained and finally a brain scan was obtained. It showed mild symmetric decreased perfusion to the primary and secondary visual cortex. The patient was seen by Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 2523**] from Neuro-ophthalmology. His impression was the patient had bilateral posterior ischemic optic neuropathy with hallucinations. Recommended to follow up with him in six to eight weeks. His phone number is [**Telephone/Fax (1) 49741**]. Also needs to follow up with Dr. [**Last Name (STitle) **] ophthalmology in [**Last Name (un) **] Diabetes Center. The patient continued to be mobilized by physical therapy daily. She was able to ambulate with TLSO brace with assistance supervision 75 feet. On day before discharge the patient was screened and accepted by rehabilitation center on [**Hospital3 **]. She will be discharged today [**2195-5-15**]. DISCHARGE DIAGNOSES: 1. Posteroanterior thoracolumbar fusion T10-L5 with instrumentation. 2. Bilateral blindness. DISCHARGE MEDICATIONS: 1. Sliding scale insulin. 2. Tylenol 325 mg po q 4 hours, please crush pill. 3. Tramadol 50 mg po q 4 to 6 hours prn. 5. Benadryl 25 mg intravenous q 6 hours prn. 6. Heparin 5000 units subq q 12 hours. 7. Ativan 1 to 2 mg intravenous q 2 to 4 hours prn agitation. The patient must have adequate AOA support prior to administration of the dose. 8. Magnesium sulfate 2 gram per 100 milliliters of D5W intravenous prn for magnesium level less then 1.8. 9. Calcium gluconate 2 grams/100 milliliters of D5W intravenous prn for calcium ionized less then 1.12. 10. Potassium chloride 40 milliequivalents per 100 ml SWIV prn for potassium less then 4.0. Call for potassium lower then 3.0. 11. Bisacodyl 10 mg po/pr q.d. prn. 12. Flexeril 10 mg po t.i.d. prn. 13. Docusate 100 mg po b.i.d. 14. Gabapentin 300 mg po b.i.d. 15. Medroxyprogesterone 2.5 mg po q.d. 16. Estradiol 0.5 mg po q.d. 17. Lisinopril 10 mg po q.d. The patient will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in one to two weeks after discharge. Please call [**Telephone/Fax (1) 3573**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**] Dictated By:[**Last Name (NamePattern1) 4307**] MEDQUIST36 D: [**2195-5-15**] 10:10 T: [**2195-5-15**] 10:28 JOB#: [**Job Number 49742**] Admission Date: [**2195-4-27**] Discharge Date: [**2168-1-18**] Date of Birth: [**2134-11-14**] Sex: F Service: ADDENDUM MEDICATIONS: The patient was given an injection of Lantus 26 units subcutaneously at h.s. Before each meal the patient was giving herself an injection of Humalog 1 unit per 15 gm of carbohydrates. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**] Dictated By:[**Last Name (NamePattern1) 4307**] MEDQUIST36 D: [**2195-5-15**] 14:05 T: [**2195-5-15**] 16:13 JOB#: [**Job Number 49743**]

[ "292.81", "401.9", "250.01", "E935.2", "377.39", "722.52", "737.30" ]

icd9cm

[ [ [] ] ]

[ "81.04", "77.89", "81.08" ]

icd9pcs

[ [ [] ] ]

1089, 1890

5323, 5419

5442, 7479

1908, 5302

1015, 1072

173, 713

736, 991

16,044

152,217

392

Discharge summary

report

Admission Date: [**2142-6-26**] Discharge Date: [**2142-7-6**] Date of Birth: [**2081-5-30**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1267**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: tPA therapy History of Present Illness: Ms [**Known lastname 3501**] is a 61 yo W s/p St. [**Male First Name (un) 923**] aortic valve replacement for severe AI by Dr. [**Last Name (STitle) 2230**] in [**2138**] who presented to her PCP five days ago for annual checkup and for SOB. At that time, she had experienced months of increasing SOB, notable over the past several weeks. Echo was obtained which showed valve dysfunction. She was thus taken to cath where fluoro demonstrated a St. [**Male First Name (un) 923**] aortic valve w/ one dysfunctional valve. She is transferred to [**Hospital1 18**] for further care. Past Medical History: Aortic Insuffiency s/p St. [**Male First Name (un) 923**] Aortic Valve Replacement in [**2138**] Asthma Gout Gastroesophageal Reflux Disease s/p Lumbar Spinal Fusion s/p Cholescystectomy s/p Total Abdominal Hysterectomy Social History: Married and lives w/husband. Nonsmoker for 20y. No EtOH. Disabled [**2-1**] back problems. Family History: Non-contributory Physical Exam: 99.9 113/67 95 20 95RA NAD; lying in bed watching TV JVD @ 8cm; II/VI HSM @ apex, RUSB; accentuated S2 CTAB Soft, nt, nd, obese, +BS WWP X 4 w/o edema, rashes neuro nonfocal Pertinent Results: Echo [**6-27**]: The left atrium is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Head CT [**6-29**]: No acute intracranial hemorrhage, mass effect, or major vascular territorial infarction. Head MRA [**6-29**]: Normal MRA of the head. Echo [**6-29**]: Thickening of the anterior leaflet of the mechanical aortic valve. Likely frozen leaflet in the "closed" position. Echo [**6-30**]: Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. A mechanical aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. Compared with the prior study (images reviewed) of [**2142-6-29**], the overall findings are similar (a peak gradient was not obtained on the prior study of last evening, but valve mobility is similar). The aortic valve gradients are reduced from the studies of the morning of [**2142-6-29**]. [**2142-6-26**] 11:10PM BLOOD WBC-9.3 RBC-4.09*# Hgb-12.2# Hct-35.0*# MCV-85 MCH-29.9 MCHC-35.0# RDW-16.7* Plt Ct-192 [**2142-7-3**] 06:05AM BLOOD WBC-7.5 RBC-3.79* Hgb-11.4* Hct-32.9* MCV-87 MCH-30.0 MCHC-34.5 RDW-16.6* Plt Ct-131* [**2142-7-4**] 09:20AM BLOOD Hct-35.3* Plt Ct-182 [**2142-6-26**] 11:10PM BLOOD PT-21.5* PTT-44.5* INR(PT)-2.1* [**2142-7-6**] 05:50AM BLOOD PT-36.5* PTT-60.7* INR(PT)-4.0* [**2142-6-26**] 11:10PM BLOOD Glucose-98 UreaN-23* Creat-1.2* Na-140 K-3.9 Cl-106 HCO3-21* AnGap-17 [**2142-7-3**] 06:05AM BLOOD Glucose-112* UreaN-23* Creat-1.4* Na-142 K-5.3* Cl-105 HCO3-25 AnGap-17 [**2142-7-4**] 09:20AM BLOOD K-4.7 [**2142-7-2**] 02:55AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.1 Brief Hospital Course: As mentioned in the HPI, Ms. [**Known lastname 3501**] was transferred to [**Hospital1 18**] on Heparin and admitted with immediate cardiac surgery consultation. Initially obtained Echo, ECG, blood work and cultures. Heparin was continued and she awaited thrombolysis. A repeat Echo was performed (TEE) which revealed a "frozen" valve leaflet in the closed position secondary to a thrombus. On hospital day four she was transferred to the CSRU for thrombolysis with tPA. During tPA she developed new aphasia and a head CT was performed. Followed by an immediate neurology consult. CT was negative and she then underwent a MRA. Which was also negative. Heparin was continued and she was then started on Coumadin. Which was titrated for a goal INR of [**3-2**].5. She remained in the CSRU for several days secondary to requiring BP support with Neo-Synephrine. On hospital day six she was transferred to the telemetry floor. Her aphasia following tPA slowly improved and resolved (most likely representing TIA from embolus). Over the next several days she remained in the hospital for anticoagulation and awaited her INR to become therapeutic. She was discharged on hospital day 11 with follow-up in [**Hospital 197**] Clinic with Dr. [**Last Name (STitle) 3497**] on Monday [**7-9**]. As well as other appropriate follow-up appointments. Medications on Admission: Desipramine 50mg qd, Gemfibrozil 600mg [**Hospital1 **], Lisinopril 5mg qd, Lopressor XL 50 qd, Quinine 325mg qd, Zoloft 50mg qd, Omeprazol 20mg qd, Allopurinol 300mg qd, Heparin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Desipramine 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 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:*0* 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by Dr. [**Last Name (STitle) 3497**] for a goal INR 3-3.5. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Dysfunctional aortic valve leaflet s/p St. [**Male First Name (un) 923**] Aortic Valve Replacement in [**2138**] PMH: Asthma, Gout, Gastroesophageal Reflux Disease, s/p Lumbar Spinal Fusion, s/p Cholescystectomy, s/p Total Abdominal Hysterectomy Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 3502**] office with questions. Please arrange all follow-up appointments. Take Coumadin as directed by Dr. [**Last Name (STitle) 3497**] with goal INR 3-3.5. First blood draw at [**Hospital 197**] Clinic on Monday, [**7-9**]. Followup Instructions: [**Hospital 197**] Clinic with Dr. [**Last Name (STitle) 3497**] on Monday and then as directed by Dr. [**Last Name (STitle) 3497**]. Dr. [**Last Name (STitle) **] in [**1-1**] weeks See cardiologist (Dr. [**Last Name (STitle) 3503**] and primary care provider (Dr. [**Last Name (STitle) 770**]in [**2-2**] weeks Completed by:[**2142-7-6**]

[ "996.71", "435.9", "401.9", "530.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.10" ]

icd9pcs

[ [ [] ] ]

6359, 6365

3650, 4988

306, 319

6654, 6660

1527, 3627

6955, 7297

1296, 1314

5217, 6336

6386, 6633

5014, 5194

6684, 6932

1329, 1508

247, 268

347, 927

949, 1170

1186, 1280

24,344

148,787

27329

Discharge summary

report

Admission Date: [**2131-3-4**] Discharge Date: [**2131-3-7**] Date of Birth: [**2074-10-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Sulfa (Sulfonamides) / Ibuprofen / Ginger / Amikacin / Advil / Adhesive Tape Attending:[**First Name3 (LF) 1493**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy [**3-7**] History of Present Illness: Ms. [**Known lastname **] is a 55F from [**Hospital3 4298**] with cirrhosis [**12-26**] autoimmune hepatitis c/b esophageal varices and portal hypertensive gastropathy who presented to OSH with BRBPR. She had a single episode at home, large amount. No similar bleeding in >1 year. Denies any associated abdominal discomfort, n/v, melena, fevers/chils, recent illness. No NSAID or warfarin use. No other bleeding. . At the OSH, vitals were T 97.9 P 102 BP 128/69 RR 20 O2 sat not listed. Labs showed Hct 35, Plts 64, INR 1.1, PTT 28. Given nexium, zofran, octreotide. Hct 35 there, given 1L, transferred to [**Hospital1 18**] for further eval. . On presentation to the ED at [**Hospital1 18**] her VS were XXX 82 127/62 16 100% on RA. Refused NG lavage. Gross blood on rectal exam. She was started on an octreotide drip and admitted to the MICU for close monitoring. Vitals prior to transfer 92 104/64 11 100% RA. Has 18g x2. GI [**Name (NI) 653**], plan to scope in the morning. . On evaluation in the MICU, she reports feeling well. ROS also notable for diminished peripheral edema. No shakiness, confusion, abdominal swelling. Past Medical History: * Autoimmune hepatitis - cirrhosis by bx [**4-29**] -- esophageal varices 3 cords grade I-II [**2131-2-13**] s/p banding -- portal hypertensive gastropathy w/ h/o bleed * DVT with h/o PE -- stopped warfarin >1mo ago s/p IVC filter in RI * DM * Esophageal candidiasis * Obesity * Umbilical hernia * Asthma * Migraines * Restless leg syndrome * Heart murmur Social History: Living Situation: Lives alone. She splits her time between RI and [**Hospital3 4298**]. Disabled. Tobacco: denied EtOH: denied IVDU: denied Family History: Positive for diabetes and CAD. No history of liver disease. Physical Exam: MICU exam Vitals 98.3 95 100/92 16 95% on RA General Pleasant, appears comfortable HEENT Anicteric, MMM Neck no JVD Pulm lungs clear bilaterally, no rales or wheezing CV regular S1 S2 II/VI systolic murmur base Abd soft nontender +bowel sounds rectal +blood in ER +external hemorrhoid Extrem warm tr bilateral edema palpable distal pulses Neuro alert, answering appropriately, no asterixis Derm no jaundice or rash ************ On discharge: gait intact, abdomen non-tender, conversational. Pertinent Results: CBC 3.9>33<67; hct was on 34 and plts 90 on [**2130-11-3**] Chem 137/4.4/99/31/27/1.2<141; creat was 1.3 on [**2130-9-8**] INR 1.2, PTT 30 . EKG at OSH SR @93, nl axis and intervals, no ST/T changes suggestive of acute ischemia . CXR at OSH (per report) retrocardiac opacity . Discharge labs: [**2131-3-7**] 12:00PM BLOOD WBC-4.3 RBC-3.15* Hgb-11.4* Hct-33.4* MCV-106* MCH-36.1* MCHC-34.0 RDW-19.8* Plt Ct-72* [**2131-3-7**] 07:35AM BLOOD PT-14.5* PTT-32.9 INR(PT)-1.3* [**2131-3-7**] 07:35AM BLOOD Glucose-68* UreaN-17 Creat-1.0 Na-140 K-3.8 Cl-104 HCO3-30 AnGap-10 [**2131-3-7**] 07:35AM BLOOD ALT-62* AST-65* LD(LDH)-194 AlkPhos-206* TotBili-2.1* [**2131-3-7**] 07:35AM BLOOD Albumin-3.1* Calcium-8.9 Phos-2.9 Mg-2.1 . [**3-7**] colonoscopy: Impression: In the rectum near the sigmoid there were 4 chains of medium sized rectal varices with no stigmata of recent bleeding. Stool and looping precluded a thorough exam of the cecum. Otherwise normal colonoscopy to cecum but cecum not well seen Recommendations: Bleeding source likely rectal varices versus small hemhorroids. would observe patient and consider local injection or TIPS if rebleeding. . [**3-4**] ECG: Sinus rhythm. Non-diagnostic Q waves in the inferior leads. Compared to the previous tracing of [**2130-4-23**] premature ventricular contractions are no longer present. Brief Hospital Course: Ms. [**Known lastname **] is a 55F with autoimmune hepatitis who presents with BRBPR. . * Rectal bleeding Patient remained hemodynamically stable without any further episodes of bleeding in hospital. She was started on an octreotide drip for concern for variceal etiology given recent intervention though suspicion for this was clinically low; this was discontinued upon transfer from ICU to floor. She did not require any blood products. She underwent a colonoscopy (one day late, due to inadequate prep as she ate a solid food meal when should have just been clears the day before colonoscopy); which showed rectal varices but without evidence of a recent bleed, felt that: bleeding source likely rectal varices versus small hemorrhoids. She received ciprofloxacin for prophylaxis in setting of bleed, not discharged with this medication as without evidence of variceal bleed. Patient did not have any further bleeding in the ICU or on the floor; her hematocrit was stable. Her abdominal exam was unremarkable. She was tolerating PO, ambulating. Started nadolol on discharge to protect against GI bleed given rectal varices present. . * Autoimmune hepatitis and cirrhosis MELD on admission was 11. LFTs are at recent baseline. Her lasix and lactulose were held initially, restarted on discharge. She continued her home prednisone and azathioprine. . * h/o DVT and PE: Not on warfarin any longer as outpt. Has filter placed at OSH. Not active issue. . * Thrombocytopenia: Platelets near recent baseline, likely [**12-26**] cirrhosis. . * Depression: not active issue, continued home regimen. . Code: FULL on admission to ICU Medications on Admission: Prednisone 5mg daily Azathioprine 75mg daily Furosemide 40mg [**Hospital1 **] Spirionolactone 100mg [**Hospital1 **] Lactulose 3-5 doses/day Glimepiride 2mg [**Hospital1 **] [**Hospital1 66980**] 150mg [**Hospital1 **] Citalopram 10mg daily Lorazepam 0.5mg prn - takes qhs Nortriptyline 100mg qhs Oxycodone 5mg q4h prn - takes qhs Ondasetron prn Albuterol 2puffs q4h prn Fluticasone nasal daily Calcium/D, MVT, Ferrous sulfate Discharge Medications: 1. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Azathioprine 50 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily). 3. Nortriptyline 25 mg Capsule [**Hospital1 **]: Four (4) Capsule PO HS (at bedtime). 4. Lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as needed for anxiety. 5. Fluticasone 50 mcg/Actuation Spray, Suspension [**Hospital1 **]: One (1) Spray Nasal DAILY (Daily). 6. Citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 8. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as needed for pain. 9. Lactulose Oral 10. Glimepiride 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 11. [**Hospital1 66980**] HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 12. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 13. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 14. Ondansetron Oral 15. Calcium-Vitamin D3 Oral 16. Multivitamin Oral 17. Ferrous Sulfate Oral 18. Nadolol 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Autoimmune hepatitis Rectal varices Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital because of bleeding from your rectum. You did not bleed anymore while in the hospital, your blood levels remained stable, both in the ICU and on the regular hospital floor. You had a colonoscopy on [**3-7**] which showed rectal varices but no evidence of bleeding. . Continue to take all of your home medications, as previously prescribed. You have one new medication to start: - Nadolol, take this medication daily, to protect against the rectal varices (blood vessels) from starting bleeding Followup Instructions: Please attend the following previously-scheduled appointment: Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2131-3-30**] 11:20 Completed by:[**2131-3-9**]

[ "537.89", "455.8", "278.00", "571.42", "288.50", "572.3", "287.5", "250.00", "571.5", "493.90", "311", "333.94" ]

icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

7496, 7502

4050, 5677

366, 390

7582, 7582

2688, 2965

8317, 8556

2100, 2161

6154, 7473

7523, 7561

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2176, 2605

2619, 2669

321, 328

418, 1548

7597, 7709

1570, 1927

1943, 2084

2,459

125,073

24072

Discharge summary

report

Admission Date: [**2181-6-12**] Discharge Date: [**2181-8-1**] Date of Birth: [**2126-2-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 5062**] Chief Complaint: Admitted [**6-12**] to ENT for embolization of R occipital artery prior to biopsy of rapidly growing R paraspinal neck mass Major Surgical or Invasive Procedure: - Chemoembolization of R occipital artery, biopsy R neck mass - Bronchoscopy x 2 - Trach [**6-27**], PEG History of Present Illness: Mr. [**Known lastname 28181**] experienced R neck pain for several months prior to admission, as well as a rapidly growing mass for 1 month. He lost 10 pounds in the previous few months, and his appetite decreased, but no fever or night sweats. . Prior to admission, CT scan of the neck revealed a hypervascular paraspinal mass (originally 4.8x4.5, 2 wks ago now 7.4x6.3cm). He was admitted on [**7-13**] for pre-biopsy embolization of the R occipital artery. Pathology of the neck mass (prelim) with poorly differentiated carcinoma presumed to be [**2-28**] head/neck malginancy. . During embolization, became delirious during and after the procedure. He recieved propofol, ketamine, sux, phenyl, anzemet and midazolam preioperatively. Also noted to have mild post-procedure hypoxia but was stable on 3L NC until night of [**6-16**] when hypoxia abruptly worsened accompanied by [**Last Name (un) **]-[**Doctor Last Name 6056**] respiration and tachypnea requiring 6L then NRB, admitted to MICU for intubation. . His MICU course was significant for several issues: . 1. Resp failure: In the MICU he was intubated with difficulty. A 7 french ET tube had to be performed by anesthesia attending. He was hypotensive on propofol and required 100% FiO2 for 7.39/32/64. Paradoxical motion of chest was noted and due to a CXR with elevated R hemdiaphragm, concerning for RL collapse, bronchoscopy was performed and significant secretions removed. Repeat CXR did not reveal much improvement. A CTA was done and ruled out PE. There was difficulty weaning pt, [**2-28**] RML pneumonia/collapse complicated by ? diaphragmatic weakness 2/2 phrenic nerve involvement and altered mental status. On [**6-27**], pt was trached [**2-28**] concern for airway compromise given neck mass. He was weaned to trach mask on [**7-4**]. . 2. Fever: Due to pneumonia. Pt was initially on levo/flagyl for possible aspiration. This was then changed to zosyn/vanco for broader coverage. On vanc/zosyn, pt's WBC fell rapidly and pt became neutropenic. He continued to have fevers while he was neutropenic so he was changed to caspo, cefepime, flagyl and vanco. His counts dropped on vanco so the vanco was d/c'd and his wbc returned to [**Location 213**]. He was then changed to linezolid for gram pos coverage and he became pancytopenic. Linezolid was then stopped and daptomycin started and his counts recovered. Caspo was stopped on [**7-7**] because he was no longer neutropenic and there was a concern for drug fever. He completed a 14-day course of cefepime/flagyl on [**7-9**]. On [**7-12**], pt's wbc again dropped (consistent with chemo) and he had a fever to 102.2 so cefepime and flagyl were restarted. . 3. Hypotension: Pt became hypotensive during intubation, likely due to propofol. He did not require pressors and his BP has been maintained only with fluid boluses. . 4. AMS: Noted to develop after biopsy (with sedation) of neck mass. LP was done and cytology negative for malignant cells. MRI and CT were also negative. Sedating meds were stopped and his mental status cleared. . 5. Neck Mass: On bx, undifferentiated high grade malignany neoplasm with unknown primary source. MRI of brain and CT torso without evidence of mets. ENT and radiation oncology following the patient. Pt is now s/p carboplatinum/taxol on [**6-29**]. On [**7-2**], pt underwent bronchoscopy with subcarinal bx showing atypical epithelial cells with prominent nucleoli which was not helpful for diagnosis. On [**6-30**], pt started on neupogen and continued on this until [**7-9**] when stopped for increasing counts. His counts starting to nadir as of [**7-12**] and neupogen was again started. . 6. Transaminitis: Pt with elevated AST/ALT, total bili and alk phos on admission. Hepatitis serolgies were negative, dopplers showed nl hepatic flow and no masses on RUQ U/S. All LFTs trended down over the ICU stay. . 7. Tachycardia: Pt had a CTA in the setting of acute hypoxia and tachycarida, neg for PE. Multiple EKGs done consistent with sinus tach. Basline rates in 110s-120s. . Transferred to the floor on [**7-14**]. Past Medical History: Hypertension Social History: Lives with wife, rare ETOH, no illicit hx,+ tobacco use, works as a consultant for [**Company **] Family History: Ovarian cancer in mother, father and grandfather with MI at 49, 50 Physical Exam: Tm 100.7 Tc 98.4 100-132/70-87 P107-135 RR 24-28 98-100% 50%TC I/O: 3530/1300 over 24 hours . General: Responds to questions, commands HEENT: serosanguinous fluid draining from R sided neck mass Pulm: cta anteriorly, no rales, ronchi CV: s1 s2 reg Abd: NABS, soft, NT Ext: no LE edema Neuro: 4-/5 BUE, [**3-31**] BLE, DTR +1, equivocal babinski Skin: shallow ulcer on LLE with erythema Pertinent Results: Studies: [**7-14**] CXR: stable RLL opacity . Path of biopsy: large cell tumor, (squamous, melanoma, germ cell tumor vs. lymphoma) . ECG [**2181-6-17**]: sinus bradycardia, no st/tw changes . [**7-15**] Labs: Micro [**7-12**] BCx x 2 pending [**7-12**] Fungal cx pending [**7-12**] UCx no growth [**2092-7-5**] sputum cx not adequate specimens [**7-2**] sputum w/ 4+ GPC in clusters, rods Brief Hospital Course: 55 y/o previously healthy M presenting with neck mass c/w undifferentiated carcinoma of unknown primary s/p embolization. Post-op course c/b change in MS [**First Name (Titles) **] [**Last Name (Titles) 61224**] respiratory failure requiring intubation. Trach placed for airway protection and pt transfered to medicine floor. . Current Onc Therapy - palliative XRT and low dose [**Doctor Last Name **]/taxol - s/p XRT #5, chemo day #6 cycle 1 - tolerating XRT/chemo well . 1. Respiratory failure: Pt was trached on [**6-27**] secondary to concern for airway compromise given neck mass. He initially required ventilator support however was weaned to trach mask on [**7-4**]. Had an episode of desaturation to 81% on [**7-14**] w/ unchanged CXR and improved with suctioning to 93%. Repeat CXR on [**7-20**] demonstrated improvement in prior lung opacities. He consistently had saturations in the 90%'s since his transfer to the floor. Lung sounds remained clear, and aggressive suctioning was ensured. Patient was placed on aspiration precautions. He was initially started on levoflox/flagyl for possible aspiration pneumonia/tracheobronchitis. These were changed to Cefepime when first neutropenic after chemo, however changed to Caspo, Cefepine, Daptomycin, and Flagyl given neutropenia and persistent fevers. Patient remianed afebrile for the balance of his stay. He was evaluated for passey-muir valve, but due to excessive secretions, we were unable to implement it effectively. . 2. Change in mental status: Etiology unclear, but could be related to his initial respiartory failure, his complications from embolization, or tumor related. There was concern for CNS disease given that mass was extending into cervical foramina and dura, however initial CSF evaluation was negative. Repeat Head CT revealed increasing mass however no evidence of CNS disease, with a question of impingment on neural foramina and vertebral arteries. All sedating meds were d/c'd. He continued to become increasingly agitated at night, when he would pull at trach and EKG leads. Haldol and ativan were given as needed, and olanzepine was started. Two point restraints were tried, mittens were used, and finally over course of stay all restraints were eventually removed. 3. Pain Control - Pain difficult to access because of communication difficulties. When asked if he has pain he often shakes his head no. PRN Morphine given for occasional complains of right neck pain. Oxycodone-Acetaminophen given prn. 4. Neck Mass: undifferentiated high-grade malignant neoplasm with unknown primary. CT torso/MRI head were negative. Treated with XRT and concurrent low dose taxol/[**Doctor Last Name **]. XRT is palliative. Family meetings with ONC/Rad Onc/[**Hospital Unit Name 153**] team were held on [**6-27**] and [**7-9**]. Family understanding of grave prognosis. Plan is to try to improve M.S. and for patient to undergo further chemo & XRT as palliation. Repeat CT neck done to evaluate mass on [**7-3**] notable for much increased size since [**6-14**] without evidence of abscess. . 4. Fever and Neutropenia: Had episode of Neutropenia which resolved on GCSF. Likely secondary to [**Doctor Last Name **]/platinum treatment however counts dropped within 4-5 days; other possibility includes linezolid, however he only received one dose prior to neutropenia. Started on Daptomycin for Gram Possitive coverage. Patient also became neutropenic on Vanco/linezolid. All blood cultures, fungal cultures, urine , and CSF cultures were negative. Sputum Culture from [**2181-6-30**] with > 25 PMN's, GPC in pairs and clusters, GPR's- OP flora. . 5. Sinus Tach - in 100s. Etiology likely secondary to agitation, anxiety about XRT/chemo, pain. ON [**7-27**] pt had tachycardia to 170s, which was sinus tach. Metoprolol was changed to TID. Pt's HR continued to be tachy, but only to low 100s. . 6. Anemia: No obvious source of bleeding. Haptoglobin, coags, DIC panel all negative. Receieved multiple units PRBC's. Hct on discharge is 29.2 and stable. . 7. Transaminitis: Initially looked to be due to obstructing process, but Liver U/S did not reveal obstruction or masses, dopplers with nl hepatic flow. LFT's normalized with stable bili. . 8. FEN: Patient had PEG on [**6-28**] because of aspiration risk and neck mass obstruction, and received tube feeds. He had an episode of Hypernatremia, which resolved with free water four times a day through PEG. Neutraphos was given to replete phosphorus. . 9. PPX: Received sc heparin for DVT prophylaxis. It was d/cd on [**7-3**] in setting of drop in platelets, likely [**2-28**] chemo, but restarted given high risk for PE. He was started on a ppi because of aspiration risk, and given a bowel regimen to prevent constipation. . 10. Code Staus: Full Code. Medications on Admission: Medications on Transfer: - Cefepime - Metronidazole - Daptomycin 250 IV qd - Albuterol - Neupogen 480mcg SQ qd - RISS - Clotrimazole troch QID - Olanzapine 5 po qhs - Lansoprazole - Heparin SQ [**Hospital1 **] - Nicotine patch - Dolasatron - Haldol prn - Trazadone prn - Senna/Colace Discharge Medications: 1. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 2. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO TID (3 times a day) as needed for hypophosphatemia. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): for excessive secretions. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Undifferentiated Head and Neck Cancer Respiratory Failure Altered Mental Status Discharge Condition: Patient in fair condition, medically stable, transferred for palliative care. Discharge Instructions: Please give all medications as directed. Please provide wound care for sacral ulcer. Ensure that patient has an appropriate bed for this problem and unsure that patient is frequently turned. Please provide trach care and PEG tube care. Patient is scheduled for regular radiation therapy and chemotherapy. Please continue these therapies to an end date of [**2181-8-6**]. If patient is improving, recommended to continue radiation therapy, if not palliative care to be provided. Patient's code status is full code. Followup Instructions: Follow up with Radiation Medicine for Radiation therapy. Follow up with Oncology Service for chemotherapy. Completed by:[**2181-8-1**]

[ "198.89", "785.6", "E947.8", "199.1", "427.89", "284.8", "486", "799.0", "V46.11", "292.81", "E849.7", "458.29", "401.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "33.21", "43.11", "96.72", "03.31", "99.25", "83.39", "96.04", "00.14", "40.11", "38.93", "31.42", "92.29", "42.23", "38.91", "31.1", "99.04", "88.41", "99.29", "99.10" ]

icd9pcs

[ [ [] ] ]

11316, 11395

5744, 7243

447, 553

11519, 11598

5329, 5721

12161, 12298

4835, 4903

10870, 11293

11416, 11498

10561, 10561

11622, 12138

4918, 5310

283, 409

581, 4668

7258, 10535

10586, 10847

4690, 4704

4720, 4819

16,738

105,557

5581

Discharge summary

report

Admission Date: [**2163-10-19**] Discharge Date: [**2163-10-28**] Date of Birth: [**2085-2-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: transfer from [**Hospital3 22439**] with hypotension and a fever to 103.8F. Major Surgical or Invasive Procedure: central line placement intubation History of Present Illness: Mr. [**Known lastname 22440**] is a 78-year-old gentleman with HTN, DM2, CAD s/p MIx2, 3 vessel CABG in [**2142**] (LIMA-LAD, SVG-D1, SVG-OM1, SVG-PDA), cath in [**4-/2163**] with stent to LAD, AFib on coumadin, ischemic cardiomyopathy with EF 30%, NSVT with Pacer/[**Hospital 3941**] transferred from OSH with fevers, hypotension. The patient was discharged from [**Hospital1 18**] on [**10-18**] after ventricular ablation for VT. . His most recent ICD firing was in [**2162-5-9**] which was felt to have been induced by exercising on a stationary bicycle. As a result, he underwent cardiac catheterization and received a stent to his LAD. Since his discharge in [**Month (only) 116**], he has had further chest discomfort and reevaluation of his coronary arteries via cardiac catheterization on [**2163-8-16**] which showed a patent LAD stent and no change in his coronary anatomy. In [**Month (only) 216**], he was hospitalized in [**Location (un) 22441**] after he developed acute onset chest discomfort and was admitted to an emergency room with wide complex tachycardia at a rate of 130 beats per minute. His ICD did not fire as it was programmed for faster rates. Reportedly his arrhythmia self-terminated and the question of atrial fibrillation with aberrency versus VT. Patient was apparently stable as the arrhythmia lasted for an hour and he never had syncope. . The patient was seen on [**9-28**] at [**Hospital **] clinic where heart histograms suggested reasonable rate control of his atrial fibrillation with his average heart rate 70-80 beats per minute. Additionally, there is no significant amount of ventricular high rates greater than 110 beats per minute which suggest that this arrhythmia which occurred in [**Location (un) 22441**] was likely to be ventricular tachycardia. He seems to tolerate the WCT hemodynamicaly (no syncope), but has significant chest pain with it. The patient was seen here on [**2163-10-18**] for an EP study that resulted in 5 ablations of the 14 discovered foci. The remaining foci was resistant to sustained Vtach by induction. The patient was discharged on [**2163-10-19**]. He complained of dysuria after discharge presumably from a traumatic foley tap in the EP lab. While on the ferry to [**Hospital1 6687**] he developed acute shortness of breath, chills, rigors and AMS. He was immediately brought to the [**Hospital3 **] with a temperature of 103.7F sating 100% on 15L NRB with a RR in the 30s and BP of 107/60 with a HR of 77. His WBC was 3, BUN was 38 and Cr and 2.1. Anesthesia attempted to intubate him, but failed. He was given 80mg IV lasix, 0.25mg IV digoxin and 100mg IV lidocaine for multiple PVCs. [**Location (un) 7622**] arrived and successfully intubated the patient for transport, but the patient became acutely hypotensive and was started on a dopamine and levophed drip and was 3L net positive. Past Medical History: HTN DM 2- recently diagnosed, diet controlled CAD s/ MIx2 , 3 vessel CABG [**2142**], and stenting [**4-/2163**], AFib on coumadin, ischemic cardiomyopathy with EF 30%, NSVT with Pacer/ICD Hypothyroidism Obstructive sleep apnea (on Bipap) Left hemi diaphragm dysfunction s/p Right inguinal hernia repair Hard of hearing (bilateral aids) Social History: Former smoker quit 40 years ago, daily [**2-11**] drinks alcohol, no drug use. Family History: Grandfather with MI at age 74, Brother with strokes starting at age 60. Physical Exam: T:99.7 BP:106/66 HR:80 RR:13 O2sat:97% intubated Wt 109 GEN: Intubated and sedated HEENT: no supraclavicular or cervical lymphadenopathy, no jvp elevation, no carotid bruits, no thyromegaly or thyroid nodules RESP: Intubated CV: RR, S1 and S2 wnl, no r/g 2/6 systolic murmur at apex. ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e. Some evidence of early venous stasis. SKIN: no rashes/no jaundice NEURO: sedated and intubated ACCESS: 3 peripheral 18 gauge IV Pertinent Results: [**2163-10-19**] 11:44PM BLOOD WBC-15.0*# RBC-3.95* Hgb-13.4* Hct-39.8* MCV-102* MCH-33.9* MCHC-33.3 RDW-14.3 Plt Ct-113* [**2163-10-20**] 06:38PM BLOOD WBC-28.6* RBC-3.73* Hgb-13.1* Hct-37.8* MCV-101* MCH-35.2* MCHC-34.8 RDW-14.7 Plt Ct-107* [**2163-10-22**] 05:21AM BLOOD WBC-21.9* RBC-3.37* Hgb-11.8* Hct-33.7* MCV-100* MCH-35.0* MCHC-35.0 RDW-14.9 Plt Ct-114* [**2163-10-23**] 06:31AM BLOOD WBC-15.2* RBC-3.33* Hgb-11.6* Hct-33.5* MCV-101* MCH-34.9* MCHC-34.6 RDW-14.8 Plt Ct-104* [**2163-10-24**] 12:49AM BLOOD WBC-7.5# RBC-3.23* Hgb-11.3* Hct-33.1* MCV-102* MCH-35.1* MCHC-34.3 RDW-14.6 Plt Ct-85* [**2163-10-26**] 05:53AM BLOOD WBC-6.9 RBC-3.29* Hgb-11.5* Hct-32.7* MCV-99* MCH-34.9* MCHC-35.1* RDW-15.3 Plt Ct-129* [**2163-10-26**] 05:53AM BLOOD PT-18.0* PTT-30.4 INR(PT)-1.7* [**2163-10-21**] 04:41AM BLOOD Glucose-163* UreaN-60* Creat-3.8* Na-134 K-4.8 Cl-103 HCO3-15* AnGap-21* [**2163-10-23**] 06:31AM BLOOD Glucose-146* UreaN-57* Creat-3.0* Na-139 K-4.0 Cl-106 HCO3-21* AnGap-16 [**2163-10-26**] 05:53AM BLOOD Glucose-116* UreaN-47* Creat-2.1* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2163-10-24**] 12:49AM BLOOD ALT-314* AST-100* LD(LDH)-190 AlkPhos-104 Amylase-49 TotBili-5.9* [**2163-10-25**] 05:55AM BLOOD ALT-198* AST-49* AlkPhos-117 TotBili-4.4* [**2163-10-27**] 07:15AM BLOOD ALT-110* AST-36 AlkPhos-148* Amylase-160* TotBili-4.4* DirBili-3.0* IndBili-1.4 [**2163-10-28**] 06:45AM BLOOD ALT-83* AST-36 LD(LDH)-169 AlkPhos-141* Amylase-151* TotBili-3.8* CXR: [**2163-10-25**]: Blunted costophrenic angles not specifically suggesting effusion. Poorly defined retrocardiac opacity probably representing atelectasis, cannot associate consolidation. No overt CHF U/S: [**2163-10-27**]: FINDINGS: Real-time ultrasound evaluation of the abdomen reveals the liver to be homogeneous in echotexture without evidence of focal lesion. The hepatic parenchymal echogenicity is normal. The gallbladder demonstrates multiple small hyperechogenic foci consistent with gallstones. There is no intrahepatic biliary ductal dilatation, and the common duct measures 5 mm. Main portal vein is patent with antegrade flow. The pancreas is not well visualized due to gas. The spleen is normal in size and echogenicity. The right kidney measures 11.8 cm and demonstrates a simple cyst in the mid pole measuring 2.2 cm. The left kidney measures 11.7 cm and demonstrates a simple cyst in the mid pole measuring 1.9 cm. There is no evidence of renal calculi or hydronephrosis. The aorta demonstrates atherosclerotic changes. IMPRESSION: 1. Cholelithiasis without evidence of cholecystitis. 2. Bilateral renal cysts. Brief Hospital Course: 78 y/o male with HTN, DM2, CAD s/p MIx2, 3 vessel CABG in [**2142**], stenting of LAD on [**4-/2163**], AFib on coumadin, ischemic cardiomyopathy with EF 30%, NSVT with Pacer/[**Hospital 3941**] transferred from OSH intubated and on pressors with fevers and respiratory distress 1 day s/p VT ablation at [**Hospital1 18**]. . Sepsis: Patient arrived to the OSH after a traumatic foley insertion during an EP study on [**10-18**] with chills, rigors and a fever to 103.7F. Patient was started on vancomycin and zosyn for empiric coverage of suspected complicated polymicrobial UTI. Flavobacterium (resistance to tetracycline otherwise pan-sensitive) and presumed enterococcus sensitive to vancomycin and penicillin were cultured at the OSH. All blood, urine and sputum cultures drawn here have been negative. Patient's antibiotics were switched to Pen G and levoquin to cover the enterococcus, flavobacterium and possible aspiration pneumonia. Patient remained afebrile for 5 days prior to transfer and his leukocytosis (WBC=28.6) resolved. The patient will continue on Pen G until [**11-2**] to finish off a 14 day course of vancomycin transitioned to pen G. He also received a 7 day course of zosyn transitioned to levoquin for possible PNA. . Cardiac: The patient underwent VT ablation on [**10-18**] resulting in 5 ablations of the 14 foci. The other 9 foci did not induce sustained VT. The patient complained of dysuria after discharge on [**10-19**] and began having chills and rigors with a temp of 103.7F at an OSH. He was transferred to the [**Hospital1 18**] CCU intubated and on pressors for presumed septic shock. Shortly after admission, the patient went into monomorphic VTACH with at least two different morphologies. He failed ICD cardioversion x 3, and he was finally paced terminated out of his VTACH. His pacer was set at 80 BPM to maintain his blood pressure. He was started on Vancomycin and Zosyn, and given 3 pressors with +7L of fluid to maintain perfusion pressures for presumed septic shock. The patient was weened off pressors and extubated over the next three days without complications. His pacer was reset to 60 bpm and he remained in Afib with a conduction in the 60-80's with occassional pacing on metoprolol 12.5mg PO BID. When we attempted to raise his metoprolol to 25mg PO BID, he became orthostatic with a rate of 60bpm and 100% paced. The patient was restarted on his coumadin for afib after we pulled the central line. His heparin was continued to bridge him to a therapeutic INR. His INR at transfer was 1.7. The patient was on amiodarone 200mg qd, asp 325mg qd, metoprolol 12.5mg [**Hospital1 **], simvastatin 40mg qd, warfarin 4mg qhs and furosemide 80 qd at the time of transfer. His blood pressure have ran in the 100's/50's. His home medications of digoxin, spironolactone and cozaar were not restarted as his bp was too low. He will need them added back on as his blood pressure tolerates. . Liver: Patient's AST/ALT were elevated and have trended down to normal during his hospital stay. This is likely due to shock liver that has resolved. His lipase, alk phos and TBili trended up during his hospital stay and was concerning for biliary obstruction vs pancreatitis vs pancreatic cancer. Patient was jaundiced and denied any abdominal pain. RUQ u/s revealed no dilation of his common bile duct with no focal lesions of the liver. His pancreas, however, could not be visualized during the study. The following day, his lipase, tbili and alk phos began to trend down and GI felt that the patient's enzyme bump was caused by biliary sludge in the setting of his septic shock and recommended a recheck lipase, alk phos and bili in a week. . ARF: Patient Cr at discharge trended down to 2.0 down from 3.8 on arrival. His baseline Cr is 1.6. His ARF was likely due to ATN caused by septic shock. . Endocrine: Patient's DM was treated with SSI and he was given his home dose of levothyroxine to treat his hypothyroidism. Medications on Admission: Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Losartan 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: as dir as dir Injection ASDIR (AS DIRECTED). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): goal INR [**2-11**]. Please check INR daily and adjust coumadin as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal QID (4 times a day) as needed for nasal dryness. 13. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback Sig: Two (2) million units Intravenous Q6H (every 6 hours) for 5 days: last day [**2163-11-2**]. million units 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: as dir as dir Intravenous ASDIR (AS DIRECTED): titrate to PTT 60-80, may discontinue when INR > 2.0 for 3 days in a row. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary: Septic shock from enterobacterium / flavobacterium ventricular tachycardia congestive heart failure Secondary: diabetes mellitus chronic renal insufficiency hypothyroidism sleep apnea Discharge Condition: patient was feeling better, and stable for discharge to [**Hospital3 **] Discharge Instructions: Please continue your medications. Some of your doses may have been changed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1200 CC daily. If you have shortness of breath, chest pain, dizziness, pass out, or have other concerns, please call your primary care physician or return to the ED. Followup Instructions: Please follow up with your PCP PEARL,[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 22442**] the week after discahrge from rehab. You have an appointment with Dr. [**Last Name (STitle) **] on [**2163-12-2**] at 3:40PM. Please call [**Telephone/Fax (1) 2934**] if you have any questions or need to reschedule. . You have an appointment with [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) 7173**], NP on [**2163-11-16**] at 1PM. Please call [**Telephone/Fax (1) 285**] if you have any questions or need to reschedule. . You also have an appointment set up for: Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Date/Time:[**2164-5-21**] 11:00 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2164-5-21**] 11:00 Completed by:[**2163-10-29**]

[ "427.1", "995.92", "427.31", "244.9", "584.9", "414.00", "V45.81", "785.52", "V45.02", "585.9", "250.00", "038.49", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13454, 13497

7048, 11040

392, 428

13735, 13810

4414, 7025

14221, 15093

3815, 3889

11956, 13431

13518, 13714

11066, 11933

13834, 14198

3904, 4395

277, 354

456, 3342

3364, 3702

3718, 3799

42,892

139,885

16026

Discharge summary

report

Admission Date: [**2115-6-28**] Discharge Date: [**2115-7-3**] Date of Birth: [**2073-4-21**] Sex: M Service: UROLOGY Allergies: Aloe / Levaquin / Tape / Penicillins Attending:[**First Name3 (LF) 824**] Chief Complaint: Bilateral nephrolithiasis s/p L PCNL([**12-14**]) Major Surgical or Invasive Procedure: Right percutaneous nephrolithotomy History of Present Illness: 42M with hx of bilat nephrolithiasis s/p L PCNL([**12-14**]), ESWL ([**3-14**], persistent right sided stone burden. Past Medical History: multiple sclerosis neurogenic bladder s/p suprapubic catheter multiple urinary tract infections with multi-drug resistant organisms Social History: Married, lives with wife. no tobacco, no illicits. Family History: Non-contributory. Pertinent Results: [**2115-7-3**] 05:37AM BLOOD WBC-9.1 RBC-3.92* Hgb-10.4* Hct-32.0* MCV-82 MCH-26.6* MCHC-32.7 RDW-14.2 Plt Ct-325 [**2115-7-3**] 05:37AM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-140 K-3.5 Cl-105 HCO3-24 AnGap-15 Brief Hospital Course: The patient was admitted to Dr.[**Name (NI) 825**] Urology service on [**2115-6-28**] after percutaneous nephrolithotripsy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient was transferred in stable condition from the OR to the PACU. The patient became febrile and tachycardic in the PACU, and was sent to the ICU for further monitoring overnight. [**Hospital Unit Name 153**] course: Pt transferred overnight with tachycardia and fever. Pt pancultured and started on vanc, ceftaz and tobramycin. Blood culture from [**6-28**] with GNR yet to be speciated at time of transfer. Continued on regimen as noted above. PICC line request placed for likely need for long-term antibiotics. Hemodynamically stable at time of transfer back to urology service. Foley discontinued. On POD2, the patient was transferred in stable condition from the ICU to the floor. His urine in both the suprapubic catheter and nephrostomy was clear yellow without clots. On the morning of POD 3, the patient was febrile, and cultures resent. He remained afebrile after POD 3. On POD 4, the PCN tube was clamped. On POD 5, the patient's PCN tube was removed. The Blood culture grew pseudomonas and Urine cultures grew pseudomonal and Providentia. ID consult was called and recommended Ceftazidime 1gm IV q8h until [**2106-7-12**]. VNA and home infusion was arranged for IV antibiotics. At discharge, patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. He is given oral pain medications on discharge, without antibiotics. He is given explicit instructions to call Dr. [**Last Name (STitle) 770**] for follow-up. Medications on Admission: Baclofen, Oxybutynin, Famotidine, MVI Discharge Medications: 1. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times a Day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: for breakthrough pain >4, take in place of Tylenol. Disp:*60 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Ceftazidime 2 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 9 days: Continue antibiotics until [**2115-7-12**]. Disp:*27 2 gram recon soln* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Nephrolithiasis status post right percutaneous nephrolithotomy Discharge Condition: Stable Discharge Instructions: VNA: 1. please administer IV antibiotics as prescribed for entire course: Ceftazidime 2 gm IV Q8H until [**2115-7-12**]. 2. Please flush PICC line per routine, monitor for signs of infection 3. Routine daily vitals, HR, BP, TEMP For the patient: -Expect drainage (bloody drainage is expected) from your back. Please change your dressings as often as needed to keep your skin as dry as possible. -You have been discharged with a PICC line in place for the continued administration of your antibiotics, this will be removed when course is finished. -Please seek medical attention if you experience fevers > 101.5, chills, chest pain, difficulty breathing, or increasing pain. -Call Dr.[**Name (NI) 825**] office upon discharge to schedule a follow-up appointment for removal of PICC line AND if you have any urological questions, [**Telephone/Fax (1) 5727**]. Followup Instructions: Call Dr.[**Name (NI) 825**] office to schedule a follow-up appointment AND if you have any urological questions, [**Telephone/Fax (1) 5727**]. Completed by:[**2115-7-3**]

[ "998.59", "995.91", "340", "596.54", "276.50", "998.11", "286.9", "038.43", "041.85", "E878.8", "599.0", "592.0" ]

icd9cm

[ [ [] ] ]

[ "55.04" ]

icd9pcs

[ [ [] ] ]

3690, 3745

1042, 2792

344, 381

3852, 3861

806, 1019

4775, 4948

768, 787

2880, 3667

3766, 3831

2818, 2857

3885, 4752

255, 306

409, 528

550, 683

699, 752

5,598

114,075

18275

Discharge summary

report

Admission Date: [**2175-5-5**] Discharge Date: [**2175-5-18**] Date of Birth: [**2117-10-10**] Sex: M Service: SURGERY Allergies: Codeine / Zestril Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain. Major Surgical or Invasive Procedure: Exploratory laparotomy with lysis of adhesions History of Present Illness: Mr. [**Known lastname 1617**] is a pleasant 57 yo white male well known to this service, who has a rather complicated PMH, including s/p bowel resection for Non-Hodgkin's B-cell lymphoma of the small bowel, recently treated conservatively in [**3-4**] for partial small bowel obstruction, who presented to [**Hospital1 18**] on [**2175-5-5**], with complaints of abdominal pain with nausea vomiting. Past Medical History: Non-Hodgkin's lymphoma Congential lymphatic atresia Seminoma s/p radiation and resection Appendectomy, perforated Cholecystectomy SBO ([**2174-12-14**]) s/p resection Social History: Supportive wife, otherwise denies [**Name (NI) **]/EtOH/IDU. Family History: Father - PVD Mother - questionable metastatic ovarian cancer Physical Exam: General: alert, oriented, well-nourished, whincing in pain HEENT: anicteric; no JVD LAD or thyromegaly Chest: CTA bilaterally CV: RRR without murmur or 3rd heart sound noted Abd: mildly distended, soft, diffusely tender Ext: Profound bilateral lower extremity edema, distal neurovascular intact Brief Hospital Course: As above, Mr. [**Known lastname 1617**], with a history of partial small bowel obstruction and Non-Hogdkin's B cell Lymphoma of small bowel, s/p resection, presented to [**Hospital1 18**] on [**2175-5-5**] with complaints of abdominal pain with nausea and bilious vomiting. A CT scan of the abdomen revealed a small bowel obstruction with a clear transition. He was admitted to the surgery service. He was made NPO, an NG tube was placed, he was hydrated well, and treated conservatively for 2 days. It was apparent that Mr. [**Known lastname **] bowel obstruction was not resolving, and on [**2175-5-8**], he underwent an exploratory laparotomy with lysis of adhesions to resolve his bowel obstruction. He tolerated the procedure well. However, because of his lymphatic atresia, Mr. [**Known lastname 1617**] is unable to adequately keep fluid in his intravascular space, and he required aggressive hydration, much of which was simply "third spaced" into his soft tissue space. He became incredibly edematous, and he remained intubated in the PACU for some time. He eventually was extubated, which he tolerated well. His recovery, while uncomplicated, was slowed by his edema. He began working with physical therapy. His diet was advanced slowly, and it was quite evident that his bowel obstruction was relieved by his operation. He eventually ambulated easily and often on his own. Before discharge, his diet was advanced to regular, his pain was well controlled with oral pain medications, and his wound appeared well healing. He was discharged to home in good condition on [**2175-5-18**]. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-1**] Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 10. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days. Disp:*20 Capsule(s)* Refills:*0* 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Small Bowel Obstruction Non-hodgkins B cell Lymphoma Discharge Condition: Good Discharge Instructions: Please keep wound area clean and dry. Take all medications as prescribed. Seek medical attention if you experience fever, chills, nausea, vomiting or increased abdominal pain. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1231**] within the first few days following discharge to schedule a follow-up appointment.

[ "263.9", "757.0", "560.2", "782.0", "560.1", "V12.59", "276.5", "560.81", "202.80", "707.05" ]

icd9cm

[ [ [] ] ]

[ "99.77", "38.93", "99.15", "54.59" ]

icd9pcs

[ [ [] ] ]

4344, 4350

1452, 3057

292, 341

4447, 4453

4679, 4839

1056, 1118

3080, 4321

4371, 4426

4477, 4656

1133, 1429

237, 254

369, 770

792, 961

977, 1040

42,346

180,391

22922

Discharge summary

report

Admission Date: [**2160-12-16**] Discharge Date: [**2160-12-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: Weakness and Cough Major Surgical or Invasive Procedure: None History of Present Illness: Primary care physician: [**Name10 (NameIs) 59215**] [**Name11 (NameIs) 6924**] ([**Telephone/Fax (1) 8417**] History of present illness: Patient is an 88 year old female with history of atrial fibrillation, type 2 diabetes melltius, and hypertension who presented with weakness and cough. According to the patient, her family, and her PCP, [**Name10 (NameIs) **] began to feel increasingly week over the last few days, as well as noted a minimally productive nagging cough. The patient and her family called her PCP on [**Name9 (PRE) 1017**] ([**2160-12-15**]), at which time it was recommended she come to the ED for evaluation. The patient and her family did not feel that she was ill enough for that, so an additional dose of lasix was prescribed. She was then started on a Z-pack as well. Given that she continued to feel poorly and more weak, she was brought in to the ED for evaluation after it was found that her oxygen saturations were low. In the emergency room, her initial vital signs were temperature of 97.3, blood pressure of 140/73, heart rate of 123, respiratory rate of 24, and oxygen saturation of 86% on 4L NC and room air (of note she was reportedly only breathing through her mouth). She was given 1 gram of ceftriaxone and 1 gram of vancomycin. She was put on a face-mask with improvement in her oxygenation. A chest x-ray was completed and a left lower lobe pneumonia was diagnosed. ABG in the ED was 7.31/70/291, and then 7.30/72/84. An initial lactate was 2.7. She was admitted to the ICU given her oxygen requirement (Non-rebreather), and tachypnea (rate in 30's), as well as possible need for BiPAP. Her code status was confirmed DNR/DNI with both patient and her family. PCP was called and offered the additional history: patient was feeling weak, wasn't herself over weekend, family didn't want to bring her in (daughter). She was started on z-pack, daughter stayed with patient overnight, and NP saw her in the morning (oxygen 80% on RA, HR 100, BP 110/70, temperature 96.3)-- at that time she was weaker and hypoxic, so sent to hospital. She is a new patient to [**Hospital3 **], has no known history of CHF, but based on office visit earlier this month to PCP, [**Name10 (NameIs) 59216**] fluid overloaded with pedal edema and rales. At that time, her BP was on lower side (90/60), and she was not SOB ([**Month (only) 1096**] suspicious of diastolic dysfunction. Past Medical History: - Atrial fibrillation, s/p pacemaker placement due to atrial fibrillation without ventricular response, on coumadin - Hypertension - Diabetes mellitus type 2 - Hyperlipidemia - Peripheral vascular disease - Peptic ulcer disease - Sick sinus syndrome status-post pacemaker placement - Glaucoma - Urinary incontinence - Skin cancer No known history of CHF, coronary artery disease, or COPD. Social History: Patient lives in lives in [**Hospital3 59217**] community. At baseline she uses a walker for assistance. She has never smoked, and drinks alcohol rarely. Family History: [**Name (NI) **] mother died sudden death at 85 and MGM died at 75 in sleep. MGM with angina. No significant past medical history on paternal side. Physical Exam: Vital Signs: Afebrile, BP 124/72, HR 100-110's, RR 20's, 98% on 35% face-mask General: Pleasant female sitting in bed, sleeping but easily aroused, in NAD, appropriate in conversation, speaking full sentences without distress HEENT: NC/AT. MMM, injection of conjunctival mucosa, erythema around eyes, no scleral icterus. MMM. Neck: Supple, JVP about 9 cm Lungs: Rales up 1/2 right side and at left base, some dullness to percussion a bases. No accessory muscle use. Cardiac: Irregulary irregular, tachycardic no m/g/r Abdomen: Distended with some typhany, but soft, +BS, non-tender Extr: 3+ Pitting edema up to knees bilaterally, right leg slightly great in size as compared to left, right leg also slightly warmer as compared to left, with increased pigmentation across shins. DP/PT 2+ bilaterally. No clubbing/cyanosis. Neuro: A&Ox3, CNs symmetric, moves all extremities and follows commands. Pertinent Results: [**2160-12-16**] 12:00PM WBC-6.8 RBC-4.18* HGB-12.3 HCT-36.7 MCV-88 MCH-29.5 MCHC-33.7 RDW-15.4 [**2160-12-16**] 12:00PM NEUTS-78.9* LYMPHS-14.9* MONOS-5.4 EOS-0.4 BASOS-0.4 [**2160-12-16**] 12:00PM GLUCOSE-213* UREA N-19 CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-35* ANION GAP-11 [**2160-12-16**] 12:09PM LACTATE-2.7* [**2160-12-16**] 12:00PM CK-MB-3 proBNP-2557* [**2160-12-16**] 12:00PM CK(CPK)-32 [**2160-12-16**] 12:00PM cTropnT-<0.01 [**2160-12-16**] 06:10PM CK-MB-NotDone cTropnT-<0.01 [**2160-12-16**] 06:10PM CK(CPK)-28 [**2160-12-16**] 12:17PM TYPE-ART PO2-291* PCO2-70* PH-7.31* TOTAL CO2-37* [**2160-12-16**] 02:02PM TYPE-ART PO2-84* PCO2-72* PH-7.30* TOTAL CO2-37* [**2160-12-19**] 05:22AM BLOOD WBC-7.2 RBC-3.95* Hgb-11.6* Hct-34.7* MCV-88 MCH-29.5 MCHC-33.6 RDW-15.2 Plt Ct-222 [**2160-12-19**] 05:22AM BLOOD PT-21.7* INR(PT)-2.1* [**2160-12-19**] 03:00PM BLOOD UreaN-15 Creat-0.6 Na-141 K-3.8 Cl-95* HCO3-43* URINE [**2160-12-16**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG, RBC-0-2 WBC-0 BACTERIA-MOD YEAST-NONE EPI-0-2, HYALINE-[**2-19**]* IMAGING CHEST (PORTABLE AP) Study Date of [**2160-12-16**] 11:49 AM Massive cardiomegaly is again noted, unchanged, and a pericardial effusion component may be possible. Pulmonary vascularity appears within normal limits however there are new small bilateral pleural effusions. Retrocardiac and right lower lobe opacities may reflect combination of atelectasis and effusion however underlying consolidation cannot be entirely excluded on this view. Left-sided pacemaker is again noted with single lead terminating in the expected region of the right ventricle. Sclerotic focus within the right humeral head appears unchanged since [**2157**]. UNILAT LOWER EXT VEINS RIGHT PORT Study Date of [**2160-12-16**] 5:31 PM No evidence of right lower extremity DVT seen. Portable TTE (Complete) Done [**2160-12-17**] at 10:02:37 AM FINAL The left atrial volume is markedly increased (>32ml/m2). The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild (non-obstructive) focal hypertrophy of the basal septum. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior and inferolateral segments. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-19**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with mild focal LV systolic dysfunction. At least moderate mitral regurgitation, directed posteriorly. Moderate to severe tricuspid regurgitation. Mild to moderate aortic regurgitation. Moderate pulmonary artery systolic hypertension. Enormous biatrial dilatation. OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION Ms. [**Known lastname 59218**] presents with mild to moderate oral and pharyngeal dysphagia characterized by swallow delay and reduced epiglottic deflection with episodes of aspiration occuring before and trace after the swallow on thin liquids. Patient appeared very fatigued during our evaluation and was often inconsistent in the timing of her swallow towards the end of today's evaluation. Swallow delay appeared to increase as patient fatigued and resulted in increased aspiration. Patient was sensate to aspiration, however cough was weak and ineffective. A chin tuck did appear effective in preventing further penetration, however limited trials were attempted and patient appears too fatigued to be able to perform this strategy consistently and effectively on her own at this time. Recommend patient continue a po diet of nectar thick liquids and regular solids, encourage soft foods to ease mastication. If patient is noted with continued coughing during meals and or worsening fatigue/mental status, please keep her NPO. We will follow-up next week to see how she is tolerating and if her diet may be upgraded when she is feeling better. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of level 4, mild to moderate dysphagia. RECOMMENDATIONS: 1. PO intake of nectar thick liquids and regular solids, encourage soft foods to ease mastication. 2. Pills crushed or whole with puree. 3. Supervision to assist with feeding and monitor swallow safety. 4. Give pos only when patient is most awake and alert. 5. Nutrition consult to monitor for adequate po intake. 6. Continue Q8 oral care. 7. If patient is noted with continued coughing during meals and or worsening fatigue/mental status, please keep her NPO. Brief Hospital Course: 88 F with AFib, HTN, DM p/w cough, hypoxia and found volume overload secondary to dilated cardiomyopathy and a possible LLL pneumonia. ICU COURSE: She was continued on vancomycin, ceftriaxone, and azithromycin started in the ED for nursing home acquired PNA. She weaned to 35% shovel mask overnight but was unable to be weaned to nasal canula. She was given IV lasix 20 mg IV once and had 500 cc urine output. Overall she was -1.7L during ICU stay. Lactate normalized and cardiac enzymes were negative. RESPIRATORY FAILURE: Patient's history, CXR and labs consistent with volume overload. On echo, she was found to have massive dilation concerning for a dilated cardiomyopathy. Her ABGs showed a respiratory acidosis with metabolic compensation suggestive of a chronic pulmonary process, possible secondary to untreated cardiomyopathy or chronic aspiration pneumoniae. A swallowing evaluation with a video swallow study showed intermittent aspiration. Her diet was changed to nectar thick liquids. She was diuresed with Lasix 40 mg IV BID for two days at a rate of 1-2L per day. She developed hypercarbia during diuresis with a HCO3 peaking at 45. She was started on acetazolamide with improvement in her hypercarbia. She was continued on ACE inhibition, although her blood pressures did not permit uptitration of this [**Doctor Last Name 360**]. For treatment of possible community acquired pneumonia, she was continued on ceftriaxone, and azithromycin. ** She should complete a 7 day course of cefpodoxime and azithromycin with the last day on [**2159-12-22**]. ** She needs outpatient cardiology follow-up for her dilated cardiomyopathy. ** She was discharged on an increased dose of 40 mg Lasix twice daily from 20 mg. This may need to be decreased once the patient is euvolemic. ** She needs an electrolyte check at rehab to evaluate potassium and lasix dosing and ensure HCO3 is stable. . DIABETES: She is on oral hypoglycemics as outpatient, which were held. She was started on an insulin sliding scale. Glipizide was reintroduced for better glucose control. She should resume her home meds on discharge. . ATRIAL FIBRILLATION: Patient has known atrial fibrillation and had heart rates in the low 100s during her stray. She was rate controlled with metoprolol and restarted on home atenolol prior to discharge. She is anticoagulated with Coumadin and had an elevated INR on admission. Coumadin was restarted Coumadin for INR goal [**1-20**]. She was restarted on a decreased dose of 4 mg daily from alternating 4mg and 6mg. . URINARY TRACT INFECTION: She had an E.coli UTI that was treated with ceftriaxone. . CODE: DNR/DNI (confirmed after discussion with patient, sons), patient would be amenable for trial of BiPAP if needed. . COMMUNICATION: Sons-- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 59219**], Cell ([**Telephone/Fax (1) 59220**] or [**Location (un) **] ([**Telephone/Fax (1) 59221**] Home, ([**Telephone/Fax (1) 59222**] Cell Medications on Admission: - Lasix 20 mg [**Hospital1 **] - Metformin 1500 mg QAM, 1000 mg QPM - Alphagin drops both eyes [**Hospital1 **] - Lisinopril 20 mg daily - Multivitamin 1 daily - Glypizide 5 mg daily - Atenolol 25 mg daily - Coumadin 6 mg Sa/T/Th/[**Doctor First Name **], 4 mg M/W/F - Potassium 40 mEq [**Hospital1 **] - Lipitor 20 mg daily - Azithromycin (family unsure of dose) since [**12-15**] Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days: Day 1 = [**12-15**] . 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Erythromycin 5 mg/g Ointment Sig: 0.5 in Ophthalmic TID (3 times a day) for 2 days. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Hold for loose stools. 9. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 days. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. Outpatient Physical Therapy Per Rehab staff recommendations 17. Outpatient Lab Work INR monitoring. Electrolytes, BUN, and Cr. Per rehab physician [**Name Initial (PRE) 7219**]. 18. Insulin Sliding Scale Insulin SC (per Insulin Flowsheet) Sliding Scale. Fingerstick QACHS. Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime. 0-65 mg/dL fruit juice, 66-149mg/dL 0 Units, 150-199mg/dL 2 Units, 200-249mg/dL 4 Units, 250-299 mg/dL 6 Units, 300-349mg/dL 8 Units, 350-399 mg/dL 10 Units, > 400mg/dL Notify M.D. 19. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO once a day: While taking lasix. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Systolic congestive heart failure, pneumonia Secondary: Diabetes, hypertension Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted with shortness of breath and fatigue. You were found to have pneumonia and evidence of heart failure. You were treated with antibiotics and medications to help remove excess fluid from your body. Once improved, you were discharged to rehab for further recovery. You still needed oxygen upon discharge, but this will continue to be weaned at rehab. Please take all medications as prescribed. Your rehab will be given a list of the medications you should be taking. Please keep all outpatient appointments. Seek medical advice if you have fever, chills, difficulty breathing, nausea, vomiting, chest pain, abdominal pain or any [**Last Name **] problem that is concerning to you. Followup Instructions: You need to arrange a follow-up appointment with cardiology. Because it is the weekend, we were unable to arrange this for you. Please call [**Telephone/Fax (1) 62**] to set up an appointment. You should also call your PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59223**], at [**Telephone/Fax (1) 6803**] to schedule a follow-up appointment. Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2161-1-9**] 10:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2161-2-24**] 1:50 Completed by:[**2160-12-23**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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282, 289

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42,078

197,680

15768

Discharge summary

report

Admission Date: [**2147-10-17**] Discharge Date: [**2147-10-24**] Date of Birth: [**2074-10-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2147-10-18**] - Redo sternotomy, Aortic valve replacement(21mm St. [**Male First Name (un) 923**] Regent Mechanical Valve), Mitral valve repair(28mm CE [**Doctor Last Name 405**] mitral band), CABGx1 (Saphenous vein->Obtuse marginal artery). History of Present Illness: 72 year old man with known AS who underwent an AVR (tissue prosthesis) in 11/98. He was hospitalized in [**8-14**] with dyspnea. A Stress stes was suggestive of ischemia with atrial fibrillation. A cardiac catheterization was performed which showed single vessel coronary artery disease and significant aortic stenosis and insufficiency. He is now referred for surgical management. Past Medical History: coronary artery disease prosthetic aortic stenosis mitral regurgitation s/p coronary stenting s/p aortic valve replacement [**10/2137**] chronic atrial fibrillation Hyperlipidemia hypertension benign prostatic hypertrophy Social History: Retired. Lives with wife in [**Name (NI) 5583**], MA. Never smoked. Drinks 1 glass of wine daily. Family History: Uncle with MI at age 57 Physical Exam: Discharge: VSS steable. 107/57 AF rate 80-90 Lungs:clear Cor: irregularly irregular, no murmur or rub Abd: soft, non-tender, non-distended Ext: trace edema EVH: c/d/i, no erythema or drainage sternal incision: c/d/i, no erythema or drainage, sternum stable Pertinent Results: [**2147-10-17**] Carotid Ultrasound No stenosis of the right carotid. 60-69% left carotid stenosis. [**2147-10-18**] ECHO Prebypass 1.No atrial septal defect is seen by 2D or color Doppler. 2.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. A bioprosthetic aortic valve prosthesis is present. Moderate to severe (3+) aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. 7. Moderate [2+] tricuspid regurgitation is seen. 8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2147-10-18**] at 1100 am. Post Bypass 1. Patient is V paced and receiving an infusion of epinephrine and phenylphrine. 2. Biventricular systolic function is unchanged. 3. There is an annuloplasty ring seen in the mitral position. It appears well seated. Immediately post bypass there was 3+ mitral regurgitation that was 2+ at the end of the case. Peak gradient across the mitral valve is 9 mm Hg. There is no [**Male First Name (un) **]. 4. Mechanical prosthesis seen in the aortic position. The valve appears well seated and the leaflets move well. There is trace central aortic insufficiency. Washing jets typical for this type of valve are also seen. Peak gradient across the aortic valve is 11 mm Hg. 5. Aorta is intact post decanulation. 6. Dr [**Last Name (STitle) **] notified of the above post bypass findings. [**2147-10-23**] 09:10AM BLOOD WBC-7.5 RBC-3.43* Hgb-10.5* Hct-29.4* MCV-86 MCH-30.6 MCHC-35.7* RDW-14.8 Plt Ct-230 [**2147-10-21**] 07:25AM BLOOD Glucose-97 UreaN-16 Creat-1.0 Na-138 K-3.8 Cl-101 HCO3-31 AnGap-10 [**2147-10-23**] 09:10AM BLOOD Mg-2.1 [**2147-10-24**] 05:40AM BLOOD PT-22.1* PTT-32.7 INR(PT)-2.1* Brief Hospital Course: Mr. [**Known lastname 45412**] was admitted to the [**Hospital1 18**] on [**2147-10-17**] for surgical management of his aortic valve and coronary artery disease. Heparin was started as a bridge to surgery as he had stop his Coumadin five days prior to admission. On [**2147-10-18**], Mr. [**Known lastname 45412**] was taken to the operating room where he underwent a redo aortic valve replacement with a [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical valve, a mitral valve repair and coronary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He weaned from bypass on neosynephrine and epinephrine. Within 24 hours, he awoke neurologically intact and was extubated. Pressors were weaned easily and he remained stable. On postoperative day one, Mr. [**Known lastname 45412**] was transferred to the step down unit for further recovery. Coumadin was resumed for AF and his mechanical valve. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Sotalol was resumed for his AF and beta blockade and digoxin were added. His AF rate was well controlled, he felt well and was ready for discharge on 11.18 Arrangements were made for his Coumadin to be regulated by Dr. [**Last Name (STitle) 14522**] as preoperatively. The INR goal is 2.5-3.5. Medications, restrictions and follow up were discussed with the patient prior to going home. Medications on Admission: digitek 250mcgm, coumadin 5/2.5, plavix 75, sotalol 120, quinipril 20, lipitor 10, synthroid 0.125, amoxicillin prn Discharge Medications: 1. Influen Tr-Split [**2146**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED) for 1 days. 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: INR 2.5-3.5. Disp:*100 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). Disp:*30 Packet(s)* Refills:*2* 11. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-12**] hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital1 40198**] VNA Discharge Diagnosis: coronary artery disease prosthetic aortic insufficiency s/p aortic valve replacement [**10/2137**] chronic atrial fibrillation s/p coronary stenting Hyperlipidemia hypertension benign prostatic hypertrophy hyperlipidemia Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 170**]) Please follow-up with Dr. [**Last Name (STitle) 14522**] in [**1-8**] weeks. Please follow-up with Dr. [**Doctor First Name 45413**] in 3 weeks. ([**Telephone/Fax (1) 45414**]) Please call for appointments wound clinic in 2 weeks Completed by:[**2147-10-24**]

[ "414.01", "V45.82", "996.02", "910.0", "433.10", "E885.9", "424.0", "600.00", "244.9", "401.9", "272.4", "427.31", "E878.1", "424.1", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "35.12", "88.72", "39.61", "35.22", "36.11" ]

icd9pcs

[ [ [] ] ]

6745, 6801

3588, 5156

344, 591

7066, 7072

1696, 3565

7849, 8205

1378, 1403

5322, 6722

6822, 7045

5182, 5299

7096, 7826

1418, 1677

285, 306

619, 1002

1024, 1247

1263, 1362

51,399

134,907

47068

Discharge summary

report

Admission Date: [**2119-9-10**] Discharge Date: [**2119-9-15**] Service: SURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Pneumovax 23 / Ibuprofen / Nitrofurantoin / Sulfamethoxazole Attending:[**First Name3 (LF) 598**] Chief Complaint: +head and back pain Major Surgical or Invasive Procedure: none History of Present Illness: 89F s/p fall last night at 5pm. Not a great historian. Tripped and fell into wall and onto the ground. No LOC, could not get up from the ground. Found by neightbors this morning. C/o head and back pain, cannot ambulate. Denies palpitations, lightheadedness prior to fall. A&OX3 for EMS, but episodes of confusion during transport and here in ED. Likely has dementia. On coumadin for previous DVT. Epistaxis of nose, ecchymosis or right temporal bone, large hematoma of right thigh Past Medical History: - probable RCC s/p renal biopsy/seed implantation [**2118-12-22**] - diverticulosis - mild gastritis - venous insufficiency - hx of vertigo ~5 years ago that lasted for 11 days after seen by chiropractor - GERD - hx of seizure x 1 - Cystocoele - OA - Migraine headache with visual scotoma "like neon lights" - on Coumadin for DVT [**2112**] Social History: She is divorced and has one son, one daughter ([**Name (NI) 4320**] [**Telephone/Fax (1) 99793**], she lives alone in an elderly persons apartment center near [**State **] square. Remote tobacco use, no etoh. Is involved in multiple social groups. Pt uses a cane. Family History: Mother died at 98, had severe migraines. Father died at 91 from complications from blood transfusion. Physical Exam: Temp: 97.3 HR: 80 BP: 106/66 Resp: 18 O(2)Sat: 95 Constitutional: Comfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact poor dentition, no acute tooth fx seen, dry mm Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: large right lateral buttock hematoma Skin: see above Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2119-9-10**] 12:23PM WBC-8.5# RBC-2.60*# HGB-8.2* HCT-24.3*# MCV-93 MCH-31.5 MCHC-33.8 RDW-15.0 [**2119-9-10**] 12:23PM NEUTS-87.9* LYMPHS-7.4* MONOS-4.3 EOS-0.2 BASOS-0.2 [**2119-9-10**] 12:23PM PLT COUNT-130* [**2119-9-10**] 12:23PM PT-30.4* PTT-31.7 INR(PT)-3.0* [**2119-9-10**] 12:23PM PHENYTOIN-31.2* [**2119-9-10**] 12:23PM CALCIUM-8.1* PHOSPHATE-3.9 MAGNESIUM-2.0 [**2119-9-10**] 12:23PM GLUCOSE-186* UREA N-21* CREAT-1.4* SODIUM-136 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16 [**2119-9-10**] 10:24PM HCT-22.5* [**2119-9-10**] 10:43PM PT-14.9* PTT-26.4 INR(PT)-1.3* [**2119-9-10**] Head CT : 1. No acute intracranial process. 2. Progressive cortical atrophy, particularly bifrontal. [**2119-9-10**] B/L Hips : Right superior and inferior pubic rami fractures. Large STS along the right hip. Please refer to subsequent CT for further details [**2119-9-10**] CT Pelvis : 1. Acute right superior and right inferior pubic ramus fractures with associated pelvic and intramuscular hematoma. 2. Large hematoma adjacent to the right hip and buttock, with a focus of active arterial extravasation. 3. Nondisplaced fracture of the right sacral ala. No associated hematoma or SI joint involvement. [**2119-9-12**] CT Pelvis : 1. Right superior and inferior pubic rami fractures, and nondisplaced right sacral fracture, with unchanged hematomas in the right pelvis and overlying the right greater trochanter/right gluteal muscles. There is however no evidence of active extravasation. 2. Mild aortobiliac atherosclerotic disease. 3. Indeterminate hyperdense lesion adjacent to the left aspect of the urethra, likely a proteinaceous or hemorrhagic cyst, unchanged from prior studies and of unlikely clinical significance. Brief Hospital Course: Mrs. [**Known lastname 99794**] was evaluated by the Trauma team in the Emergency Room and scans were reviewed. She had a pubic rami fracture and a large right gluteal hematoma. Her INR was 3.0 and her hematocrit was 24. She was given FFP in the ER along with 2 units of packed red cells as her hematoma appeared to be expanding. The Ortho Trauma team also evaluated her in the ER and recommended non operative treatment for now. She was admitted to the Trauma ICU for further management and resuscitation. Her hematocrit gradually dropped to 20 and she required 3 additional units of blood over the next 48 hours. She maintained stable hemodynamics and interventional radiology was consulted in case there was active extravasation. A repeat CTA of the pelvis was done with delayed imaging on [**2119-9-12**] and there was no evidence of an active bleed. Her hematocrit gradually levelled out in the 28-29 range and she continued to have stable hemodynamics. She remained off of Coumadin which was for treatment of an old DVT and her INR normalized. Following transfer to the Trauma floor she continued to do well. Her weight bearing status is as tolerated on both legs and she continues to work with Physical Therapy to help increase her mobility. Non operative treatment of her pubic rami fracture is the goal. Her appetite has been modest and she was placed on Megase today to try to stimulate her appetite. Calorie counts will be helpful. Of note she was admitted on Dilantin 300 SR daily and had a level of 31. Her Dilantin held then resumed at a lower dose (200mg) on [**2119-9-14**] with a level on [**2119-9-15**] of 16. Her Coumadin has been stopped but she is getting SC Heparin prophylactically and her hematocrit has been stable. After a long hospital course she is being discharged to rehab on [**2119-9-15**] and will follow up in the [**Hospital **] Clinic in 4 weeks. Medications on Admission: premarin, vitamin D2, lasix 40', dilantin ER 300 qhs, KCl, simvastatin 20', tizanidine 2qhs, coumadin 1.5', asa 81', prilosec Discharge Medications: 1. tramadol 50 mg Tablet Sig: 1/2-1 Tablet PO TID (3 times a day) as needed for Pain. 2. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for agitation. 3. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)) as needed for agitation. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. tizanidine 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily). 11. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 12. megestrol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 13316**]Healthcare Center - [**Hospital1 10478**] Discharge Diagnosis: S/P Fall 1. Right superior/inferior pubic rami fracture 2. Right gluteal hematoma with active extravasation 3. Acute blood loss anemia 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 falling with multiple injuries including a pelvic fracture, a collection of blood around your hip and buttock due to bleeding. You required blood transfusions as your blood count was too low. After the effects of the Coumadin were reversed, the bleeding stopped but nevertheless you have a collection of blood in your buttock which will resorb in time. * The Orthopedic doctors [**Name5 (PTitle) **] not [**Name5 (PTitle) 9004**] to operate on your pelvic fracture. They hope that over time it will heal. You can bear weight on both legs as tolerated. You will need to undergo physical therapy to help increase your ambulation during this time. * Do not take any more Coumadin until you discuss it with your primary care doctor. * Youe Dilantin dose was also decreased as your levels were high on admission. * If you develop any lightheadedness, dizziness or any other symptoms that concern you, please call your doctor or return to the Emergency Room. Followup Instructions: Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up appointment in 4 weeks. If you have any questions about this admission please call the Acute care Clinic at [**Telephone/Fax (1) 600**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2119-9-15**]

[ "599.0", "V10.52", "V58.61", "285.1", "715.90", "V12.51", "403.90", "922.32", "459.81", "784.7", "808.2", "585.9", "E934.2", "535.50", "790.92", "780.39", "584.9", "346.90", "294.8", "E885.9", "924.00", "805.6", "293.0", "920", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7159, 7248

4026, 5932

320, 327

7427, 7427

2247, 4003

8633, 8989

1499, 1602

6109, 7136

7269, 7406

5958, 6086

7603, 8610

1617, 2228

261, 282

355, 837

7442, 7579

859, 1201

1217, 1483

48,115

138,322

36845

Discharge summary

report

Admission Date: [**2126-7-15**] Discharge Date: [**2126-7-30**] Date of Birth: [**2044-5-21**] Sex: M Service: UROLOGY Allergies: Hayfever Attending:[**First Name3 (LF) 11304**] Chief Complaint: Left renal mass Major Surgical or Invasive Procedure: Left Radical nephrectomy, IVC thrombectomy History of Present Illness: 82-year-old gentleman who was noted to have some increasing creatinine when he was in [**State 108**]. This led to an ultrasound and eventually a CT scan, unfortunately revealing a large left renal mass with extension into the left renal vein and inferior vena cava. [**Location (un) 72812**] denies any fever, nausea, vomiting, chills, or changes in appetite. He has lost about 5 pounds over the past six months. Denies any gross hematuria, urinary infections, history of kidney stones, or other obvious urinary symptoms. Past Medical History: HTN, A Fib, Anemia, Osteoarthritis, Bilateral carotid occlusion Social History: Nonsmoker, one glass of wine daily. He is an active sailor. He is currently retired. He worked with GE for many years in acoustics, and developed his own company. Formerly lived in [**Location **]. The company was bought out and he moved to [**State 1727**] near Sebago [**Doctor Last Name **], and also spends time in [**Last Name (LF) 83229**], [**First Name3 (LF) 108**]. Family History: Family history is negative for kidney cancer. Mother died at 99 with breast cancer. Physical Exam: On exam, he is 136 pounds. His vital signs are stable. He is alert and oriented x3, appears younger than stated age. Head, eyes, ears, nose, and throat grossly within normal limits. Chest expands equally with normal effort, 2+ radial pulses irregular. No cervical adenopathy. Abdomen is soft, nontender. There is a hint of a left fullness in the upper quadrant, but no palpable masses. Penis is uncircumcised with a tight phimotic foreskin. Testicles are both descended. There is a small, left varicocele. Normal rectal tone, 40 g prostate, smooth, no nodules. No extremity edema. Pertinent Results: [**2126-7-21**] 05:45AM BLOOD Glucose-114* UreaN-93* Creat-6.5* Na-138 K-5.0 Cl-109* HCO3-20* AnGap-14 [**2126-7-15**] 05:15PM BLOOD Glucose-206* UreaN-22* Creat-1.7* Na-142 K-4.2 Cl-116* HCO3-14* AnGap-16 [**2126-7-22**] 05:55AM BLOOD WBC-5.4 RBC-2.78* Hgb-8.9* Hct-26.4* MCV-95 MCH-32.1* MCHC-33.8 RDW-13.8 Plt Ct-201 [**2126-7-23**] 05:35AM BLOOD WBC-4.7 RBC-2.75* Hgb-8.9* Hct-25.6* MCV-93 MCH-32.3* MCHC-34.7 RDW-13.7 Plt Ct-218 [**2126-7-24**] 05:50AM BLOOD WBC-4.2 RBC-2.92* Hgb-9.1* Hct-27.0* MCV-92 MCH-31.2 MCHC-33.9 RDW-14.2 Plt Ct-274 [**2126-7-25**] 06:28AM BLOOD WBC-4.3 RBC-2.77* Hgb-8.8* Hct-25.9* MCV-94 MCH-31.8 MCHC-34.0 RDW-13.9 Plt Ct-303 [**2126-7-30**] 06:40AM BLOOD WBC-6.8 RBC-2.93* Hgb-9.2* Hct-26.7* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.1 Plt Ct-447* [**2126-7-29**] 05:50AM BLOOD WBC-6.9 RBC-3.02*# Hgb-9.7*# Hct-27.8* MCV-92 MCH-32.1* MCHC-34.9 RDW-14.5 Plt Ct-468* [**2126-7-28**] 11:55PM BLOOD Hct-24.3* [**2126-7-28**] 11:16AM BLOOD Hct-22.9* [**2126-7-28**] 05:30AM BLOOD WBC-4.9 RBC-2.20* Hgb-7.0* Hct-20.4* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.5 Plt Ct-400 [**2126-7-30**] 06:40AM BLOOD PT-17.9* PTT-28.8 INR(PT)-1.6* [**2126-7-29**] 05:50AM BLOOD PT-24.5* PTT-30.1 INR(PT)-2.3* [**2126-7-28**] 05:30AM BLOOD PT-27.2* PTT-31.1 INR(PT)-2.7* [**2126-7-30**] 06:40AM BLOOD Glucose-102 UreaN-45* Creat-4.0* Na-142 K-4.6 Cl-109* HCO3-23 AnGap-15 [**2126-7-29**] 05:50AM BLOOD Glucose-97 UreaN-48* Creat-4.2* Na-138 K-4.7 Cl-106 HCO3-23 AnGap-14 [**2126-7-28**] 05:30AM BLOOD Glucose-121* UreaN-54* Creat-4.4* Na-138 K-4.4 Cl-108 HCO3-23 AnGap-11 [**2126-7-27**] 01:00PM BLOOD Glucose-96 UreaN-59* Creat-4.9* Na-141 K-4.9 Cl-107 HCO3-20* AnGap-19 [**2126-7-27**] 05:20AM BLOOD Glucose-111* UreaN-61* Creat-4.9* Na-138 K-5.3* Cl-109* HCO3-21* AnGap-13 [**2126-7-26**] 06:25AM BLOOD Glucose-109* UreaN-70* Creat-5.0* Na-139 K-5.1 Cl-109* HCO3-20* AnGap-15 Brief Hospital Course: Patient was admitted to Urology on [**2126-7-15**] after undergoing left radical nephrectomy, IVC thrombectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the ICU from the OR in stable condition. The patient's ICU course was complicated by requiring pressors for low MAP's, increasing creatinine secondary to likely ATN from vascular clamping during IVC repair, and delirium. The pressors were titrated to off by POD 2. The patient's creatinine continued to rise. The patient was transferred to the floor in stable condition on POD 3. Renal consultation was requested, and they recommended conservative management and IV fluids. Renal and IVC U/S showed wall-to-wall flow without evidence for thrombus in the IVC at the level of the liver as well as extending approximately 9 cm more inferior to this. Normal vascular waveforms in the right renal artery and vein. Normal flow in the main portal vein, middle hepatic vein, and right hepatic vein. Creatinine peaked at 6.5 on POD 6 and started to trended downward. On POD11 a CBC revealed a HCT of 20.2 and the patient was subsequently transfused with 3 units of blood. Serial HCT's were collected q 6 hours, and a abdominal CT without contrast was obtained with the following read: Large mixed-density collection in the left nephrectomy bed consistent with hematoma. Without the ability to give the patient contrast the acuity of a bleed was indeterminate. However following transfusion the patients HCT remained stable and for this reason we assume that the hematoma noted on CT was not related to an ongoing bleed. On POD13 the patients HCT remained stable at 26.7. Additionally his Cr decreased to 4.0, the renal team was consulted and felt the patient from a renal standpoint was stable for discharge. PT Consult was requested, and the patient was cleared to go home without services. The patient was discharged on POD14 in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incisions was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic for a CBC,Chem 7, and INR on [**2126-8-2**] at 10am in the [**Hospital Ward Name 23**] Center and then for an office appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] at 11:00 am of the same day. He was given detailed discharge instructions related to changes in medications, restarting his coumadin and follow up with his primary care related to continued management of his HTN meds and INR, and subsequent follow up with Urology and Renal. Medications on Admission: Avodart, Pravastatin 20, Coumadin 5, Ferrous sulfate, Toprol, lisinopril, calcium, iron, glucosamine. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Avodart Oral 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1.0 Tablet PO every 4-6 hours as needed for pain: Do not drive or consume alcohol while taking pain medication. Disp:*60 Tablet(s)* Refills:*0* 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Left renal mass status post radical nephrectomy, IVC thrombectomy Discharge Condition: Stable Discharge Instructions: -You have been provided a laboratory order slip please return to the [**Hospital Ward Name 23**] Clinical Center on Friday [**2126-7-26**] in the morning to have blood drawn for analysis (creatinine and INR). Someone will follow up with you by the end of the day regarding the labs, please stay in the local vicinity until the labs have been processed and evaluated by Dr. [**Last Name (STitle) 3748**]. -Please contact your PCP upon discharge to arrange for continued management of your Coumadin daily dose and INR levels. Upon discharge your INR was ___ at a daily Coumadin dose of 2.5 mgs. Also, your lisinopril has been discontinued due to your kidney function. We added amlodipine 5mg by mouth daily for blood pressure control while you are off the lisinopril. Also, your metoprolol has been increased to 37.5mg by mouth twice a day. -You may shower but do not bathe, swim or immerse your incision for 2 weeks. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofin) until you see your urologist in follow-up. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. -Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office upon discharge to set up follow-up appointment and if you have any urological questions. [**Telephone/Fax (1) 3752**] Followup Instructions: Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to arrange/confirm follow up and if you have any urological questions. [**Telephone/Fax (1) 3752**] Call Dr.[**Name (NI) 9920**] (Renal Physician) office to arrange follow up appointment in [**Month (only) **]. [**Telephone/Fax (1) 60**] Additionally please follow up with previously scheduled appointments listed below: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2126-8-14**] 3:00 Provider: [**First Name8 (NamePattern2) 25**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2126-8-14**] 3:00 Completed by:[**2126-7-30**]

[ "788.5", "584.5", "285.1", "276.2", "997.5", "998.12", "453.2", "276.7", "401.9", "293.0", "189.0", "E878.6", "433.10", "715.90", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.07", "39.59", "55.51" ]

icd9pcs

[ [ [] ] ]

7668, 7674

3999, 6807

285, 330

7784, 7793

2100, 3976

9497, 10230

1387, 1474

6961, 7645

7695, 7763

6833, 6938

7817, 9474

1489, 2081

230, 247

358, 885

907, 973

989, 1371

21,900

113,956

50105

Discharge summary

report

Admission Date: [**2204-9-10**] Discharge Date: [**2204-9-14**] Date of Birth: [**2142-12-26**] Sex: F Service: MEDICINE Allergies: Norvasc / Infed Attending:[**First Name3 (LF) 4765**] Chief Complaint: Burning chest pain and shortness of breath Major Surgical or Invasive Procedure: Dialysis Removal of tunneled dialysis catheter History of Present Illness: Pt is a 61 yo F w/ CAD s/p MI (in [**2-3**]) and previous 2 stents in RCA and LAD, scleroderma, HTN, ESRD on HD MWF ([**12-28**] scleroderma) s/p transplant x2 currently failing with initiation of dialysis since [**Month (only) 205**], and systolic HF (EF 20-25%) who comes in with substernal, burning chest pain that feels like "fire." She reports this pain has been ongoing and intermittent for months, and has been occuring every night for the past few weeks. She notes this pain only occurs at night and begins after she lays flat to sleep. She reports that it is exacerbated by food. She finds herself having to sit almost upright to help relieve her pain. She has tried antacids, maalox, and omeprazole with no relief. She has also tried nitroglycerin which will relieve her pain for about 1/2-1 hour, but then the pain returns. She has requested oxygen at her last two dialysis sessions which helps her and she usually feels better after her HD sessions. She also has associated dyspnea along with the pain that is much improved with oxygen and sitting in an upright position. . Of note, she was admitted to [**Hospital1 18**] last in [**6-4**] w/ pulmonary edema and dyspnea, had a tunneled IJ line placed and was initiated on dialysis in the setting of her renal transplant failure and volume overload. She was intubated for respiratory distress and had good relief with lasix gtt with return of adequate oxygen saturations on room air. She was discharged on furosemide 80mg [**Hospital1 **] but reports now that she does not make any urine, a few drops if any. . She was evaluated by PCP for this chest pain most recently 5 days ago. He noted that she hasn't had any weight changes nor increase swelling in her BLEs. He believes chest pain is GI in origin patient is scheduled for outpatient endoscopy for further evaluation this Thursday along with treatment with omeprazole. . In the ED, vitals 97.1 104 118/65 22 97%. CXR with pulmonary edema, EKG with LAD, IVCD without changes compared prior. Patient started on CPAP in ED given tachypnea was unable to wean off. Vitals prior to transfer HR: 91, 100% on Bipap, BP 107/66. Pt arrived to the CCU floor on a NRB, but then slowly transitioned to 4L NC w/ oxygen saturations 92-95%. Pt felt comfortable as long as she was sitting up straight and felt better with the oxygen. . 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 dyspnea on exertion, ankle edema, palpitations, syncope or presyncope. Past Medical History: -- Multivessel CAD, S/P anterior STEMI 03/[**2203**]. s/p RCA and LAD stenting previously. -- Ischemic CMP, LVEF 30% -- HTN -- Dyslipidemia -- PVD s/p R to L fem-fem bypass, R external iliac stenting -- Scleroderma -- ESRD on HD, s/p renal transplant x2 in [**2197**], now w/ rejection -- osteoporosis -- hx GI bleed Social History: Lives at home with husband - [**Name (NI) 1139**] history: Heavy [**Name (NI) 1818**] ~ [**11-27**] PPD for > 30 years, quit in [**Month (only) 205**] - ETOH: Denies - Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: DM, passed away 4 years ago - Father: [**Name (NI) **] cancer, died in his 30s Physical Exam: ADMISSION PHYSICAL EXAM VS: Afebrile, BP=118/65 HR= 95 RR=30 O2 sat= 93 GENERAL: In mild respiratory distress but calm. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry mucous membranes. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVD 8cm. 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 slightly labored. Crackles on b/l lung fields mid-way up the lung. No wheezes/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+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM Vitals - Tm/Tc: 98.8/98.8 HR:85 BP:89-97/53-56 RR: 02 sat: 95% RA In/Out: Last 24H: 240/anuric Last 8H: Weight: 66.9( ) Tele: SR, rate 60's-80's, few runs of WCT, irregular, unclear if VT vs aberrency, asymptomatic GENERAL: 61 yo F in no acute distress, stitting in chair HEENT: PERRLA, no pharyngeal erythemia, mucous membs dry, no lymphadenopathy, JVP non elevated CHEST: Crackles left base only, no rhonchi or wheezes CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: A/O, pleasant and cooperative Pertinent Results: ADMISSION LABS [**2204-9-10**] 11:00AM BLOOD WBC-5.0 RBC-2.91* Hgb-8.7* Hct-27.4* MCV-94 MCH-29.8 MCHC-31.7 RDW-15.3 Plt Ct-216 [**2204-9-10**] 11:00AM BLOOD Neuts-73.0* Lymphs-15.2* Monos-4.7 Eos-6.4* Baso-0.7 [**2204-9-10**] 11:00AM BLOOD PT-13.7* PTT-28.1 INR(PT)-1.2* [**2204-9-10**] 11:00AM BLOOD Glucose-159* UreaN-44* Creat-6.6* Na-137 K-4.8 Cl-96 HCO3-27 AnGap-19 [**2204-9-10**] 11:00AM BLOOD CK-MB-4 proBNP- > [**Numeric Identifier **] [**2204-9-10**] 11:00AM BLOOD cTropnT-0.16* [**2204-9-10**] 05:56PM BLOOD CK-MB-10 MB Indx-15.4* cTropnT-0.22* [**2204-9-11**] 04:00AM BLOOD CK-MB-23* MB Indx-16.4* cTropnT-0.75* [**2204-9-11**] 12:10PM BLOOD CK-MB-14* MB Indx-12.1* cTropnT-0.82* [**2204-9-10**] 11:00AM BLOOD CK(CPK)-33 [**2204-9-10**] 05:56PM BLOOD CK(CPK)-65 [**2204-9-11**] 04:00AM BLOOD CK(CPK)-140 [**2204-9-11**] 12:10PM BLOOD CK(CPK)-116 [**2204-9-11**] 04:00AM BLOOD Calcium-9.7 Phos-5.2* Mg-1.8 . DISCHARGE LABS [**2204-9-14**] 07:01AM BLOOD WBC-5.0 RBC-2.85* Hgb-8.7* Hct-26.1* MCV-92 MCH-30.5 MCHC-33.2 RDW-15.1 Plt Ct-202 [**2204-9-13**] 05:55AM BLOOD PT-13.2 PTT-32.2 INR(PT)-1.1 [**2204-9-14**] 07:01AM BLOOD Glucose-191* UreaN-44* Creat-5.2*# Na-134 K-4.5 Cl-94* HCO3-28 AnGap-17 [**2204-9-14**] 07:01AM BLOOD Calcium-10.1 Phos-2.5* Mg-1.8 [**2204-9-11**] 04:00AM BLOOD tacroFK-4.7* [**2204-9-12**] 05:35AM BLOOD tacroFK-5.4 [**2204-9-12**] 11:22AM BLOOD tacroFK-3.9* [**2204-9-14**] 07:01AM BLOOD tacroFK-4.9 [**2204-9-12**] 11:22AM BLOOD Fibrino-461* [**2204-9-12**] 11:22AM BLOOD LD(LDH)-236 TotBili-0.7 DirBili-0.3 IndBili-0.4 [**2204-9-12**] 11:22AM BLOOD Hapto-216** . MICROBIOLOGY [**2204-9-10**] MRSA SCREEN: No MRSA isolated . IMAGING [**2204-9-10**] CHEST (PORTABLE AP): There is bilateral diffuse reticulonodular opacity in the lower lung fields and ground-glass haziness. These findings are compatible with pulmonary edema. Dialysis catheter is in unchanged position with tip seen in the distal SVC/cavoatrial junction. Cluster of calcifications in the right mid lung are unchanged. The aorta is tortuous and calcified. There is mild cardiomegaly. No definite pleural effusions are seen. . [**2204-9-11**] TTE: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferior akinesis and near akinesis of the distal half of the septum and anterior walls. The apex is aneurysmal and akinetic. The remaining segments contract well (LVEF 30%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and extensive regional systolic dysfunction c/w multivessel CAD or other diffuse process. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2204-6-4**], the severity of mitral regurgitation is increased and global left ventricular systolic function is improved with slight decrease in cavity size. Regional left ventricular dysfunction is similar. . [**2204-9-11**] CHEST (PORTABLE AP): In comparison with the study of [**9-10**], there has been substantial decrease in the pulmonary [**Month/Year (2) 1106**] congestion with the pulmonary vessels now only mildly engorged. Minimal atelectatic change is seen at the left base and there may be blunting of the costophrenic angle. Hemodialysis catheter remains in place. Brief Hospital Course: 61 yo F w/ CAD s/p MI (in [**2-3**]) and previous 2 stents in RCA and LAD, scleroderma, HTN, ESRD on HD s/p transplant x2, and systolic HF (EF 20-25%) who comes in with chronic burning chest pain and acute systolic heart failure. . # Acute Systolic CHF: Patient presented with increased dyspnea and chest x-ray showed pulmonary edema. Physical exam demonstrated rales to mid lung fields. Patient reports increased dyspnea prior to dialysis recently and may need change to dry weight. She had a session of ultrafiltration the night of admission and then a truncated 2-hour session of dialysis the following day. In keeping with her outpatient schedule, the pt went for a full session of dialysis on Wednesday. ECHO showed an EF of 30% and so she was started on metoprolol succinate 25mg qHS, with lisinopril 2.5mg to possibly be started as an outpatient (and to be titrated up as her blood pressure will tolerate it and also to be held on her dialysis days). After her dialysis session, pt's symptoms improved, physical exam demonstrated clear lung fields, and chest xray showed interval improvement in pulmonary edema. . #. Chest Pain/Burning: Pts pain was atypical. Her symptom has bothered her each evening for a very long time, and is exacerbated when she lies on her back. It is thought to be GI related per outpatient providers and will follow up with GI in one week. EKG was without changes, and discomfort resolved on arrival and with subsequent nitroglycerin. Her cardiac enzymes were trended until they peaked. She was put on PPI and carafate, which seemed to provide relief of her pain. . #. ESRD sp transplant on HD: Pt had a session of ultrafiltration on the night of admission and was continued on her outpatient schedule of dialysis, Monday, Wednesday, Friday. Her graft is well-functioning and her tunneled catheter was pulled. She was continued on her home prednisone, cellcept, tacrolimus, and calcitriol. Her tacrolimus levels were within target. The amount of fluid they were able to take off and the length of time spent on dialysis was limited by pt's low blood pressure. She will continue to have 4 hours of dialysis, three times a week, with the next session on Monday and an estimated dry weight of 67.5kg. . # CAD: Pt was continued on her home statin and ASA. . # RHYTHM: Pt was in sinus rhythm, and had no active issues with her rhythm during the admission. She was monitored on telemetry . #. Normocytic Anemia: At recent baseline. Secondary to ESRD. She was continued on Aranesp with dialysis per her outpatient regimen and given 1 unit pRBC with an appropriate increase in her hematocrit. . # HTN: Blood pressure was well controlled on presentation. She was started on metoprolol succinate 25mg qHS, with lisinopril to possibly be started as an outpatient as long as her blood pressure can tolerate it. Her lisinopril should be held on hemodialysis days due to low blood pressures. . # HLD: Pt was continued on her home Lipitor. . TRANSITIONAL ISSUES # Recommend initiating lisinopril 2.5mg daily as an outpatient as long as her blood pressures can tolerate it. This medication should be held on hemodialysis days. STOP taking calcitriol START nephrocaps as a vitamin for your kidneys START pantoprazole twice daily for your heartburn START carafate up to four times per day for your heartburn, do not take this within 1 hour of your other medications START taking Maalox (calcium and simethicone) as needed for your heartburn START Metoprolol at night to lower your heart rate and avoid chest pain. Medications on Admission: - Lipitor 80 mg daily - Aspirin 81 mg daily, - Nitroglycerin sublingual p.r.n. - Calcitriol 0.25 mcg daily - Aranesp - Albuterol MDI p.r.n. - Prednisone 2 mg daily, - Tacrolimus 1 mg b.i.d. - CellCept [**Pager number **] mg b.i.d. Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual as directed as needed for chest pain. 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Maalox Max Quick Dissolve 1,000-60 mg Tablet, Chewable Sig: One (1) tab PO three times a day as needed for heartburn. tab 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day): Do not take within 1 hour of your other medications. Disp:*120 Tablet(s)* Refills:*2* 11. 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* 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 13. Aranesp (polysorbate) Injection Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Acute on chronic systolic congestive heart failure Ends stage renal disease Coronary artery disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [**Hospital1 18**]. You had some chest discomfort that brought you into the hospital. We think that some of this discomfort is because of your stomach and have started you on a new medicine and scheduled an appt with a gastroenterologist on Tuesday [**9-18**]. At the same time, you had too much fluid in your lungs and we removed a little more fluid with dialysis and adjusted your dialysis medications. Your weight this morning is 150 pounds. This should be considered your new dry weight. Weigh yourself every morning, call your nephrologist if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. You were also anemic and received one unit of blood. Please call Dr. [**Last Name (STitle) 171**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) 37741**] have chest pain/burning at home that is worse than the mild chest burning you have experienced for the last few months. You may take Calcium carbonate for this burning, sit up straight in a chair and avoid spicy or acidic foods. . We made the following changes to your medicines: 1. STOP taking calcitriol 2. START nephrocaps as a vitamin for your kidneys 3. START pantoprazole twice daily for your heartburn 4. START carafate up to four times per day for your heartburn, do not take this within 1 hour of your other medications 5. START taking Maalox (calcium and simethicone) as needed for your heartburn 6. START Metoprolol at night to lower your heart rate and avoid chest pain. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2204-9-25**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: TUESDAY [**2204-9-18**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: TUESDAY [**2204-10-9**] at 10:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report+report+report+addendum+addendum+addendum

Admission Date: [**2116-10-30**] Discharge Date: [**2116-11-17**] Date of Birth: [**2053-12-21**] Sex: M Service:HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 62 year old man presenting with nausea, vomiting and failure to thrive. One year prior to admission, the patient presented with obstructive jaundice concerning for cholangiocarcinoma and Mirizzi syndrome with obstruction of the hepatic duct by gallbladder bile duct mass. The patient had an exploratory laparotomy with pathology which was negative for malignancy, however, pathology of the liver was consistent with Stage III-IV fibrosis. The patient also has portal hypertension. His hepatitis panel as of [**10-22**], was negative, negative [**Doctor First Name **]/AMA. He had presumed diagnosis of secondary biliary cirrhosis, status post roux-en-y hepatojejunostomy in [**9-23**], was admitted with a massive variceal bleed requiring ventilatory support and more than 40 units of packed red blood cells, status post TIPS, was complicated by VRE and Methicillin resistant Staphylococcus aureus in the bowel. The patient did well and was discharged to home but had insidious progressive anemia, status post recent admission in [**10-23**], for workup and did not receive a colonoscopy secondary to inability to tolerate GoLYTELY and prep. He underwent an esophagogastroduodenoscopy that was positive for gastritis. The patient is now readmitted with the same, status post five liter paracentesis, with a SAG of 0.9, and [**2116-11-2**], cholangiogram with changing of the biliary drain. PAST MEDICAL HISTORY: 1. Upper gastrointestinal bleed, intubated in [**9-23**], with more than 40 units of packed red blood cells with esophageal varices, status post TIPS for portal hypertension. 2. Coronary artery disease, status post percutaneous transluminal coronary angioplasty and stent. 3. Diabetes mellitus type 2. 4. Chronic renal insufficiency. 5. Hypertension. 6. T12 compression fracture. 7. Hemorrhagic cerebrovascular accident. 8. Methicillin resistant Staphylococcus aureus and VRE in bowel in [**9-23**]. 9. Status post coiling of the brachial artery pseudoaneurysm. 10. Hepatic encephalopathy. 11. Peptic ulcer disease. 12. Mirizzi syndrome. 13. Status post common bile duct excision with hepatic jejunostomy. 14. TPN. 15. Stage III-IV fibrosis. 16. Ejection fraction 40 to 45%. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: On admission, temperature was 96.9, pulse 86, blood pressure 106/58, respiratory rate 29, oxygen saturation 99% in room air. He is a comfortable man, older than stated age, in no acute distress, anicteric. The oropharynx is clear. Dry mucous membranes. Neck without lymphadenopathy. The heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally. The abdomen is soft, obese, positive ascites, nontender, drain site times two, dry and intact. Extremities positive tenting, no edema. Rectum - brown stool, normal tone, no masses, guaiac positive. LABORATORY DATA: On admission, white blood cell count was 3.8, hematocrit 28.1, platelet count 28,000. Sodium 135, potassium 4.7, chloride 103, bicarbonate 20, blood urea nitrogen 36, creatinine 2.4, INR 1.2. Electrocardiogram is consistent with old inferior wall myocardial infarction, normal sinus rhythm. HOSPITAL COURSE: 1. Ophthalmology - The patient complained of blurry vision and was evaluated by ophthalmology. Changes were found to be consistent with CMV retinitis. The patient had CMV serologies that came back all negative. The patient was subsequently found to grow out [**Female First Name (un) 564**] out of his blood. He was started on AmBisome. 2. Acute renal failure - The patient had acute on chronic renal failure, partially prerenal secondary to his third spacing and ascites. The patient also had a urinary stone of proximal right ureter dilatation and right renal pelvis dilatation. The patient was seen by urology for stone removal. In addition, the patient may also have had some hepatorenal syndrome contributing to his renal failure. He had received Vancomycin which may have contributed. The patient had been empirically treated for spontaneous bacterial peritonitis given his worsening state, however, was to be retapped. 3. Hematology - The patient had low hematocrit, anemia likely secondary to multiple causes including anemia of chronic disease, blood loss anemia. The patient was continued guaiac positive stool as well as bone marrow suppression given the lower reticulocyte count. The patient's thrombocytopenia is likely multifactorial. Likely contributing factors include splenomegaly, as well as component of bone marrow suppression. The patient had a decreased white blood cell count, was HIV negative, likely due to bone marrow suppression. 4. FEN - The patient had not been able to tolerate his tube feeds due to nausea and vomiting. Subsequently, he improved with treatment of the fungemia. The patient was treated for fungemia with Caspofungin. The course of the patient after [**2116-11-8**], will be dictated in a discharge summary addendum. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 757**] MEDQUIST36 D: [**2116-11-17**] 18:34 T: [**2116-11-17**] 19:23 JOB#: [**Job Number 45156**] Admission Date: [**2116-10-30**] Discharge Date: [**2116-12-28**] Date of Birth: Sex: M Service: ADDENDUM: This is an Addendum to the previous Discharge Summary. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 1. RETINITIS/EPISCLERITIS ISSUES: The patient underwent two vitrectomies; one on [**2116-12-4**] at [**Hospital1 346**] and one on [**2116-12-14**] at the [**State 350**] Eye & Ear. The vitreal cultures from [**12-4**] showed no growth to date; however, the biopsy showed granulomatous inflammation. This could be consistent with fungus or some other type of process such as tuberculosis. Thus, the patient underwent a second vitrectomy and biopsy on [**12-14**]. The stain from this biopsy was consistent with [**Female First Name (un) 564**]. Thus, the patient underwent a right eye evisceration surgery on [**2116-12-25**]. He was to be fitted for a prosthesis in six weeks by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**] out of the [**State 350**] Eye & Ear. In the meantime, he was to continue caspofungin 35 mg intravenously once per day until otherwise notified by Dr. [**Last Name (STitle) 17233**]. The length of intravenous antibiotics depends upon the progression or regression of disease in his left eye. His follow-up appointment with Dr. [**Last Name (STitle) 17233**] is scheduled for [**1-13**]. In the meantime, he was also to continue eyedrops to his left eye as he has been and erythromycin ointment to his right eye. The patient's pain was controlled with oxycodone as needed. 2. FAILURE TO THRIVE ISSUES: The patient did have an episode of emesis after some pain medications on [**12-15**], and his Dobbhoff tube became coiled. Thus, the Dobbhoff tube was replaced by Interventional Radiology on [**12-15**]. He is on an Imodium 2 mg twice per day schedule for diarrhea and Reglan, Compazine, and Zofran as needed. He is on tube feeds (per the diet order), and Nutrition Service recommendations were followed. The patient electrolytes were repleted as needed; such as magnesium and phosphate. 3. DEPRESSION ISSUES: Paxil 10 mg once per day was continued. 4. INFECTIOUS DISEASE ISSUES: On the day after his second vitreal biopsy, he spiked a temperature to 101 degrees Fahrenheit. Blood cultures were obtained, and 1/2 bottles grew gram-positive cocci in pairs and clusters; which were eventually showed to be coagulase-negative Staphylococcus. Thus, vancomycin (which had been started) was discontinued. A urine culture was negative. He had a chest x-ray which was consistent with aspiration pneumonia; showing a right middle lobe infiltrate. Thus, the patient was placed on intravenous Zosyn and by mouth ciprofloxacin for a total of 12 days. These antibiotics also cover spontaneous bacterial peritonitis. 5. HEMATURIA ISSUES: For painless hematuria, the Urology Service was consulted and Proscar 5 was started in order to prevent prostatic bleeding. The patient has a follow-up appointment with Urology for his stent placement. 6. CIRRHOSIS/ASCITES ISSUES: Strict ins-and-outs and daily weights were obtained. The patient was fluid restricted to 1.5 liters per day with a 2-gram sodium diet. He should be continued on Aldactone 25 mg twice per day. Lasix is on hold secondary to a rise in his creatinine; however, his creatinine is stable right now. The patient underwent an ultrasound-guided paracentesis on [**11-7**] by Radiology. His serum albumin ascites gradient was 0.9; which is not quite consistent with cirrhosis. Thus, tuberculosis studies were added on to this ascites fluid. Both tuberculosis PCR and adenosine deaminase were negative. These were sent out laboratories. 7. ANEMIA ISSUES: The patient has a history of an esophageal variceal bleed, frank hematuria, guaiac-positive stool. His Epogen dose was doubled to 40,000 units every Sunday. The patient did not require any transfusions during his last month here. He is very difficult to cross match as he has had many transfusions in the past. His hematocrit has been stable throughout the past several weeks. 8. RENAL ISSUES: The patient received albumin 50 g intravenously on [**12-15**] to protect his kidneys during his febrile episode. His creatinine is now back to baseline and is stable. 9. ACCESS ISSUES: The patient has a peripherally inserted central catheter in place. 10. PROPHYLAXIS ISSUES: We have him on subcutaneous heparin and Protonix. DISCHARGE DISPOSITION: The patient is being screened for rehabilitation. DISCHARGE DIAGNOSES: 1. Failure to thrive. 2. Severe blood loss anemia. 3. Nausea. 4. Vomiting. 5. Fevers. 6. Cirrhosis. 7. Ascites. 8. Portal hypertension. 9. Fungemia. 10. Retinitis. 11. Hydronephrosis. 12. Renal caliculi. 13. Urinary tract infection. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with a Liver Center appointment on Wednesday, [**1-28**], at 8 a.m. at the [**Hospital Unit Name 20119**] with Dr. [**First Name (STitle) **]. 2. The patient was to follow up with a Transplant Surgery appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2117-2-3**] on the seventh floor of the [**Hospital Unit Name **]. 3. The patient was to follow up with an Ophthalmology appointment with the retina specialist at the [**Last Name (un) **] Center with Dr. [**Last Name (STitle) 17233**] on [**1-13**] at 10:40 a.m. At this appointment, Dr. [**Last Name (STitle) 17233**] will determine the length of time that the patient needs to be on intravenous caspofungin. 4. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7363**]. The patient was to follow up with Dr. [**First Name (STitle) 7363**] in a week or two at any time he would like. He was to call ahead of time (telephone number [**Telephone/Fax (1) 12045**]). The patient will need to be fitted for a prosthesis in six weeks. 5. The patient was to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 4229**] with Urology on [**2117-1-12**] at 10:30 a.m. 6. The patient was instructed to follow up with Dr. "[**Doctor Last Name 1027**]" with Infectious Disease on [**2117-1-26**] at the [**Hospital Unit Name **] basement at 11 a.m. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to rehabilitation. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Folic acid 3 mg once per day. 2. Metoclopramide 10-mg tablets take one tablet three times per day. 3. Pantoprazole 40 mg once per day. 4. Ursodiol 300 mg three times per day. 5. Prednisone acetate 1% drops one drop four times per day in the left eye only. 6. Oxycodone 5-mg tablets one to two tablets by mouth q.4h. as needed (for pain). 7. Metoprolol 25 mg by mouth twice per day. 8. Paroxetine 10 mg once per day. 9. Atropine sulfate 1% ophthalmic drops one drop twice per day in the left eye only. 10. Flurbiprofen sodium 0.03% ophthalmic drops one drop four times per day to the left eye only. 11. Loperamide 2 mg twice per day (hold for constipation). 12. Finasteride 5 mg once per day. 13. Caspofungin 35 mg intravenously once per day. 14. Ondansetron 2 mg/mL 4 intravenously q.4-6h. as needed (for nausea). 15. Spironolactone 25 mg twice per day. 16. Epogen 40,000 units one times per week (on Sunday). 17. Multivitamin one time per week. 18. Magnesium oxide 400-mg tablets one tablet three times per day. 19. Tylenol 325 mg q.4-6h. as needed (for pain or fever). 20. Subcutaneous heparin 5000 units q.12h. 21. Erythromycin 5 mg/g ophthalmic ointment one twice per day to the right eye only. 22. Regular insulin sliding-scale. PAGE 1 REFERRAL INFORMATION: 1. The patient is to have fingerstick checks four times per day and follow the regular insulin sliding-scale. 2. The patient is to have erythromycin ointment placed in his right eye twice per day. 3. The patient is to have vital signs checked and strict ins-and-outs documented, as the Liver Service may want to tweak his diuretic regimen. 4. The patient is on tube feeds. The patient is to follow the directions under Diet Information listed below with his tube feeds. 5. The patient's electrolytes should be checked three times per week; on sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, calcium, magnesium, and phosphate as the patient often needs phosphate and magnesium repletion. 6. The patient's hematocrit is to be checked at least once per week. The patient has anemia and has a history of guaiac-positive stools. 7. Intravenous caspofungin is to be administer until otherwise notified by Dr. [**Last Name (STitle) 17233**] of Ophthalmology based on the progression or regression of disease in his eye. 8. The patient is also to receive physical therapy while in the rehabilitation facility. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 45157**], M.D. [**MD Number(1) 45158**] Dictated By:[**Last Name (NamePattern1) 9789**] MEDQUIST36 D: [**2116-12-28**] 14:02 T: [**2116-12-28**] 14:16 JOB#: [**Job Number 45159**] cc:[**State 45160**] Admission Date: [**2116-10-30**] Discharge Date: [**2116-12-28**] Date of Birth: Sex: M Service: ADDENDUM: The patient is to continue levofloxacin 500 mg by mouth once per day for life for cholangitis prophylaxis (per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 9789**] MEDQUIST36 D: [**2116-12-31**] 15:39 T: [**2116-12-31**] 15:50 JOB#: [**Job Number 45161**] Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 8297**] Admission Date: [**2116-10-30**] Discharge Date: [**2116-11-21**] Date of Birth: [**2053-12-21**] Sex: M Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: In brief, this is a 62 year old male with a complex medical history significant for cirrhosis, portal hypertension and ascites secondary to a secondary biliary cirrhosis who initially presented with insidious blood loss and here for inadequate p.o. intake. HOSPITAL COURSE: 1. Fever - The patient continues to have intermittent fevers to 101 degrees, approximately q.o.d. Blood cultures have been negative to date and are negative upon discharge, however, the patient has had Pseudomonas and history of Vancomycin-resistant enterococcus on his bowel. The patient also has a urine culture positive for Stenotrophomonas, additionally with negative blood cultures. The patient also had a history of fungemia secondary [**First Name5 (NamePattern1) 1441**] [**Last Name (NamePattern1) **]. The patient will be discharged on Fluconazole 250 mg p.o. q.d. for approximately four weeks and will receive a treatment of Bactrim for Stenotrophomonas for approximately two weeks following discharge. 2. Fungemia - The patient had a history of fungemia and initially was treated with caspofungin intravenously for approximately one week and was switched to Fluconazole 250 mg p.o. q.d. and at discharge blood cultures were negative for fungus. 3. Persistent nausea, vomiting with decreased p.o. intake - The patient continues as on his admission and has difficulty tolerating p.o. food and p.o. intake. The cause of this has been determined. The patient at the time of discharge has a Dobbhoff tube in place receiving Nephro and plus ProMod at approximately 40 cc/hr for tube feeds in addition to his p.o. intake. The patient will continue to have tube feeds at his outside facility until he is able to maintain an adequate p.o. diet. The patient will use antiemetics, Reglan and Zofran as needed for nausea and vomiting. 4. Cirrhosis/ascites/secondary biliary cirrhosis - During the [**Hospital 1325**] hospital stay he had multiple diagnostic and therapeutic taps and paracentesis. All taps were negative for any evidence of spontaneous retroperitonitis and were followed by aggressive volume and albumin repletion to prevent any associated renal impairment. The underlying causes of the disease still remains unknown and he is being closely followed by Hepatology and the Transplant Service. Please see the transplant surgery notes for details regarding his hospital stay procedures. The patient will be followed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 833**] as an outpatient and will have close follow up. 5. Retinitis - The patient was diagnosed with retinitis, believed to be secondary to disseminated fungemia. He initially presented with severe pain, photophobia and change of vision that has improved dramatically over the course of admission and treatment for his fungal infection. All cytomegalovirus cultures have been negative to date and he was not started on antivirals. He will be followed by ophthalmology and continued on Cyclogyl 1% b.i.d. right eye and Prednisone Forte 1% q.i.d. He will follow up with [**Hospital 8298**] Clinic and Dr. [**Last Name (STitle) 8299**] the week following discharge. 6. Renal failure - The patient had an acute and chronic renal failure with a baseline creatinine of 1.5 to 2.0 range. Initially this was thought to be secondary to either a superimposed acute tubular necrosis or interstitial nephritis. He was followed by Renal in-house. Additionally it was felt that given his complex volume state given his ascites and limited ability to maintain p.o. intake and thus there may be a volume component on top of his renal dysfunction. On discharge his creatinine was stable, however, may be at a new baseline, an approximate 2.3 to 2.7 range. 7. Hydronephrosis - The patient had a ureteral stone and right kidney hydronephrosis during his stay and he was treated with an interurethral stent and limited cystoscopy per Urology. The stent relieved the obstruction and hydronephrosis resolved. Post procedure the patient will be followed by Urology and Dr. [**Last Name (STitle) 1182**] on discharge. 8. Hyponatremia - The patient has been hyponatremic, reportedly secondary to his cirrhosis and ascites. He has been stable in the high 120s to 130s range. He was treated with fluid restriction diet of less than 1.5 liters per day. CONDITION ON DISCHARGE: The patient's condition on discharge is much improved compared to his admission. He is ambulating with assistance, maintaining his oxygenation well and on room air. He does have a feeding tube in place but he is able to intake p.o. as tolerated. DISCHARGE INSTRUCTIONS: The patient is to make an appointment with Dr. [**Last Name (STitle) **], Liver Center, phone #[**Telephone/Fax (1) 906**] for an appointment in two to four weeks for follow up of his evolving liver disease. 2. The patient is to call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 242**] for an appointment in one to two weeks with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 833**] on the same day. 3. The patient has an ophthalmology appointment at the [**Hospital1 8300**] Eye Center with Dr. [**Last Name (STitle) 8299**] on Monday [**2116-11-21**], at 1:15, telephone #[**Telephone/Fax (1) 8301**], please call if any changes are needed. 4. The patient has an appointment with Dr. [**First Name (STitle) 1185**] [**Name (STitle) 1182**], [**Hospital Ward Name **] Surgical Center on [**2116-12-8**], phone #[**Telephone/Fax (1) 5721**] for evaluation of interurethral stent. DISCHARGE DIAGNOSIS: 1. Failure to thrive 2. Insidious blood loss 3. Anemia 4. Nausea and vomiting 5. Fever 6. Cirrhosis 7. Ascites 8. Portal hypertension 9. Fungemia 10. Retinitis 11. Hydronephrosis and renal calculi 11. Urinary tract infection DISCHARGE MEDICATIONS: 1. Folic acid 1 mg tablets, please take three tablets p.o. q.d. 2. Metoclopramide 10 mg tablet 3. Polyvinyl alcohol 1.4% drops one to two drops prn as needed for dry eyes 4. Pantoprazole 40 mg tablets p.o. q.d. 5. Ursodiol 300 mg tablets, one tablet p.o. b.i.d. 6. Lactulose 15 to 30 ml q. 8 hours as needed for constipation and prevention of encephalopathy, please titrate to 3 to 5 loose bowel movements per day. 7. Cyclopentolate 1% drops one drop ophthalmologic b.i.d. 8. Prednisolone acetate 1% drops one drop four times a day 9. Oxycodone 5 mg tablets, one to two tablets q. 4 hours as needed for pain 10. Fluconazole 200 mg tablets, one tablet p.o. q. 24 hours for 30 days 11. Bactrim 800-160 mg tablets one tablet p.o. by mouth for ten days from the time of discharge 12. Zofran 4 mg/5 ml solution, 48 mg/10 ml p.o. q. 4-6 hours prn as needed for nausea 13. Clotrimazole cream one application TP b.i.d., apply to head of penis for one to two weeks for discomfort [**Name6 (MD) 904**] [**Name8 (MD) **], M.D. [**MD Number(1) 6350**] Dictated By:[**Last Name (NamePattern1) 4517**] MEDQUIST36 D: [**2116-11-19**] 14:09 T: [**2116-11-19**] 14:49 JOB#: [**Job Number 8302**] This is update to [**11-20**] when patient transg=ferred back to MICU with myocardial ischemia and sepsis post-cholangiogram. Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 8297**] Admission Date: [**2116-10-30**] Discharge Date: [**2116-12-7**] Date of Birth: [**2053-12-21**] Sex: M Service: ADDENDUM: To prior dictation summary from [**2116-11-20**], until [**2116-12-7**]. In summary, this is a 62 year old male with a history of cirrhosis, ascites, portal hypertension, prior life threatening variceal bleeds and chronic liver disease secondary to benign biliary stricture, who initially presented with failure to thrive and insidious blood loss in early [**Month (only) 5298**]. He was being prepared for discharge to rehabilitation on [**2116-11-20**], when he went to have cholangiogram and repositioning of his biliary stent which was complicated by sepsis. The hospital course from [**2116-11-20**], to [**2116-12-7**], relates to the treatment and resolution of sepsis, continuing failure to thrive, progressive retinitis and episcleritis, worsening depression, non ST elevation myocardial infarction in relation to sepsis and demand ischemia, persistent hematuria and anemia. 1. Sepsis - The patient was scheduled for reevaluation of his biliary tree with cholangiogram and biliary stent manipulation on [**2116-11-20**], when the patient became septic in the interventional radiology suite. The patient became febrile, hypertensive followed by hypotension, tachycardia and experienced severe chest pain while on the procedure table. The patient has had a history of VRE in the past with involvement of the biliary system. He also had been intermittently spiking fevers, approximately q.o.d. prior to the procedure. The patient did not have a fever on the day of the cholangiogram. Unfortunately, the patient was unable to receive antibiotics prior to having his cholangiogram and subsequently became bacteremic and septic, infected with Ampicillin sensitive Enterococcus resistant to Levofloxacin and pansensitive pseudomonas. The patient had four out of four positive blood cultures from [**2116-11-20**]. Following the procedure, the patient received broad spectrum antibiotics including Zosyn and Linezolid until final cultures and sensitivities were obtained. The patient was subsequently transferred to the Intensive Care Unit for close hemodynamic monitoring and blood pressure support. The patient was subsequently transferred out of the Intensive Care Unit on [**2116-11-23**], at which time he was afebrile and hemodynamically stable. Repeat blood cultures from [**2116-11-24**], demonstrated clearing of the bacteremia as no organisms were isolated. With the final sensitivities obtained, the patient was continued on Zosyn dosed for his renal failure for a two week course from the last negative blood culture, with the last expected day of Zosyn on [**2116-12-8**]. The patient has remained afebrile and hemodynamically stable since his transfer from the Intensive Care Unit. It should be noted that if the patient is to have additional biliary manipulation, that he should be treated with antibiotics preferably Linezolid given the fact that the patient has had a history of VRE even though this episode of sepsis occurred with pseudomonas and a Vancomycin sensitive Enterococcus fecalis species. 2. Non ST elevation myocardial infarction - The patient experienced a non ST elevation myocardial infarction with a new right bundle branch block which was attributed to demand ischemia in the setting of sepsis. This was the opinion of cardiology. The patient was initiated on a low dose beta blocker and has been asymptomatic with flat troponin and cardiac enzymes since the event. The patient will be discharged on Lopressor 25 mg twice a day to be titrated up as tolerated by his primary care physician. 3. Retinitis/episcleritis/vitreitis - The patient has had a long history during this hospitalization of worsening vision, photophobia and eye pain. This was initially thought to be due to a disseminated fungal infection via [**First Name5 (NamePattern1) 1441**] [**Last Name (NamePattern1) 7074**]. CMV and PCR have consistently been negative. The patient was followed by ophthalmology on a daily basis. The patient had initially been treated with Kaspafungin during his hospital stay. Subsequently he developed acute on chronic renal failure and was transitioned to Fluconazole, however, as his creatinine improved and it was apparent that he was failing Fluconazole therapy, he was restarted on Kaspafungin. Following serial ophthalmologic examinations, it was determined that there was little improvement clinically and there appeared to be more vitreal involvement. Consequently, on [**2116-12-4**], the patient had vitrectomy and intravitreal Amphotericin injection. He was started on Prednisone Forte 1% four times a day drop, Atropine 1% twice a day and Ocuflex drops four times a day with continuation of the Kaspafungin for approximately six weeks with the start date being [**2116-11-24**]. He has continued to be followed by ophthalmology and will need aggressive persistent outpatient follow-up following discharge from the hospital. Please see ophthalmology notes for additional details. 4. Cirrhosis/ascites - The patient has chronic liver disease secondary to benign biliary stricture. During his hospital stay, as stated in the previous dictation summary and addendum, he had multiple diagnostic and therapeutic taps demonstrating large amounts of fluid collection within the abdomen. Goal had been 1500cc fluid restriction with strict in and out and daily weights. Following his episode of sepsis and bacteremia, he was initiated on Zosyn, initially Linezolid in conjunction with Kaspafungin therapy, all of which were intravenous. He also was initiated on tube feeds with varying rates from 20 to 65cc per hour making it difficult to maintain his current weight. Consequently, he was scheduled for a therapeutic tap on either [**2116-12-7**], or [**2116-12-8**], followed by aggressive use of Albumin in order to maintain his intravascular volume. This was an attempt to prepare the patient for discharge. The patient was also initiated on Aldactone which will be titrated up as tolerated following his potassium and creatinine to follow hyperkalemia and worsening of chronic renal insufficiency. The patient will continue to be followed for his liver disease by Dr. [**Last Name (STitle) **] and by the liver/hepatology service including Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 833**]. At this point in time, the patient is scheduled for follow-up at the transplant center at [**Telephone/Fax (1) 8303**] on [**2116-12-15**], at 9:30 a.m. 5. Failure to thrive - The patient has had a persistent inability to maintain p.o. intake. This is a presenting problem of this patient on his initial presentation in [**Month (only) **] and it has continued to be a problem through this dictation summary. The patient is able to tolerate minimal p.o. intake and has had difficulty tolerating tube feeds as well. At the present time, the patient has a nasal jejunostomy tube in place in the distal part of the duodenum, proximal part of the jejunum. He seems to be tolerating tube feeds well moving to a semialimental formula away from concentrated feeds. The patient does continue to have diarrhea which has been negative for Clostridium difficile colitis. He is continuing to be worked up at the time of this dictation summary. 6. Hematuria - The patient has had persistent hematuria since his admission to the Intensive Care Unit. Urology was consulted. It was thought this to be secondary to traumatic Foley which as stated in the urology notes can persist for up to three weeks. Imaging of his J-J stent in his right ureter shows appropriate placement without migration. The patient will be followed up by Dr. [**Last Name (STitle) 8304**], scheduled for [**2116-12-8**], at 3:00 p.m. for assessment and for possible removal or placement of a permanent stent. 7. Anemia - The patient remains anemic with fluctuating hematocrit from the mid 20s to low 30s. He has required multiple transfusions. He has had persistent hematuria and intermittent occult positive stool. In the past he has had esophagogastroduodenoscopy demonstrating severe esophageal bleeding, however, this is not a [**Last Name **] problem, however, he was never worked up with a colonoscopy from below secondary to his development of fungemia during this hospital stay. This should be considered on an outpatient basis when the patient is stable as he is now on discharge. Iron studies and additional anemia workup were pending at the time of this dictation. 8. Thrombocytopenia - The patient became thrombocytopenic with platelets in the 60,000 to 90,000. Following his episode of sepsis and in the setting of cirrhosis, currently his platelets are resolving with marked improvement in his thrombocytopenia. 9. FEN - The patient has required electrolyte supplementation including potassium, magnesium and phosphorus multiple times. The patient will need follow-up on his electrolytes at discharge as he was initiated on a new diuretic regimen. He will be continue to be receiving tube feeds on discharge. ADDITIONAL DISCHARGE DIAGNOSES: 1. Sepsis. 2. Pseudomonas bacteremia. 3. Enterococcus bacteremia. 4. Non ST elevation myocardial infarction in the setting of sepsis. 5. Retinitis/episcleritis/vitreitis. 6. Chronic liver disease, cirrhosis, ascites, portal hypertension. 7. Failure to thrive. 8. Hematuria. 9. Anemia. 10. Thrombocytopenia. 11. Hypokalemia. 12. Hypophosphatemia. 13. Resolving acute on chronic renal insufficiency. Please note discharge medications and time and place of follow-up will be added as an addendum when the patient is formally discharged from the hospital, expected to be this week. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7895**] Dictated By:[**Last Name (NamePattern1) 4517**] MEDQUIST36 D: [**2116-12-7**] 15:09 T: [**2116-12-7**] 18:17 JOB#: [**Job Number 8305**] Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 8297**] Admission Date: [**2116-10-30**] Discharge Date: [**2116-12-31**] Date of Birth: [**2053-12-21**] Sex: M Service: Patient was waiting a bed at a rehab facility, and thus discharge date is [**2116-12-31**]. Of note, a couple of questions that have come up recently. His tube feeds should be continued for the next 2-4 weeks or longer depending on Liver service recommendations and the patient's clinical improvement. Additionally, the Liver service should be contact[**Name (NI) **] for all questions regarding the patient's care the other primary care givers, these doctors including Dr. [**First Name (STitle) 21**], Dr. [**Last Name (STitle) 833**], and Dr. [**Last Name (STitle) 3575**], can be contact[**Name (NI) **] at the Liver Center at [**Telephone/Fax (1) 906**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 1023**] MEDQUIST36 D: [**2116-12-31**] 11:12 T: [**2116-12-31**] 11:18 JOB#: [**Job Number 8323**]

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icd9cm

[ [ [] ] ]

[ "99.04", "51.98", "16.31", "14.74", "96.6", "45.13", "96.07", "54.91", "59.8", "99.22", "99.05", "00.14", "87.54" ]

icd9pcs

[ [ [] ] ]

9921, 9972

32008, 34030

21360, 31987

21102, 21337

11866, 15518

15823, 19875

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10282, 11728

2452, 3336

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15547, 15805

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7,979

181,445

54287

Discharge summary

report

Admission Date: [**2112-3-20**] Discharge Date: [**2112-3-23**] Date of Birth: [**2069-8-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Ciprofloxacin Attending:[**First Name3 (LF) 3565**] Chief Complaint: hypothermia Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 42 year old woman with history of astrocytoma s/p resection with resultant MR, refractory epilepsy, and panhypopituitarism who presents with temperature 90F, and rectal temperature in ED 93F. . In the ED, initial vitals were: 95.8 63 130/69 18 97% RA. Labs notable for WBC 5.2, Hct 39.1, Plt 195, normal chem 7, Ca [**10**].4, ALT 50, AP 146, Tbili, 0.1, Alb: 4.3, AST 48. UA without signs of infection. Blood cultures sent. Given hydrocortisone 50mg IV once (cortisol level sent prior to administration). Also received her PM home medications administered by her case manager. CXR not completed prior to transfer. She had a single convulsive seizing episode during which time she sat up and became red. Neurology saw patient who thought she was at baseline (has seizures approximately 1/week). Vitals prior to transfer: [**2015**]: T rectal: 34.1 HR 79, BP 106/72, Sat 96 16-18 RA. . Upon arrival ICU: patient is alert and speaking in short sentences, and parents feel that the patient is more clear now and back to her baseline. No recent medication changes other than increase in Zonegran during her last hospitalization. She has had problems getting her progesterone while she was in [**Hospital 38**] rehab ([**2-/2029**] - [**3-18**]) but she has been on correct medications since she got back to group home on [**3-18**]. She did have an episode of hypothermia in [**2096**], family does not recall the cause at that time. Pt was doing very well recently, just out with her parents over the weekends. Of note, patient had recent dental procedure with prophylactic clarithromycin. Patient denies cough, diarrhea or dysuria. No known sick contacts at the group home. Complaining of left arm pain and abdominal pain. No n/v. Past Medical History: 1. right parietal astrocytoma age 1.5 yrs, s/p resection and radiation (so baseline left hemiparesis), complicated by hydrocephalus s/p VP shunt 2. refractory seizures on multiple AEDs, s/p [**Year (4 digits) 15741**]; mother says she has little seizures all the time and points out a variety of manifestations (turns red in the face; brief movements of her eyes, brief moments of non-responsiveness). Mother says she swipes the [**Name (NI) 15741**] magnet to activate [**Name (NI) 15741**] frequently for such events. Last ?generalized seizure with post-ictal period noted in OMR chart was sometime in [**Month (only) 404**], preceeded by sometime in [**Month (only) **]. Last [**Month (only) 15741**] update in [**11-5**]. sleep apnea with obese neck; snores/wakes frequently (including for nocturia); does not tolerate CPAP. 4. Panhypopituitarism (hypogonadism, adrenal insufficiency, hypothyroidism); on glucocorticoid and thyroid replacement, progesterone) 5. Depression 6. Osteoporosis with unclear h/o knee and shoulder pain 7. Meningiomas (Right parietal, growing @2cm; RF=XRT@youth) 8. Developmental Delay / MR 9. s/p Mohs surgery for a recurrent nodular basal cell cancer on the left occiput; also s/p BCC Tx with Aldara. 10. h/o urinary incontinence and nocturia, chronic 11. h/o VPS in RLV, reportedly removed in [**2091**] (but seen on current and prior head imaging, with dilated ventricle) 12. s/p cholecystectomy in [**2099**] Social History: Patient lives in a group home (Open [**Doctor Last Name 7730**]). Recent stressor = her favorite worker at the home is leaving soon for medical reasons. Bed/wheelchair-bound, dependent, verbal. Parents visit and take her out. No history of illicits/EtOH/tobacco (controlled living environment). Family History: Adopted Physical Exam: Physical Exam on Admission: T: 95.5 (axillary), HR 90 BP 113/68 RR 19 O2 93% RA General: Alert, speaking in short but full sentences, no acute distress HEENT: PERRL, Sclera anicteric, MMM, oropharynx clear Neck: obese neck, supple, JVP difficult to appreciate Lungs: congested upper airway sounds but otherwise clear to auscultation anteriorly, no wheezes, rales, rhonchi Chest: palpable [**Doctor Last Name 15741**] on L breast, no overlying erythema, no fluctuance, no pain with palpation CV: faint heart sounds, RRR, normal S1 + S2, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: mild difficulty following commands with neuro exam, however, eyes conjugate without deviation, PERRL. EOMI on tracking objects around the room, however, difficulty following commmands. mild L lower facial asymmetry. tongue protrusion midline. trapezius weaker on left than right. On strength exam, LUE and LLE weaker than right, which is her baseline. LUE contracted, antigravity; can lift LLE off the bed briefly and wiggle toes bilaterlaly. Physical Exam on Discharge: Tmax: 37 ??????C (98.6 ??????F) Tcurrent: 36.5 ??????C (97.7 ??????F) HR: 89 (83 - 114) bpm BP: 95/77(81) {95/43(53) - 148/92(103)} mmHg RR: 25 (14 - 29) insp/min SpO2: 95% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 94.9 kg (admission): 95.5 kg Height: 57 Inch General: mild, diffuse complaints of tenderness of chest, abdomen, extremities Otherwise exam unchanged from admission Pertinent Results: ADMISSION LABS: [**2112-3-20**] 05:02PM BLOOD WBC-5.2 RBC-4.16* Hgb-13.1 Hct-39.1 MCV-94 MCH-31.6 MCHC-33.5 RDW-14.0 Plt Ct-195 [**2112-3-20**] 05:02PM BLOOD Neuts-65.3 Lymphs-26.4 Monos-5.8 Eos-1.5 Baso-1.0 [**2112-3-20**] 05:02PM BLOOD PT-9.8 PTT-45.1* INR(PT)-0.9 [**2112-3-20**] 05:02PM BLOOD Glucose-84 UreaN-17 Creat-0.9 Na-137 K-4.8 Cl-103 HCO3-23 AnGap-16 [**2112-3-20**] 05:02PM BLOOD ALT-50* AST-48* CK(CPK)-89 AlkPhos-146* TotBili-0.1 [**2112-3-20**] 05:02PM BLOOD Lipase-48 [**2112-3-20**] 05:02PM BLOOD Albumin-4.3 Calcium-10.4* Phos-4.2 Mg-1.8 ENDOCRINE: [**2112-3-20**] 05:02PM BLOOD TSH-3.4 [**2112-3-20**] 05:02PM BLOOD Free T4-1.5 [**2112-3-20**] 05:02PM BLOOD Cortsol-7.3 TOX SCREEN: [**2112-3-20**] 05:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2112-3-20**] 10:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG UA: [**2112-3-20**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG MICROBIOLOGY: BCx [**2112-3-20**], [**2112-3-21**]: pending UCx [**2112-3-20**]: final no growth Studies: Cardiovascular Report ECG Study Date of [**2112-3-20**] 4:30:22 PM Sinus rhythm. Non-specific T wave inversion in the precordial leads could be a normal variant in a female. No significant change compared to previous tracings of [**2105-12-17**] and [**2103-9-17**]. Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-3-20**] 7:50 PM IMPRESSION: Extremely limited exam. No definite large consolidation. Consider repeat if clinically indicated. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2112-3-21**] 1:47 PM IMPRESSION: 1. No appreciable change in right parietal lobe extra-axial dense mass, most compatible with meningioma. 2. Stable moderate dilatation of the lateral ventricles. Ventricular catheter terminates in the left frontal [**Doctor Last Name 534**]. Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-3-21**] 2:05 PM FINDINGS: As compared to the previous radiograph, there is no relevant change. Normal size of the cardiac silhouette. No pleural effusions. No parenchymal opacity suggesting pneumonia. No pneumothorax. Lab results on Discharge: [**2112-3-22**] 05:16AM BLOOD WBC-4.6 RBC-4.23 Hgb-12.6 Hct-39.7 MCV-94 MCH-29.8 MCHC-31.8 RDW-14.1 Plt Ct-167 [**2112-3-21**] 03:00PM BLOOD Neuts-65.0 Lymphs-28.4 Monos-5.2 Eos-0.8 Baso-0.6 [**2112-3-22**] 05:16AM BLOOD Plt Ct-167 [**2112-3-22**] 05:16AM BLOOD Glucose-89 UreaN-11 Creat-1.0 Na-141 K-3.8 Cl-111* HCO3-22 AnGap-12 [**2112-3-22**] 05:16AM BLOOD ALT-48* AST-42* LD(LDH)-164 AlkPhos-138* TotBili-0.2 [**2112-3-22**] 05:16AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.8 [**2112-3-22**] 05:16AM BLOOD Free T4-1.2 [**2112-3-23**] 05:06AM BLOOD LEVETIRACETAM (KEPPRA)-PND Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 42yo female with PMH of astrocytoma s/p resection at 18 months of age with resultant seizure disorder with [**Month/Day/Year 15741**], pan-hypopituitarism, and mental retardation who presents with hypothermia to [**Age over 90 **]F rectal in the ED. Patient is otherwise at baseline level of interactiveness and is asymptomatic. With an overnight ICU stay, patient's temperature has recovered to 98F rectal. She experienced increased seizure activity on the day after admission with several minor seizures and one generalized tonic-clonic seizure. Her Keppra dose was increased to 100mg PO BID and she was discharged to follow-up without further increased seizure activity. ACUTE CARE 1. Hypothermia: Patient presented from group home with temperature found to be 93F rectal on initial presentation. Potential considered etiologies of patient's hypothermia included hypothyroidism, hypoadrenalism, hypopituitarism, hypothalamic dysfunction related to seizure, drug-induced, or inactivity. Her degree of hypothermia was mild without electrolyte or EKG abnormalities. Lipase was normal, pointing away from pancreatitis. Infectious cause was considered but WBC count was normal and patient was normotensive with normal lactate making sepsis less likely an etiology. Patient's glucose was normal on admission (108), which ruled out hypoglycemia. Anxiolytics could cause hypothermia, but less likely as patient has been on ativan for a long time without frequent episodes of hypothermia. Patient was treated with bair hugger with improvement in her temperature, and eventually weaned off bair hugger with maintained temperature. Endocrine work up was done and showed normal TSH and free T4. Cortisol was also within normal limits (PM random draw) but patient was started on overnight stress dose hydrocortisone for empiric coverage of hypoadrenalism with taper following thereafter. Endocrinology felt that her steroids could be tapered down from the stress dosing given no obvious infectious source and rapid resolution of her hypothermia with active rewarming. Exact nature of hypothermia may be multifactorial and has resolved without obvious precipitating factors. She will be followed by PCP and neurology. 2. Seizure Disorder: Patient has a long history of rather refractory seizure disorder leading to multiple AED's and [**Age over 90 15741**] implantation. She reportedly has multiple small seizure episodes weekly requring activation of the [**Age over 90 15741**]. Patient possibly has hypothermia related to hypothalamic involvement with a seizure. Patient was continued on home antiepileptic therapies including [**Age over 90 15741**], lamotrigine, levitiracetam, high dose progesterone, and Zonergan. Patient had a witnessed, short lasting seizure in ED, and another one in the ICU. We titrated Keppra to 1000 PO BID given a witnessed grand mal seizure on [**2112-3-21**]. An infectious source was considered as a precipitant, but no source was identified by discharge and she had no elevated white count or other sign or symptom of infection. She was discharged on the increased keppra dose and neurology follow-up. CHRONIC CARE: 1. Secondary Hypothyroidism: Patient has long-standing hypothyroidism and this presentation with hypothermia was unlikely an exacerbation of that underlying condition. TSH and free T4 were checked and were within normal limits. Her synthroid was continued. 2. Secondary Hypoadrenalism: Patient is on maintenance dose of hydrocortisone at home, but it was initially unclear if her hypothermia represented acute adrenal insufficiency. This is unlikely given absence of electrolyte abnormalities and normotension but patient was treated empirically with stress dose steroids for a day given her hypothermia and concern for hypoadrenalism. Endocrine was consulted and felt hypoadrenism is unlikely. Her steroids were tapered down to home dosing per Endocrine's recommendations. 3. Hypopituitarism: Patient has resultant hypopituitarism from her childhood resection of astrocytoma. Her hormonal insufficiencies were treated as above. In addition, patient is on progesterone 100mg PO TID for seizure prophylaxis and her home medication was brought in by group home as the exact formulation was not available in the hospital. 4. Intellectual Disability: Patient has had significant intellectual disability resulting from parietal astrocytoma resection and long course of seizure disorder. She lives at a group home and is completely dependent in her activities of daily living. Updates were given to her caregiver and her parents. TRANSITIONS IN CARE: 1. CODE STATUS: DNR/DNI (discussed with parents/HCP) 2. Communication: Patient, parents, group home 3. Medication Changes: These CHANGES were made to your medications: INCREASE Keppra to 1000 mg twice daily by mouth 4. Follow-up: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: WEDNESDAY [**2112-3-30**] at 11:10 AM With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a member of Dr/NP??????s team as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care provider Department: NEUROLOGY When: WEDNESDAY [**2112-4-27**] at 10:00 AM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN [**Telephone/Fax (1) 876**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: WEDNESDAY [**2112-4-6**] at 11:15 AM With: [**Doctor Last Name 3833**] [**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: NEUROLOGY When: WEDNESDAY [**2112-4-13**] at 1 PM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN [**Telephone/Fax (1) 876**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage 5. OUTSTANDING CLINICAL ISSUES: [ ] follow up on pending blood cultures [ ] Keppra level sent on the morning of discharge per neurology recommendations Medications on Admission: Multivitamin 8 am Cortef 15mg qam, 5mg 4pm Synthroid 112mcg qam Lamictal 400mg qam 300mg qpm Tylenol 325mg [**Hospital1 **] standing for headaches Progesterone 100mg TID (8am, 4pm, 8pm) Keppra 750mg qam, 500mg qpm Tums 1000mg [**Hospital1 **] Ativan 0.5mg 8pm Zonergan 300mg 8pm Metamucil 1pkg qd z-asorb [**Hospital1 **] to abdominal folds ativan 0.5 mg prn seizure >15 mins or clusters of >3 seizures magnesium hydroxide 400 mg/5 mL daily as needed for constipation Robitussin-DM 10-100 mg/5 mL Syrup, One teaspoon by mouth every six hours as needed for cough Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. progesterone micronized 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): at 8 AM, 4 PM and 8 PM. 5. Lamictal 150 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Lamictal 100 mg Tablet Sig: One (1) Tablet PO in morning: in addition to 300 mg, for total of 400 mg daily in AM. 7. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at 8 PM. 8. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 8PM (). 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 11. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to abdominal folds. 13. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO qAM. 14. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO qPM: Please give at 4PM. 15. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) teaspoon PO once a day as needed for constipation. 16. Robitussin-Cough-Chest-Cong 10-100 mg/5 mL Syrup Sig: One (1) teaspoon PO every six (6) hours as needed for cough. 17. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 5 mins as needed for seizures >15 mins or clusters of seizures >3. 18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day: Please administer once daily at 8pm. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: hypothermia, refractory partial epilepsy, panhypopituitarism Secondary Diagnosis: astrocytoma s/p resection and radiation therapy, meningiomas Discharge Condition: Mental Status: Patient with baseline intellectual disability secondary to medical conditions, dependent for all ADLs. Verbal at baseline. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted to the hospital because your temperature was low, and you were warmed with hot air blanket. You were given higher dose of steroids and work up for infection was done and did not show any obvious source. While you were in the hospital, you had several seizures, likely related to your missing doses of medications while we were waiting for them to come in from your group home. Your Keppra was increased and you did not have any more seizures. Please follow up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] as scheduled. These CHANGES were made to your medications: INCREASE Keppra to 1000 mg twice daily by mouth Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: WEDNESDAY [**2112-3-30**] at 11:10 AM With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a member of Dr/NP??????s <name> team as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care provider Department: NEUROLOGY When: WEDNESDAY [**2112-4-27**] at 10:00 AM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN [**Telephone/Fax (1) 876**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: WEDNESDAY [**2112-4-6**] at 11:15 AM With: [**Doctor Last Name 3833**] [**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: NEUROLOGY When: WEDNESDAY [**2112-4-13**] at 1 PM With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN [**Telephone/Fax (1) 876**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "780.65", "342.90", "733.00", "V15.3", "225.2", "319", "V49.86", "327.23", "253.2", "V10.85", "345.51" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17137, 17143

8366, 13111

317, 323

17348, 17348

5531, 5531

18402, 19930

3900, 3909

15505, 17114

17164, 17244

14918, 15482

17626, 18379

3924, 3938

5127, 5512

7772, 8343

13131, 14892

266, 279

351, 2103

17265, 17327

5547, 7757

3952, 5099

17363, 17602

2125, 3572

3588, 3884

16,490

103,952

5851

Discharge summary

report

Admission Date: [**2150-9-17**] Discharge Date: [**2150-9-17**] Date of Birth: [**2074-1-11**] Sex: F Service: MEDICINE Allergies: Percocet / Serax Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypoxia and Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 76-yo woman w/ MMP incl DM2, Afib, ESRD on HD, CAD s/p MI / CABG, CHF, sarcoidosis, COPD, p/w hypotension on the way to dialysis. She was on her way from home at her long term care facility to HD, when the ambulance noted that her SBP was 70s, so she was taken straight to the nearest ED instead. There she also was hypoxic to the 60s. She was started on peripheral Levophed and a facemask, given a dose of Vancomycin, and transferred to [**Hospital1 18**] ED. On arrival here, her SBP dropped from 110 to 52, so she was started on Neosynephrine in addition to the Levophed, and these were run in to her HD line due to the inability to gain adequate other CVL access. She also became more hypoxic, requiring a NRB. She was noted to have a waxing and [**Doctor Last Name 688**] mental status. CT Head was unremarkable, but CT Torso showed significant findings c/w pneumonia, sarcoidosis vs. malignancy, and pulmonary congestion. She was given CTX and Levo. Her VS - afebrile, BP 125/29, HR 80, R 22, O2-sat 97% NRB. Her DNR/DNI status was confirmed. She was admitted to the MICU. On arrival to the MICU, the patient appeared quite distressed, and remained hypoxic at 85% on 100% NRB + 6L O2 NC. Her SBPs were holding in the 120s. She was in severe respiratory distress, so she was given 0.5mg Morphine IV, with reasonable effect. The family was notified, and DNR/DNI was confirmed. The possibility of BiPAP was raised, which the family declined. The family decided to come in for further discussion regarding her care and anticipation of moving towards Comfort Measures. Past Medical History: Diabetes mellitus Type 2 Hypothyroidism Hyperlipidemia Hypertension CAD s/p MI x2, s/p CABG PVD A-fib - wide complex a-fib w/ RVR, Amio for rate control CHF - tx w/HD in past ESRD on HD Nephrogenic systemic fibrosis Sarcoidosis COPD Centrilobular emphysema h/o Breast Ca s/p left mastectomy, no chemo/XRT h/o Colon polyps Pleural effusions Social History: Lives w/ husband in [**Name (NI) **]. She is dependent with her ADLs and wheelchair-bound at home. Has [**Name (NI) 269**] and husband to care for her. Tobacco: 25 50 pack year smoking history, quit [**2124**]. No EtOH. Family History: FAMILY HISTORY: One sister had lung cancer, one brother had lung cancer and leukemia, five of the patient's six siblings have diabetes. Father died of myocardial infarction at age 66. There is a strong family history of hypertension. Physical Exam: VS - Afeb, HR 70s, SBP 120s, O2-sat 85% on NRB+6L NC Gen - ill-appearing elderly woman Heart - RRR, no MRG Lungs - coarse crackles and rhonchi throughout Abdomen - soft/NT/ND, no rebound/guarding Extrem - cool, no c/c/e Pertinent Results: [**2150-9-17**] 01:20AM GLUCOSE-106* UREA N-39* CREAT-4.1*# SODIUM-136 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-24 ANION GAP-20 [**2150-9-17**] 01:20AM estGFR-Using this [**2150-9-17**] 01:20AM CK(CPK)-28 [**2150-9-17**] 01:20AM cTropnT-0.12* [**2150-9-17**] 01:20AM CK-MB-NotDone [**2150-9-17**] 01:20AM CALCIUM-8.4 PHOSPHATE-6.8*# MAGNESIUM-2.9* [**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4 BASOS-0.4 [**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4 BASOS-0.4 [**2150-9-17**] 01:20AM PLT COUNT-226 [**2150-9-17**] 01:20AM PT-57.7* PTT-99.2* INR(PT)-6.8* Brief Hospital Course: ASSESSMENT AND PLAN: 76-F w/ MMP incl DM2, Afib, ESRD on HD, CAD s/p MI / CABG, NSF, CHF, sarcoidosis, COPD, p/w hypotension and hypoxia. . #. Hypotension: The etiology of her hypotension is unclear, the differential includes sepsis vs. cardiogenic vs. combined. Pt arrived on 2 pressors with SBPs in 120s through HD line. Now broadly covered with Vanc / CTX / Levo, although adequate coverage would include Vanc / Zosyn. Other possibility is severe congestive heart failure, but pt is anuric and unable to benefit from HD at this time given her inability to sustain BPs. Family was aware of situation and preferred to continue pt on multiple pressors until all family was able to visit prior to transitioning to Comfort Measures. . #. Hypoxia: Also of unclear etiology, DDx includes pneumonia, aspiration, congestive heart failure, and massive burden of sarcoidosis vs. recurrent metastatic cancer. Pt appears in severe respiratory distress, with an oxygen saturation of 85% on 100% NRB + 6L NC. Patient's code status was DNR/DNI, which was confirmed with family. Family also declined BiPAP, which would have been a temporizing measure for at least the overlying fluid congestion. Family was aware as above, preferred continuing current treatment with O2 until all family was able to visit prior to transitioning to Comfort Measures. see below . #. Goals of Care: Pt and family were aware of situation re: pt's hypotension and hypoxia. Initially, pt was continued on admitting treatment of antibiotics and pressors without escalation. Family came in to see pt today, and after a family meeting, the decision was made to transition to comfort focused care. At this point, antibiotics and pressors were discontinued, and morphine was used for comfort for respiratory distress. Over several hours, the patient gradually became increasingly hypotensive and bradycardic, and developed agonal respirations. At 19:46 on [**2150-9-17**], the patient died. The family requested a postmortem exam, and the paperwork for the death and postmortem was completed. . Medications on Admission: Tylenol #3 PO Q6hrs PRN pain Amiodarone 100mg PO daily Nexium 40mg PO daily Lunesta 1mg PO QHS PRN Glargine 5units SQ QAM Lactulose 15ml PO daily PRN constipation Levothyroxine 300mcg PO QOD, alternating with 200mcg PO QOD Midodrine 5mg PO prior to HD Sevelamer 400mg PO TID Simvastatin 20mg PO QHS Warfarin 2mg PO QAM ASA 81mg PO daily Beneprotein 1 tablespoon TID Cranberry extract RISS Glucerna 4oz PO daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Respiratory Arrest Respiratory Failure Chronic Obstructive Pulmonary Disease Congestive Heart Failure End Stage Renal Disease Sarcoidosis Nephrogenic Systemic Fibrosis Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6221, 6230

3668, 5731

301, 307

6441, 6451

3032, 3645

6503, 6509

2556, 2776

6193, 6198

6251, 6420

5757, 6170

6475, 6480

2791, 3013

238, 263

335, 1921

1943, 2285

2301, 2523

66,259

108,028

38817

Discharge summary

report

Admission Date: [**2129-6-9**] Discharge Date: [**2129-6-14**] Date of Birth: [**2061-7-5**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Mold Extracts Attending:[**First Name3 (LF) 2724**] Chief Complaint: Gait Difficulties Major Surgical or Invasive Procedure: T8 - T10 LAMINECTOMY TUMOR RESECTION History of Present Illness: Ms. [**Known lastname 86154**] was seen by Dr. [**Last Name (STitle) 548**] in the spine center for neurosurgical consultation. She is a 67-year-old woman with mild cognitive issues. She presented with a complaint of progressive reliance on a walker since [**Month (only) 404**] and incontinence that has been more prominent since [**Month (only) 956**]. She has had increasing difficulty with ambulation. Past Medical History: dev delay, ht murmer,osteoporosis, r atrophic kidney, SOB on exertion/COPD Social History: No tobacco, no alcohol Family History: NC Physical Exam: [**Hospital 4452**] clinic examination [**5-17**]: Her motor strength was 4+/5 in the right iliopsoas. The left was [**6-1**]. The remainder of her lower extremity exam was normal. There was clonus bilaterally.Babinski was upgoing on the right and equivocal on the left. Her sensory examination was intact with respect to modality of light touch. An attempt to identify sensory level was unsuccessful. Upon Discharge:as above, at baseline, wound clean dry intact with staples Pertinent Results: CXR [**2129-6-9**]: pt more kyphotic. ETT tip 1.6 cm above carina. OGT in stomach. increased bibasilar ill-defined opacities, possible aspiration and/or atelectasis in setting bronchiectasis. surgical skin staples in place. An MRI of the thoracic spine was available for review. That study demonstrates a homogeneously enhancing dorsal lesion that is intradural approximately T8-T9. It imparts significant compression of the spinal cord and occupies approximately 80% of the canal. Brief Hospital Course: Ms [**Known lastname 86154**] was admitted to the neurosurgery service on [**6-9**] and underwent a T8 - T10 laminectomies for tumor resection. She was kept intubated and was traNSfered to the ICU post-operatively. She was extubated on [**6-10**], diet and activity advanced. Wound was clean and dry with staples.She was transferred to the floor. She was evaluated by PT who felt her suitable for rehab which was arranged. Foley was attempted to be removed but required replacement for retention. She will need bladder training at rehab. Medications on Admission: Acetaminophen, Albuterol, Colace, Fosamax, Lasix, Lescol, Ativan and Resperdal Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever,pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 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. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation TID (3 times a day). Discharge Disposition: Extended Care Facility: Evanswood Center for Older Adults - [**Location (un) 8072**] Discharge Diagnosis: T9 meningioma urinary retention Discharge Condition: AT BASELINE Discharge Instructions: ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up / begin daily showers [**6-14**] ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake if you experience muscle stiffness and before bed for sleeping discomfort ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation Followup Instructions: PLEASE HAVE YOUR STAPLES REMOVED [**6-20**] AT REHAB OR CALL DR [**Doctor Last Name **] OFFICE FOR APPT FOR REMOVAL OF YOUR STAPLES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINTMENT Completed by:[**2129-6-14**]

[ "788.29", "587", "336.3", "496", "225.4", "788.30", "733.00", "315.9" ]

icd9cm

[ [ [] ] ]

[ "03.4" ]

icd9pcs

[ [ [] ] ]

3673, 3760

1981, 2523

328, 367

3835, 3848

1473, 1958

4558, 4893

956, 960

2652, 3650

3781, 3814

2549, 2629

3872, 4535

975, 1378

271, 290

1393, 1454

395, 802

824, 900

916, 940

6,292

159,041

7001

Discharge summary

report

Admission Date: [**2172-12-22**] Discharge Date: [**2173-2-15**] Date of Birth: [**2097-7-18**] Sex: M Service: SURGERY Allergies: Plavix / Potassium / Magnesium / Demerol / Morphine Attending:[**First Name3 (LF) 668**] Chief Complaint: This 75 year old patient with prior history of coronary artery disease and stenting presented again with congestive heart failure and was investigated with an angiogram and was found to have a 70% left mainstem lesion and he was scheduled for coronary artery bypass graft Major Surgical or Invasive Procedure: PD s/p CABG x 2 [**1-5**] and sternal dehiscence [**2173-1-31**] now s/p open chole, G-J placement, R fem HD access [**2-7**] History of Present Illness: 75 y.o. male with CAD, Ef 40%, pacer, sick sinus syndrome, PAF, CRI on HD, HTN, recent ARDS, intubation transfered here from [**Hospital3 3583**] for catherization re: elevated troponins. Pt initially presented with acute SOB was intubed in ED for ARDS and found to have b/l pneumonia. Pt was found to have increasing tropoining 2.3 -> 3.9. EKG are difficult to interpret due to V pacing. Pt was also hypotensive and was on Dopamine drip. His course was further complicated by ARF and rising WBC with fevers. Pt was treated with Vanco, Ceftaz, Ceftriaxone, Azithro. He was eventually extubated. Immediately after there was further concern for undergoing ischemia and worsening LV. Pt has been receiving his cardiac meds intermittenlty during his stay at the CCU. Last night ([**12-21**]) back on the floor, patient experiences CP, his anginal equivalent, and was transfered back to CCU on NTG drip that relieved his pain. . Past Medical History: PMHx: 1. CAD, s/p several caths, last one 2. HTN 3. CRI/peritoneal Dialysis - Cr up to 10 recently; 4. pacer - CPI Guidant DDD - with sick sinus syndrome. 5. PAF 6. Anemia - baseline in [**2170**], Low 30s, macrocytic. Social History: Pt lives at home with wife in [**Name (NI) 3320**] prior to hospitalization, daughter and son-in- law live nearby. Pt has 8 siblings, most of whom are in the area. Pt has been on dialysis for past 5 years, managing PD at home pore recently. Wife reports pt has always been resilient and vigorous after medical complications in past. Wife and daughter are [**Hospital **] healthcare proxy and alternate. They state the pt would not want extreme measures taken to sustain life if he could have no meaningful quality of life. Family were somewhat tearful, acknowledging pt's situation is grave, and were in anticipation of family meeting for further clarification re: pt's current status. Family articulated their frustration around communication during family/team meeting. Physical Exam: . PE: Vitals: 97.0 122/67 81 20 95% 2L 5ft 8inch 132 lbs Gen: pleasant, interactive male in Nad HEENT: NC, AT, anicteric, PERRL, CV: rrr, nl s1, s2 no m/r/g Chest: ctab/l, poor air movement, Abd: + BS, SNT/ND, no hsm Ext: + 1 weak DP/PT, no c/c/e . Pertinent Results: EKG: V-paced @ 90; Labs from [**Hospital1 46**]: [**Date range (1) 26214**]-11/20-etc: 19.5 WBC -19.4-20.1-15.9 35 Hct - 36.8-37.4-35 INR 1.13 . Na 136 4.2 93 25 195 gluc 97 BUN 8.2 Cr 7.8 Ca 7.2 Phos CK 50-74 MB 4.1-5.1 Trop I <0.038 (0.08) - same-0.067-s-0.225 ct 1/12/6 There now appears to be a large amount of intraperitoneal blood. The liver also appears markedly abnormal, although the examination is limited by lack of contrast streaking and beam hardening artifact. The major differential within the liver, particularly within segments VI and VII rests between contusion or infarction, with the former favored. Brief Hospital Course: Mr. [**Known lastname **] is a 75-year-old male who underwent a CABG approximately 3 weeks ago. This was complicated by a sternal dehiscence. His postoperative course included prolonged intubation and recently development of sepsis, pressure requirement and a leukocytosis. He underwent CT scan that demonstrated markedly edematous gallbladder. Gallblader removed in OR 1/8/6. Pt with ESRD, Respiratory failure, hypotensive requiring pressors, developed GI bleeding and subcaposular hematoma. fammily expressing pt desire of not living dependant on ventilaroe support. Pt made CMO espired 1/16/6/ Medications on Admission: . Meds @ home: Lopressor Lipitor Ace Amiodarone . [**Last Name (un) **]: Plavix, Magnesium, Demerol, Morphine Discharge Disposition: Expired Discharge Diagnosis: MULTIORGAN FAILURE Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Completed by:[**2173-2-15**]

[ "486", "789.5", "519.4", "575.0", "414.01", "995.92", "585.6", "038.9", "286.9", "428.31", "998.31", "998.11", "478.74", "518.84", "V53.31", "287.5", "577.0", "707.03", "403.91", "578.9", "410.71" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.79", "88.72", "51.22", "36.11", "39.95", "77.61", "88.53", "39.61", "88.56", "31.43", "33.24", "38.95", "34.09", "89.64", "37.23", "34.91", "54.98", "96.72", "36.15", "44.32" ]

icd9pcs

[ [ [] ] ]

4390, 4399

3631, 4229

583, 711

4461, 4470

2984, 3608

4420, 4440

4255, 4367

4494, 4532

2714, 2964

272, 545

739, 1665

1687, 1908

1924, 2699

80,084

135,815

34212

Discharge summary

report

Admission Date: [**2138-10-1**] Discharge Date: [**2138-10-5**] Date of Birth: [**2063-11-14**] Sex: F Service: ORTHOPAEDICS Allergies: Vicodin Attending:[**First Name3 (LF) 64**] Chief Complaint: failed R THR Major Surgical or Invasive Procedure: Revision R THR History of Present Illness: 74F with failed R THR Past Medical History: Hypothyroidism, osteoarthritis, glaucoma Social History: NC Family History: NC 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 Pertinent Results: [**2138-10-2**] 05:32AM BLOOD WBC-10.2 RBC-2.86* Hgb-9.0* Hct-26.7* MCV-93 MCH-31.4 MCHC-33.7 RDW-13.1 Plt Ct-171 [**2138-10-1**] 07:17PM BLOOD WBC-10.3# RBC-3.12*# Hgb-10.1*# Hct-28.7*# MCV-92 MCH-32.3* MCHC-35.0 RDW-12.8 Plt Ct-183 [**2138-10-2**] 05:32AM BLOOD Plt Ct-171 [**2138-10-1**] 07:17PM BLOOD Plt Ct-183 [**2138-10-2**] 05:32AM BLOOD Glucose-153* UreaN-12 Creat-0.5 Na-138 K-4.2 Cl-103 HCO3-29 AnGap-10 [**2138-10-1**] 07:17PM BLOOD Glucose-132* UreaN-14 Creat-0.6 Na-140 K-3.4 Cl-105 HCO3-31 AnGap-7* [**2138-10-2**] 05:32AM BLOOD CK(CPK)-818* [**2138-10-1**] 07:17PM BLOOD CK(CPK)-546* [**2138-10-2**] 05:32AM BLOOD CK-MB-9 cTropnT-<0 [**2138-10-1**] 07:17PM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-<0.01 [**2138-10-2**] 05:32AM BLOOD Calcium-7.9* Phos-4.0 Mg-2.3 [**2138-10-1**] 07:17PM BLOOD Calcium-7.9* Phos-3.8 Mg-1.8 [**2138-10-2**] 05:32AM BLOOD TSH-0.59 [**2138-10-1**] 05:46PM BLOOD Type-[**Last Name (un) **] pH-7.40 [**2138-10-1**] 05:46PM BLOOD Glucose-110* Na-138 K-3.3* [**2138-10-1**] 05:46PM BLOOD Hgb-11.0* calcHCT-33 [**2138-10-1**] 05:46PM BLOOD freeCa-1.11* Brief Hospital Course: The patient was admitted on [**2138-10-1**] and, later that day, was taken to the operating room by Dr. [**Last Name (STitle) **] for revision L THR. In particular, the femoral component only was revised. Please see operative report for details. Intraoperatively the patient experienced an episode of sustained ventricular tachycardia which resolved spontaneously. The patient remained asymptomatic throughout. Postoperatively the patient was transferred to the ICU for close monitoring. She experienced no further events and was transferred to the floor on POD#1. With regard to analgesia, 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. The patient underwent an echo as part of her cardiac workup which revealed "hyperdynamic left ventricle without resting outflow tract obstruction or major valve dysfunction." While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. In particular, she received a 1-unit transfusion for postop anemia associated with decreased urine output on POD#2. 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. The operative extremity was neurovascularly intact and the wound was benign. The patient was discharged to home with services 50% PWB. Medications on Admission: synthroid 137, xalatan drops, truspot drops Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 3 weeks: To be followed by aspirin 325mg twice daily for 3 weeks. Disp:*21 syringes* Refills:*0* 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: Do not drink, drive or operate heavy machinery while taking this medication. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: failed R THR 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 on the operative leg. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2138-10-31**] 11:10 CC:[**Telephone/Fax (1) 78806**]

[ "365.9", "E878.1", "715.95", "338.18", "244.9", "996.77", "V43.64", "285.1", "427.1" ]

icd9cm

[ [ [] ] ]

[ "81.53", "03.90" ]

icd9pcs

[ [ [] ] ]

4514, 4587

1721, 3600

284, 300

4644, 4653

610, 1698

7055, 7245

451, 455

3694, 4491

4608, 4623

3626, 3671

4677, 6280

470, 591

232, 246

6292, 7032

328, 351

373, 415

431, 435

22,846

143,425

30614+57708+57709

Discharge summary

report+addendum+addendum

Admission Date: [**2198-5-6**] Discharge Date: [**2198-5-24**] Date of Birth: [**2122-12-22**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 1234**] Chief Complaint: Infected leg ulcer with abscess on the right. Major Surgical or Invasive Procedure: [**5-7**] OR I&D R calf: debridement of dead R gastrocnemius muscle, placement of L fem dialysis catheter [**5-14**] OR I&D R calf, partial closure, VAC History of Present Illness: Mr. [**Name13 (STitle) **] is a 75 year-old gentleman transferred from [**Hospital1 **] to [**Hospital1 69**] with a huge abscess in his right calf. He was found to be anuresis, BUN of 118 and a creatinine of 5.8. Past Medical History: PMH: DM, COPD, CAD s/p stent '[**90**], s/p CABG '[**93**], HTN, CVA '[**96**], anemia, mild mental retardation, CRI Social History: non smoker no alcohol no illicit drugs use Family History: not known Physical Exam: a/o x 3 / slight decrease in mental capability ncat perrl / eomi supple / farom neg lypmphanopathy cts rr benign Sugical site - open wound / good granulation tissue Palp L, dopp R DP/PT Pertinent Results: [**2198-5-20**] 05:30AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.2* Hct-26.9* MCV-89 MCH-30.4 MCHC-34.2 RDW-16.3* Plt Ct-346 [**2198-5-21**] 05:21AM BLOOD PT-31.3* PTT-38.7* INR(PT)-3.3* [**2198-5-20**] 05:30AM BLOOD Glucose-136* UreaN-21* Creat-1.1 Na-141 K-3.9 Cl-112* HCO3-23 AnGap-10 [**2198-5-8**] 08:10PM BLOOD ALT-17 AST-22 LD(LDH)-244 AlkPhos-101 Amylase-56 TotBili-0.7 [**2198-5-20**] 05:30AM BLOOD Calcium-6.7* Phos-3.1 Mg-1.8 [**2198-5-11**] Cardiology Report ECHO PATIENT/TEST INFORMATION: Indication: Left ventricular function. Height: (in) 68 Weight (lb): 212 BSA (m2): 2.10 m2 BP (mm Hg): 132/41 HR (bpm): 61 Status: Inpatient Date/Time: [**2198-5-11**] at 09:39 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Tape Number: 2007W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Suboptimal MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.3 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.1 cm Left Ventricle - Fractional Shortening: 0.39 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 216 msec TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild regional LV systolic dysfunction. No LV mass/thrombus. No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior wall. The other segments contract normally, and overall LVEF is preserved at 55%. No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated. Right ventricular systolic function is 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. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction. Mildly dilated right ventricle. Mild aortic regurgitation. Moderate pulmonary hypertension. [**2198-5-7**] 8:19 AM RENAL U.S. PORT RENAL ULTRASOUND: There is normal corticomedullary differentiation with normal cortical thickness bilaterally. The right kidney measures 12.1 cm. The left kidney measures 11.5 cm. There is no hydronephrosis, stones, or masses. The urinary bladder is catheterized and decompressed limiting detailed evaluation. IMPRESSION: No evidence of hydronephrosis, stones, or masses. [**2198-5-6**] 3:42 AM BILAT LOWER EXT VEINS FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of both common femoral, superficial femoral and popliteal veins were performed. Normal flow, augmentation, compressibility and waveforms are demonstrated. Intraluminal thrombus is not identified. IMPRESSION: No evidence of DVT. Brief Hospital Course: 75M transferred from [**Hospital3 **] to [**Hospital1 18**] with a huge abscess in his right calf. Pt started on broad spectrum antibiotics. CX's taken. FFP / Vit K given for INR 5. Pt with ARF / Femoral dialysis catheter placed for emergent dialysis. Secondary to ischemic ATN. CVVH performed on pt intermitantly during this hospital stay. On Dc pt making urine / creat noormal at 1.1. [**5-7**] PROCEDURE: 1. Incision and drainage of right leg abscess. 2. Debridement of right gastrocnemius muscle. Tolerated the procedure well. No complications. Transfered to the floor in stable condition, after recovering from anesthesia. [**5-8**] heparin drip started. PTT monitered throughout the hospital stay. [**5-11**] pt with rash / Zosyn discontinued / levofloxacin started / vanco and flagyl continued. [**5-13**]: Creat sarting to improve / pt starts makong urine. [**5-14**] PROCEDURE: Incision and drainage, debridement of muscle, fascia and skin, partial closure and a VAC dressing. Tolerated the procedure well. No complications. Transfered to the floor in stable condition, after recovering from anesthesia. [**5-15**] Heparin / coumadin bridge started [**5-17**] HD line removed GRAM STAIN (Final [**2198-5-14**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): BUDDING YEAST. ENTEROCOCCUS SP.. RARE GROWTH. [**Female First Name (un) **] PARAPSILOSIS. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S PENICILLIN------------ 4 S VANCOMYCIN------------ <=1 S AB adjusted according to sensitivities. VAC changed / wound improve [**5-18**] heparin DC'd / Continue with coumadin. INR monitered. [**5-21**] Vac changed [**5-22**] Stable for DC On DC creat - INR - Medications on Admission: [**Last Name (un) 1724**]: levaquin 500' (for this infection), glyburide 5', gemfibrozil 600', prostat 30", ASA 81', Fe, combivent, flovent, Cozaar 50', Imdur 120', lipitor 10', protonix 40', primivil 20', coumadin (for DVT) Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Moniter INR goal is [**2-17**]. 6. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 weeks. 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: check cbc and lft weekly. . 11. GlyBURIDE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day): prn 13. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed. 18. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 20. Insulin Insulin SC, Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice and 15 gm crackers 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 4 Units 4 Units 4 Units 4 Units 161-200 mg/dL 6 Units 6 Units 6 Units 6 Units 201-240 mg/dL 8 Units 8 Units 8 Units 8 Units > 240 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: DM RLE DVT infected R calf hematoma ARF - resolved (Creat 1.1) / high 4.9 Discharge Condition: Stable Discharge Instructions: Open Wound: VAC DRESSING Patient's Discharge Instruction Introduction: This will provide helpful information in caring for your wound. If you have any questions or concerns please talk with your doctor or nurse. You have an open wound, as opposed to a closed (sutured or stapled) wound. The skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. Premature closure or healing of the skin can result in infection. Your wound was left open to allow new tissue growth within the wound itself. The wound is covered with a VAC dressing. This will be changed around every three days. The VAC: helps keep the wound tissue clean absorbs drainage prevents premature healing of skin promotes healing When to Call the Doctor Watch for the following signs and symptoms and notify your doctor if these occur: Temperature over 101.5 F or chills Foul-smelling drainage or fluid from the wound Increased redness or swelling of the wound or skin around it Increasing tenderness or pain in or around the wound Followup Instructions: Call Dr [**Last Name (STitle) 8888**] office at [**Telephone/Fax (1) 1241**]. This should be with in one week. Completed by:[**2198-5-22**] Name: [**Known lastname 12100**],[**Known firstname 33**] J Unit No: [**Numeric Identifier 12101**] Admission Date: [**2198-5-6**] Discharge Date: [**2198-5-24**] Date of Birth: [**2122-12-22**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 270**] Addendum: COUMADIN: Please check INR daily untill INR is [**2-17**]. Pt was on coumadin 3 mg qhs. On [**5-22**] INR 5.4. Hold dose on [**5-22**]. Restart at coumadin at 1 mg qhs on [**5-23**]. PT HCT WAS 23.6 ON [**5-22**]. PT [**Name (NI) 12102**] 1 UNIT PRBC. PLEASE CHECK HCT ON [**5-23**]. pt ciprofloxacin and linazolid dc / do not have to follow cbc and lft Discharge Disposition: Extended Care Facility: [**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**] Completed by:[**2198-5-22**] Name: [**Known lastname 12100**],[**Known firstname 33**] J Unit No: [**Numeric Identifier 12101**] Admission Date: [**2198-5-6**] Discharge Date: [**2198-5-24**] Date of Birth: [**2122-12-22**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 270**] Addendum: COUMADIN: Please check INR daily untill INR is [**2-17**]. Pt was on coumadin 3 mg qhs. On [**5-23**] INR 5.4. Hold dose on [**5-23**]. Restart at coumadin at 1 mg qhs on [**5-24**]. PT HCT WAS 23.6 ON [**5-22**]. PT [**Name (NI) 12102**] 1 UNIT PRBC. HCT DC 26.3 Discharge Disposition: Extended Care Facility: [**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**] Completed by:[**2198-5-23**]

[ "496", "V45.82", "707.12", "584.5", "403.91", "V12.51", "728.88", "V45.81", "250.00", "728.89", "693.0", "682.6", "V58.61", "041.04", "E930.0", "428.0", "317" ]

icd9cm

[ [ [] ] ]

[ "93.59", "99.07", "89.64", "86.22", "39.95", "96.6", "38.95", "38.93", "83.45", "99.04" ]

icd9pcs

[ [ [] ] ]

12867, 13114

5508, 7378

311, 467

10022, 10031

1158, 1635

11128, 11967

926, 937

7654, 9792

9925, 10001

7404, 7631

10055, 11105

1661, 5485

952, 1139

226, 273

495, 710

732, 850

866, 910

31,971

176,994

32419

Discharge summary

report

Admission Date: [**2192-12-17**] Discharge Date: [**2192-12-26**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**2192-12-18**] Apico-Aortic Conduit(utilizing a 19mm [**Company 1543**] Freestyle Aortic Root Heart Valve) via Left Thoractomy History of Present Illness: 86 yo F with critical AS. PMH sig for CABG [**04**] years ago, PPM placement, and NSTEMI in [**9-3**] with LM DES and aortic valvuloplasty x 2. Readmitted at OSH for ?ileus/CHF and transferred to [**Hospital1 **] for surgical eval. Past Medical History: Aortic Stenosis Congestive Heart Failure Coronary Artery Disease - s/p CABG, s/p Left Main Drug Eluding Stent, History of NSTEMI Peripheral Vascular Disease Cerebrovascular Disease - history of TIA Bilateral Carotid Disease Hypertension Pacemaker in Situ GERD History of Lyme Disease Bilateral Cataract Surgery Social History: Retired - worked in resturant. Lives in apartment next to daughter. [**Name (NI) 1139**] quit > 20 years ago, smoked [**11-28**] cigarettes/ day for 40 years. Denies ETOH. Family History: Son deceased at age 42 of myocardial infarction Physical Exam: Vitals: General: WDWN HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2192-12-25**] 04:40AM BLOOD WBC-11.4* RBC-4.10* Hgb-11.8* Hct-34.9* MCV-85 MCH-28.7 MCHC-33.7 RDW-15.4 Plt Ct-137* [**2192-12-25**] 04:40AM BLOOD Plt Ct-137* [**2192-12-23**] 02:09AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.2* [**2192-12-26**] 04:50AM BLOOD Glucose-92 UreaN-41* Creat-1.1 Na-138 K-3.4 Cl-102 HCO3-27 AnGap-12 CHEST (PORTABLE AP) [**2192-12-25**] 9:22 AM CHEST (PORTABLE AP) Reason: eval ptx with chest tubes clamped [**Hospital 93**] MEDICAL CONDITION: 86 year old woman s/p apicoaortic conduit REASON FOR THIS EXAMINATION: eval ptx with chest tubes clamped INDICATIONS: 86-year-old woman status post apical aortic conduit placement. Please evaluate for pneumothorax with chest tubes clamped. CHEST, PORTABLE AP: Comparison is made to the prior day. The configuration of two left-sided chest tubes, a right internal jugular central venous catheter, and a dual-lead pacemaker/ICD device is unchanged. There is no evidence for pneumothorax or effusion. Mild prominence of central pulmonary vessels is unchanged. Left basilar atelectasis appears improved. IMPRESSION: No evidence of pneumothorax. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 75681**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75683**] (Complete) Done [**2192-12-18**] at 11:59:16 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2105-12-29**] Age (years): 86 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Redo AVR ICD-9 Codes: 402.90, 786.05, 786.51, 799.02, 440.0, V43.3, 424.1, 424.0 Test Information Date/Time: [**2192-12-18**] at 11:59 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: [**Pager number **] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: *1.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Aorta - Ascending: *3.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *5.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *103 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 58 mm Hg Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec Aortic Valve - LVOT diam: 1.8 cm Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Severe symmetric LVH. Moderately depressed LVEF. RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. AORTA: Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Severe AS (AoVA <0.8cm2). MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pred-CPB: No spontaneous echo contrast is seen in the left atrial appendage. There is severe symmetric left ventricular hypertrophy. Overall left ventricular systolic function is moderately depressed (LVEF= 30 - 35 %). with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. There is severe aortic valve stenosis (area <0.8cm2). The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient received a valved conduit from the LV apex to the descending aorta, on bypass, with continuous VFib. Meds are Amiodarone infusion and low dose Phenylephrine. A-Paced. LV fxn is still moderately depressed with EF 30%. There is a conduit from the LV apex to the descending aorta, with flow noted. There is considerable reduction in the flow thru the LVOT. Aorta is intact otherwise. RV systolic fxn mildly to moderately reduced. Brief Hospital Course: She was admitted preoperatively. On [**12-18**] she underwent an apico-aortic conduit with 19 mm tissue valve. She was transferred to the ICU in stable condition. She was extubated on POD #1. She was started on amio and must remain on it for life. She remained in the ICU for pulmonary toilet. Creatinine bumped but peaked at 1.9, and has returned to [**Location 213**]. She was transferred to the floor on POD #6. She had an air leak and her chest tubes were placed to water seal and then clamped with no pneumothorax prior to being discontinued. She was ready for discharge to rehab on POD #8. Medications on Admission: ECASA 325, plavix 75, atenolol 50", altace 5, Vytorin [**9-16**], zantac 300", protonix 40", MVI, lasix 20', Famotidine 20 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for LM stent. 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 200 mg daily x 1 week, then 200 mg daily ongoing for life. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: 40 [**Hospital1 **] x 7 days then 20 daily as prior to surgery. 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: Friendly [**Name2 (NI) **] INC Discharge Diagnosis: Aortic Stenosis - s/p Apico-Aortic Conduit Postoperative Anemia Coronary Artery Disease - prior CABG Congestive Heart Failure(Systolic) Pacemaker in Situ Hypertension Peripheral Vascular Disease Bilateral Carotid Disease History of TIA Discharge Condition: Stable Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**3-2**] weeks, call for appt Dr. [**Last Name (STitle) 64868**] in [**12-30**] weeks, call for appt Dr. [**Name (NI) 71003**] in [**12-30**] weeks, call for appt Completed by:[**2192-12-26**]

[ "424.1", "401.9", "428.0", "428.22", "412", "997.1", "998.0", "V45.01", "285.9", "443.9", "V45.81", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.93", "99.04", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

8977, 9034

6561, 7158

274, 405

9314, 9323

1589, 2023

9658, 9891

1206, 1255

7331, 8954

2060, 2102

9055, 9293

7184, 7308

9347, 9635

1270, 1570

231, 236

2131, 6538

433, 666

688, 1000

1016, 1190

77,690

121,387

33956

Discharge summary

report

Admission Date: [**2110-11-17**] Discharge Date: [**2110-12-3**] Date of Birth: [**2042-4-5**] Sex: M Service: MEDICINE Allergies: Hydrochlorothiazide / Norvasc Attending:[**First Name3 (LF) 11839**] Chief Complaint: presyncope Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: . 68 yo M with Stage III nonsmall cell lung cancer (adenocarcinoma) with metastatic disease to brain discovered in [**9-/2110**] after focal seizure s/p cyberknife and hx of complete heart block s/p pacemaker who presents to the ED today after a presyncopal episode. . Patient reports that he was walking out of CVS on th eday of admission and suddenly collapsed to the ground and was unable to get up. He denied any preceding symptoms such as chest pain, palpitations, sob, lightheadedness or dizziness. No focal weakness. Denies any LOC or head trauma. No reported confusion, bowel/bladder incontinence, tongue biting or witnessed shaking. Found to be hypotensive to 88/44 by EMS. Denied any headaches, visual changes, muscle weakness or parasthesias. Patient reports he was in his usual state of health prior to the fall. No recent infections, cough, URI sx or dysuria. No abdominal pain, brbpr or melena. . Wife [**Last Name (un) **] reported some concerns regarding her husband's health over the weekend. Wife said he had "labored breathing" and appeared unsteady on his feet. He did not leave the house this weekend. She was planning on taking him to his primary care today. Also with decreased po intake. Mild confusion that has been present since starting chemo. . Of note, patient reported isolated incident of tonic-clonic right arm shaking two weeks ago that lasted approximately 60 seconds. No LOC. Patient had similar right arm seizure like activity in [**Month (only) 359**] for which he was hospitalized and found to have a new brain met. He has since been on a decadron taper that finished today and completed cyberknife. . In ED: 98 76P 110/42 20 95%RA; guaiac negative; given 2L NS and hydrocortisone 100mg for presumed adrenal insufficiency; CXR showed PNA - started on cefepime and vancomycin; Head CT showed improvement of vasogenic edema; abdominal CT showed stable AAA and no rp bleed . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: Oncology history: DIAGNOSIS: 1. Stage III nonsmall cell lung cancer (adenocarcinoma) with a potential T4N0 tumor (stage III, 7th TNM), EGFR wild-type 2. Metastatic disease to brain discovered in [**9-/2110**] after focal seizure. CURRENT TREATMENT: Surveillance TREATMENT: 1. Status post chest radiotherapy to 6600 cGy completed on [**2109-4-1**]. 2. Status post 2 cycles of cisplatin 50 mg/m2 D1, D8 and etoposide 50 mg/m2 D1-D5 of a 28 day cycle on [**2109-2-18**] and [**2109-3-18**].He started concurrent chemoradiation therapy on [**2109-2-15**]. Day 8 cisplatin was held during cycle 1 for AAA repair. Day 8 cisplatin was held during cycle 2 for thrombocytopenia. 3. S/p cyberknife and decadron taper for brain mets PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Complete heart block status post pacemaker. 4. Arthroscopic knee surgery. 5. Arthritis 6. Coronary artery disease 7. Rosacea 8. Status post endovascular aortic aneurysm repair on 03/[**2108**]. Social History: Patient lives with wife, 6 children. Retired engineer for telephone company. Distant tobacco, no alcohol currently (had [**12-22**] manhattens daily previously), no illicits. Family History: No fhx of lung cancer. Myocardial infarction in his father sustained at the age of 68. There is no history of premature coronary artery disease. No family history of malignancy. Physical Exam: Admission physical exam: 98.5 106/68 68P 18 96%RA Appearance: alert, NAD Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmm, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally Pulm: diminished at bases Abd: soft, nt, nd, +bs Msk: 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, 5/5 strength, no pronator drift, normal finger-to-nose, downgoing babinski, 2+ reflexes ue/le, sensation grossly intact Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Rectal: guaiac negative in ED Pertinent Results: [**2110-11-17**] 06:45PM cTropnT-<0.01 [**2110-11-17**] 04:57PM LACTATE-1.4 [**2110-11-17**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [**2110-11-17**] 01:33PM PT-13.0 PTT-26.0 INR(PT)-1.1 [**2110-11-17**] 01:10PM GLUCOSE-159* UREA N-21* CREAT-0.9 SODIUM-127* POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-22 ANION GAP-15 [**2110-11-17**] 01:10PM cTropnT-<0.01 [**2110-11-17**] 01:10PM WBC-3.7*# RBC-3.09* HGB-10.0*# HCT-28.4* MCV-92 MCH-32.4* MCHC-35.3* RDW-13.6 [**2110-11-17**] 01:10PM NEUTS-93.4* LYMPHS-5.0* MONOS-1.2* EOS-0.3 BASOS-0.1 . [**2110-11-17**] BCx: negative [**2110-11-17**] UCx: negative [**2110-11-17**] EKG: 63 V-paced, no change from [**10-10**] . [**2110-11-17**] NCHCT: 1. No acute hemorrhage or mass effect. 2. Decreased area of vasogenic edema in left frontal vertex compared to [**2110-10-12**]. . [**2110-11-17**] A/P CT WO Contrast: 1. Stable size of AAA, measuring 6.8 x 6.4 cm (compared to 6.9 x 6.2 cm on [**10-14**]). 2. No retroperiotneal hematoma. . [**2110-11-17**] Pa/Lat CXR: Bilateral upper lobe pneumonia. . [**2110-11-18**] CT chest without contrast: IMPRESSION: 1. New severe alveolitis or other alveolar filling process primarily involving the upper lobes and therefore most likely connected to prior radiation therapy denoted by longstanding paramediastinal pulmonary fibrosis. The differential diagnosis includes delayed cryptogenic organizing pneumonia, drug-induced pneumonitis potentiated by prior radiation (given the appropriate clinical history of ongoing chemotherapy, unknown to me). Diffuse pulmonary hemorrhage and widespread atypical pneumonia are alternative possibilities. 2. Severe atherosclerosis, involving coronaries. . [**2110-11-19**] Immunoflourescent test for Pneumocystis jirovecii (carinii)(Final [**2110-11-20**]): NEGATIVE for Pneumocystis jirovecii (carinii). . [**2110-11-19**]: B-GLUCAN Fungitell (tm) Assay for (1,3)-B-D-Glucans Results: >500 pg/mL* Reference Ranges Negative: Less than 60 pg/mL Indeterminate: 60 - 79 pg/mL Positive: Greater than or equal to 80 pg/mL . [**2110-11-20**] Legionella Urinary Antigen: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . [**2110-11-21**] Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2110-11-24**]): NEGATIVE for Pneumocystis jirovecii (carinii). . [**2110-11-21**] Chest xray: IMPRESSION: In addition to the biapical radiation changes, there is likely overlying atypical organism infection, possibly PCP, [**Name10 (NameIs) **] drug toxicity from chemotherapy that has now spread to the left mid, left lower, and right lower lung fields. . [**2110-11-24**] Ultrasound L upper extremity: IMPRESSION: No DVT in the left upper extremity. . [**2110-11-25**] CT of C, T and L spine: C Spine IMPRESSION: No evidence of metastatic disease. Extensive degenerative disc disease of the cervical spine, as described above. T Spine IMPRESSION: 1. No evidence of spinal metastatic disease. 2. Diffuse bilateral ground-glass opacities are partially imaged and are further characterized on CT exam of [**2110-11-18**]. Small bilateral pleural effusions, right greater than left, appears slightly increased in size from prior. 3. Calcified disk protrusion at T6-7 with likely cord compression. L Spine IMPRESSION: 1. No evidence of metastatic disease. No suspicious lytic or sclerotic lesion is seen within the bones. 2. Stable appearance of the infrarenal abdominal aortic aneurysm. Numerous sigmoid colon diverticula without associated inflammatory changes. Brief Hospital Course: 1. Hypoxic Respiratory Failure, progressive alveolar process: This is a 68 year old gentleman with CHB s/p PPM and Stage IV NSCLC (adenoCa) with a single brain metastasis s/p cyberknife one month ago and subsequent decadron taper terminating on the day of admission. He presented to the ED following a presyncopal episode during which he was found to be hypotensive by EMS. This hypotension resolved without intervention prior to his arrival in the ED where he was given broad spectrum antibiotics (HCAP coverage) for bilateral apical infiltrates and stress dose steroids for potential adrenal insufficiency. He was admitted to the general medical floor. A Head CT with contrast demonstrated improvement of his vasogenic edema and abdominal CT demonstated a stable AAA. CT scan of the chest on the evening of admission demonstrated new severe alveolitis or other alveolar filling process primarily involving the upper lobes, but also with patchy involement in other lung fields. The differential diagnosis entertained included COP as a late term sequelae of the chest radiation he had received one year prior, atypical PCP with particular concern for PCP, [**Name10 (NameIs) **] less likely possiblities such as hypersensitivity pneumonitis, vasculitides, and pulmonary hemmorhage. He had no oxygen requirement on the day of admission despite pronounced findings on chest CT. He developed rapidly progressive hypoxemia. On HD2, he required 2L by nasal cannula to maintain O2 sats in the low 90s. In addition to the vancomycin and cefepime he had been receiving since admission, he was started on azithromycin and high dose IV bactrim with steroids (to empirically cover PCP and also potentially steroid-responsive inflammatory lung diseases such as COP). Pulmonary was consulted regarding bronchoscopy, but this was cancelled given his worsening oxygen requirement which progressed despite empiric treatments. He was transferred to the medical ICU on [**11-22**] as he began to require a non-rebreather to maintain sats in the low 90s. On admission to ICU, it was noted that pneumonitis hypersensitivity panel, [**Doctor First Name **] and ANCA were negative. Sputum was negative for PCP x 2. However, B-glucan was grossly elevated to >500, galactomannam was elevated at 0.5, and LDH was elevated up to 754, suspicion was high for PCP pneumonia and patient was started on bactrim DS and steroids. He improved greatly over several days, weaned down to 5L NC, at which time he was transferred back to the floor. He completed a 7 day course of broad spectrum antibiotics (vancomycin, cefepime and azithromycin) to cover for HCAP. The patient's oxygenation steadily improved on bactrim and prednisone although he continues to require supplement O2 ( 5 lits ) per nasal cannula.As below, pt developed transaminitis and pan-cytopenia while on bactrim. CBC, lfts and chem 10 will need to be followed closely at the outside faciliy and pt will also be followed by the [**Hospital **] clinic. His hospitalization was also notable for: 2. Concern for adrenal insufficiency which prompted ED physicians to give stress dose steroids. His AM cortisol over 24 hours after stress dose steroids were stopped was 20, making this very unlikely.Pt is being d/c on prednisone ( as part of treatment for PCP [**Name Initial (PRE) 1064**]) and will need a slow taper after completion of treatment dose. . 3. Hyponatremia: His serum sodium dropped as low as 125 but pt remained asymptomatic. Likely causes included some element of SIADH secondary to lung inflammation/NSCLC and this was likely exacerbated by mild hypovolemia as his sodium did increase with normal saline. Treated with high sodium diet, mild fluid restriction and intermittant IVF as required by his volume status.Pt being d/c with low dose of oral supplemental salt. . 4. Pancytopenia: On admission, His thrombocytopenia and leukopenia improved without intervention and was attributed to acute illness. However, his anemia recurred mostly likley from myelosuppression due to high dose bactrim and he required 2 units PRBCs on [**2110-11-30**] and [**2110-12-1**]. Iron studies, B12 and folate did not show deficiencies and work up did not support hemolysis.On d/c plts are trending down and levels need to be followed closely as an outpt. . 5. NSCLC/ Code Status: Initially the patient was listed as DNR/DNI, but given his progressive oxygen requirement from a potentially reversible/treatable process and his relatively good response thus far from an oncologic point-of-view, this was discussed with the patient and his wife [**Name (NI) 382**] on [**2110-11-20**] by the hospitalist caring for him and he was switched to FULL CODE. The patient's son was also present for this conversation. . 6. Lower extremity weakness: Patient complained of progressively worsening weakness. Non contrast head CT showed no worsening of his brain mets. A CT spine (patient's pace maker is NOT compatible with MRI) showed no mets in the spinal cord but did reveal cord impingement due to DJD at T6. The patient was seen in consultation with neuro oncology who felt that this radiologic finding was not causing clinical symptoms, had been documented on prior studies and was stable. Differential diagnosis included neuromuscular process, paraneoplastic process, and deconditioning given prolonged hospitalization. TSH and CPK levels were wnl.Symptoms did improve spontaneously and likely cause is deconditioning due to prolonged hospital stay including ICU admission. Pt will need PT. . 7. Hyperkalemia: Likely due to high dose bactrim. In the acute circumstance the patient received kayexalate on two occasions. Long term the issue was managed by decreasing the patient's carvedilol dose, adding low torsemide every other day with or without IV hydration depending on the patient's volume status.Pt being d/c on a low K diet and electroltyes will need to be monitored as an outpt. . 8. Transaminitis with elevated alkaline phos and normal bilirubin: The patient was assymptomatic and these laboratory changes were thought most likely due to drug effect. Hepatitis serologies pending on d/c. The patient's statin was discontinued and his keppra was changed to zonisamide. High dose bactrim may also be contributing and dose reduced after dsicussion with the ID service . . 9. Stage III NSCLC / brain mets: Repeat Head CT with contrast showing no new lesions, edema decreased. Pt will continue f/u with primary oncologist. . 10. History of Seizures: Secondary to brain mets.As above, DC'd keppra, started Zonisamide due to elevated LFT's. . 10. HTN: Held home meds on admission. DECREASED carvedilol (coreg) 12.5 mg [**Hospital1 **] --> 3.125 [**Hospital1 **] to allow every other day torsemide to manage hyperkalemia. BP remained stable on this dose after discontinuation of torsemide but may need to titrated back up. . 11. GERD: Continued omeprazole. . 12. HLD: Given his transaminitis, discontinued simvastatin. . 13. Acute delerium at night: managed with Haldol 0.5-1 mg QHS with marked improvement though not complete resolution. He remained oriented during the day. . 14. Left upper extremity edema: etiology unclear. ultrasound negative. Emergency contact: [**Name (NI) **] (wife) [**Telephone/Fax (1) 78434**] (H), [**Telephone/Fax (1) 78435**] (C). Medications on Admission: Carvedilol 25mg [**Hospital1 **] Dexamethasone taper - finished today, taper started [**2110-10-27**] with 4mg daily Levetiracetam 1000mg [**Hospital1 **] Lisinopril 10mg daily Prilosec 20mg [**Hospital1 **] Simvastatin 20mg daily ASA 81mg daily MVI Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for confusion. 7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)) for 1 days. 10. prednisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)) for 8 days: will need taper after [**2110-12-13**]- to discuss with primary oncologist. 11. insulin lispro 100 unit/mL Solution Sig: Two (2) units Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: 2.5 Tablets PO every six (6) hours for 11 days. 13. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO QOD (). Discharge Disposition: Extended Care Facility: [**Hospital3 **] [**Location (un) 1121**] Discharge Diagnosis: PCP (pneumoncystis) pneumonia Lung cancer with brain metastases Elevated Liver function tests Hyperkalemia (high potassium) Hypoxemia (low oxygen) Hyponatremia (low sodium) Diffuse weakness Degenerative joint disease Left arm swelling Delerium at night High blood pressure High cholesterol Heart burn pan-cytopenia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with shortness of breath from PCP (pneumoncystis) pneumonia that required intensive care unit monitoring for your oxygen levels. You are being treated with 3 weeks of bactrim antibiotics with prednisone steroid medication and you have been steadily improving. You have continued to need oxygen, but this is expected to improve over time. Your strength has been improving and tests did not reveal a cause for weakness.You liver function tests have been elevated so your statin has been stopped and your anti seizure medication has been changed.Your potassium has been high probably from the bactrim antibiotic you need for your pneumonia. This has been treated with a water pill (toresamide), IV fluids, and decreasing your carvedilol blood pressure medication.You have received 2 blood transfusions for anemia with good response. You have had confusion at night time that has been treated with Haldol at bedtime. pending results: hepatitis serologies Followup Instructions: F/U blood pressure-carvedilol may need to be titrated up. F/U CBC and chem 10 in 2 days and then at least twice a week. Results to be faxed to Dr [**Last Name (STitle) 10351**] , fax # [**Telephone/Fax (1) 34802**] ## Pt will be contact[**Name (NI) **] for f/u with the [**Hospital **] clinic , if you do not hear from them please contact [**Telephone/Fax (1) 457**] to set a f/u in [**4-26**] days. Department: [**Location (un) 2352**] PHYSICAL THERAPY When: MONDAY [**2110-12-8**] at 2:00 PM With: [**Name (NI) 78436**] [**Name (NI) 33923**], PT [**Telephone/Fax (1) 4832**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2110-12-25**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2110-12-25**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

16881, 16949

7977, 15288

302, 323

17308, 17308

4382, 7954

18479, 19825

3556, 3737

15588, 16858

16970, 17287

15314, 15565

17486, 18456

3777, 4363

252, 264

351, 2333

17323, 17462

3103, 3346

3362, 3540

223

105,694

27870

Discharge summary

report

Admission Date: [**2157-5-1**] Discharge Date: [**2157-7-1**] Date of Birth: [**2089-10-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: 67M with fever and cough Major Surgical or Invasive Procedure: [**2157-6-1**] CABG x 4 (LAD, PDA, [**Last Name (LF) **], [**First Name3 (LF) **]) Cardiac cath History of Present Illness: Pt is a 67yo homeless man with pmh sig for "enlarged heart" who presents to the ED by EMS complaining of fever/chills and productive cough with progressively worsening SOB over the past 3-4 days. Denies palp/n/v. Has had diaphoresis. No orthopnea/pnd. In the [**Name (NI) **] pt had increased O2 requirements to 100% NRB, given solumedrol, ceftriaxone, azithromycin. Given elevated cardiac enzymes, EKG changes pt started on heparin drip. Past Medical History: ?cardiomegaly knee pain Social History: +smoker former golf pro homeless + former alcohol use - quit 7 yrs ago no ivda Family History: unable to obtain Physical Exam: T 96.9 HR 98 BP 70/50 AC 500X18 Fio2 100% RR 20 GEN: using accessory muscles to breath, diaphoretic NECK: JVD to mandible CARD: Tachycardia, no mrg, no s3s4 LUNGS: b/l soft exp wheeze, no rales, decreased bs on left lower lung field ABD: soft nt nd nabs EXT: cool, no edema NEURO: AAO x 3, mae rectal guiac neg Pertinent Results: [**2157-6-5**] 02:16AM BLOOD WBC-6.3 RBC-3.31* Hgb-10.1* Hct-28.9* MCV-87 MCH-30.7 MCHC-35.1* RDW-16.4* Plt Ct-110* [**2157-6-30**] 05:45AM BLOOD PT-11.0 PTT-23.8 INR(PT)-0.9 [**2157-6-30**] 05:45AM BLOOD Glucose-91 UreaN-17 Creat-0.8 Na-137 K-4.4 Cl-101 HCO3-25 AnGap-15 RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2157-6-30**] 1:27 PM CHEST (PA & LAT) Reason: pleural effusion [**Hospital 93**] MEDICAL CONDITION: 67 yo M s/p cabgx4, avr [**6-1**] REASON FOR THIS EXAMINATION: pleural effusion REASON FOR THE STUDY: Assessment for pleural effusion in a patient after CABG. TECHNIQUE: PA and lateral views of the chest, and the study is compared to the previous one done on [**2157-6-4**]. FINDINGS: Heart, mediastinal and hilar contours are normal. Lungs are clear. There are no pleural effusions or pneumothorax. Impression:Normal study. No evidence of pleural effusion. DR. [**First Name (STitle) **] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Cardiology Report ECHO Study Date of [**2157-6-1**] PATIENT/TEST INFORMATION: Indication: Intraoperative TEE for AVR/CABG Height: (in) 67 Weight (lb): 145 BSA (m2): 1.77 m2 BP (mm Hg): 109/67 HR (bpm): 65 Status: Inpatient Date/Time: [**2157-6-1**] at 11:20 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% (nl >=55%) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: *3.0 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 36 mm Hg Aortic Valve - LVOT Diam: 2.0 cm Aortic Valve - Valve Area: *0.8 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Mild global LV hypokinesis. Mildly depressed LVEF. LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior - hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal - hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral - hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex - hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex - hypo; RIGHT VENTRICLE: Borderline normal RV systolic function. AORTA: Focal calcifications in aortic root. Focal calcifications in ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. Focal calcifications in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate AS. Mild to moderate ([**12-6**]+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the for the patient. Conclusions: PRE-CPB 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 global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. Right ventricular systolic function is borderline normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. Mild to moderate ([**12-6**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-CPB Patient is receiving epinephrine by infusion. Normal right ventricular systolic function. Left ventricle with septal "bounce" consistent with ventricular pacing. Overall systolic function is slightly improved from pre-CPB. Bioprosthesis in aortic valve position is well seated and displays normal leaflet function. There is trace valvular AI. No other changes from pre-CPB. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2157-6-1**] 15:52. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 67910**]) Brief Hospital Course: The pt. was admitted on [**2157-5-1**] to the MICU and intubated for respiratory distress and profound acidosis. He was on Levophed for hypotension and had bacteremia and sepsis. His pneumonia was treated with Ceftriaxone and Azythromycin and was on Levo for quite some time. He had an echo on admission which revealed an EF of 55% and no wall motion abnormality. He eventually had a NSTEMI and refused cardiac cath. He eventually agreed and underwent cardiac cath on [**2157-5-13**] which revealed: 70%LM stenosis, prox 80%LAD, 50% [**Date Range **] 1, 80% [**Date Range **] 2, 90% prox LCX, 100% L PDA, mod. AS with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9 cm2 and a peak gradient of 30mmHg, and [**12-6**]+MR. Cardiac surgery was consulted and he needed to wait for surgery until he was off Plavix for 5 days, and he had 2 teeth extracted. On [**2157-6-1**] he had a CABGx4(LIMA->LAD, SVG->PDA, [**Date Range **], and OM)/AVR w/ 23mm Magna Pericardial valve. The cross clamp time was 136 mins. and total bypass time was 166 mins. He tolerated the procedure well and was transferred to the CSRU on Epi, Nitro, and Propofol. He was agitated and followed by psychiatry who recommended Haldol. He was extubated on POD#1 and had his chest tubes d/c'd on POD#3. His epicardial pacing wires were d/c'd on POD#3 and he was weaned off Levophed. He was transferred to the floor on POD#4 and continued to progress. He remained in the hospital for the next 3 weeks to have his sternum heal as he will be released to a homeless shelter and will need to be completely independent. He completed an application for the [**Location (un) 18437**] and will hopefully get a bed and agree to live there in the next month. He was discharged in POD#30 in stable condition. Medications on Admission: none Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: CAD Pneumonia Sepsis NSTEMI Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No heavy lifting or driving. Shower, No baths, no lotions, creams or powders to incisions. Followup Instructions: Dr. [**First Name (STitle) **] (PCP at [**Name9 (PRE) 1268**] VA) 1-2 weeks Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 [**Telephone/Fax (1) 58913**] Completed by:[**2157-7-1**]

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icd9cm

[ [ [] ] ]

[ "00.17", "36.15", "39.61", "35.21", "96.04", "38.93", "23.19", "99.04", "96.72", "37.23", "88.56", "36.13", "88.72", "96.6" ]

icd9pcs

[ [ [] ] ]

8836, 8870

6587, 8379

344, 442

8942, 8950

1440, 1831

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8434, 8813

1868, 1902

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1107, 1421

280, 306

1931, 2548

470, 914

6522, 6564

936, 961

977, 1058

83,115

171,852

41013

Discharge summary

report

Admission Date: [**2141-2-15**] Discharge Date: [**2141-2-18**] Date of Birth: [**2064-2-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: Fall, rhabdomyolysis, hypothermia Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is a 76 year old woman with a past medical history significant for hypertension found at the bottom of a flight of stairs now admitted found to have a L2 fracture and shoulder subluxation now admitted to the MICU for hypothermia and rhabdomyolysis. The patient was found down at her home today by Physical Therapy at the bottom of the basement stairs. She reports that she was walking down her stairs on Monday when she tripped and fell, and was unable to get up. She was oriented x3 per EMS and denied any pain. Of note, the last time she was in contact with family was 3 days prior to admission (Monday). . In the [**Hospital1 18**] ED, initial VS 32.3 (rectal) 52 111/65 14 100%RA. Labs notable for a CK 3387 and a WBC of 12.5. She had a negative CTH and CT cspine, with CT torso demonstrating a non-displaced fracture of the right transverse process of L2 vertebra and shoulder film demonstrating anterior medial subluxation. Neurosurgery and vascular surgery were consulted, and she was then admitted to the MICU for further management. . Currently, the patient states that she has some right shoulder pain, but otherwise denies any CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, HA, hip pain. . ROS: As above, otherwise negative. Per discussion with brother, has had right shoulder pain x6 months, holding it against her chest. History of frequent falls. Past Medical History: Rheumatic fever age 18 - per pt no valvular problems HTN R arm immobility x approx 2 years, gradual in onset, now has no use of R hand, extensive w/u without cause found, thought could be due to ? atypical ALS, + recent shoulder dislocation [**2-8**], relocated at ED, placed in sling and dc'ed home Social History: Lives alone. Retired worker in a candy factory - no exposures per pt [**Name (NI) 6934**] unaided. Per pt, independent in IDLs, does own shopping and cleaning. Tobacco - none. EtOH - social. Denies IV, illicit, or herbal drug use. Family History: Mother died 69 of CAD Father died 93 of old age Sister with brain aneurysm Physical Exam: VS: 35.7 72 137/62 18 99%RA Gen: Frail elderly female, NAD with echymosses throughout. HEENT: Bilateral periorbital echymosses. Abrasion over bridge of nose. Poor dentition, but OP otherwise clear. Neck supple. CV: Nl S1+S2, no m/r/g Pulm: CTAB anteriorly Abd: S/NT/ND +bs Ext: Venous stasis signs, trace pitting edema bilaterally. Right arm cool to touch with increased edema. Palpabled right radial pulse, CR<2 seconds. Neuro: AOx3, CN II-XII intact. Skin: Bilateral periorbital bruising, bruising down entire back and buttocks, bilateral shoulders, right upper arm, left elbow, bilateral hips, bilateral knees, left shin, and toes. MSK: Right shoulder displaced anteriomedially. Pertinent Results: Admission labs: [**2141-2-15**] 01:15PM BLOOD WBC-12.5* RBC-4.72 Hgb-14.1 Hct-41.6 MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-272 [**2141-2-15**] 01:15PM BLOOD Neuts-69.7 Bands-0 Lymphs-26.8 Monos-2.9 Eos-0.1 Baso-0.6 [**2141-2-15**] 01:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2141-2-15**] 01:15PM BLOOD PT-13.2 PTT-28.6 INR(PT)-1.1 [**2141-2-15**] 01:15PM BLOOD Glucose-139* UreaN-41* Creat-0.7 Na-137 K-4.1 Cl-102 HCO3-24 AnGap-15 [**2141-2-15**] 01:15PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-2.4 . Other labs: [**2141-2-17**] 06:40AM BLOOD Ret Aut-1.7 [**2141-2-15**] 01:15PM BLOOD ALT-88* AST-108* CK(CPK)-3387* AlkPhos-62 TotBili-0.8 [**2141-2-15**] 09:35PM BLOOD CK(CPK)-1722* [**2141-2-16**] 04:08AM BLOOD CK(CPK)-1342* [**2141-2-17**] 06:40AM BLOOD LD(LDH)-536* CK(CPK)-673* TotBili-0.4 [**2141-2-15**] 01:15PM BLOOD Lipase-18 [**2141-2-15**] 01:15PM BLOOD cTropnT-<0.01 [**2141-2-15**] 09:35PM BLOOD CK-MB-46* MB Indx-2.7 cTropnT-<0.01 [**2141-2-16**] 04:08AM BLOOD CK-MB-30* MB Indx-2.2 cTropnT-<0.01 [**2141-2-16**] 04:08AM BLOOD calTIBC-198* Ferritn-287* TRF-152* [**2141-2-17**] 06:40AM BLOOD VitB12-535 Folate-8.7 Hapto-43 [**2141-2-15**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2141-2-15**] 01:22PM BLOOD Glucose-138* Lactate-1.5 Na-142 K-4.0 Cl-102 calHCO3-24 . Discharge labs: [**2141-2-18**] 07:00AM BLOOD WBC-5.5 RBC-3.07* Hgb-9.2* Hct-27.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-14.1 Plt Ct-162 [**2141-2-18**] 07:00AM BLOOD Glucose-98 UreaN-18 Creat-0.5 Na-143 K-3.8 Cl-112* HCO3-24 AnGap-11 [**2141-2-18**] 07:00AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.9 . . Urine: [**2141-2-15**] 07:13PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.050* [**2141-2-15**] 07:13PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2141-2-15**] 07:13PM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2141-2-15**] 07:13PM URINE CastHy-1* [**2141-2-15**] 07:13PM URINE Mucous-RARE . . Microbiology: [**2141-2-17**] STOOL FECAL CULTURE-PENDING; CAMPYLOBACTER CULTURE-PENDING; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING [**2141-2-16**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2141-2-15**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2141-2-15**] URINE URINE CULTURE- NEGATIVE [**2141-2-15**] MRSA SCREEN NEGATIVE [**2141-2-15**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2141-2-15**] BLOOD CULTURE Blood Culture, Routine-PENDING . . Radiology: PELVIS (AP ONLY) Study Date of [**2141-2-15**] 1:15 PM FINDINGS: CHEST: Single supine AP portable view of the chest was obtained. Underlying trauma board partially obscures the view. Given this, the lung fields appear clear. No focal consolidation or evidence of pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No displaced fracture is identified. PELVIS: Single AP portable view of the pelvis was obtained. Underlying trauma board partially obscures the view. Given this, no evidence of acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are intact. The visualized aspect of the lower lumbar spine demonstrates degenerative change. Vascular calcifications are also noted. Mild osteoarthritic changes are noted at both hip joints. IMPRESSION: 1. No evidence of acute intrathoracic process given underlying trauma board. 2. No evidence of acute fracture or dislocation in the pelvis. . CHEST (PORTABLE AP) Study Date of [**2141-2-15**] 1:15 PM COMPARISON: None. FINDINGS: CHEST: Single supine AP portable view of the chest was obtained. Underlying trauma board partially obscures the view. Given this, the lung fields appear clear. No focal consolidation or evidence of pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No displaced fracture is identified. PELVIS: Single AP portable view of the pelvis was obtained. Underlying trauma board partially obscures the view. Given this, no evidence of acute fracture or dislocation is seen. The pubic symphysis and sacroiliac joints are intact. The visualized aspect of the lower lumbar spine demonstrates degenerative change. Vascular calcifications are also noted. Mild osteoarthritic changes are noted at both hip joints. IMPRESSION: 1. No evidence of acute intrathoracic process given underlying trauma board. 2. No evidence of acute fracture or dislocation in the pelvis. . CT C-SPINE W/O CONTRAST Study Date of [**2141-2-15**] 2:13 PM INDINGS: No acute fractures are identified in the cervical spine. The cervical spine alignment and vertebral body heights are preserved. There is no prevertebral soft tissue swelling. There is mild anterolisthesis of C3 on C4. Minimal posterior osteophytes are seen at C5-C6 level, indenting the thecal sac, without significant spinal canal stenosis. The imaged portion of the thyroid gland is unremarkable. Minimal emphysema is seen in the imaged lung apices. IMPRESSION: No acute cervical spine fracture. . CT HEAD W/O CONTRAST Study Date of [**2141-2-15**] 2:13 PM INDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect or large vascular territorial infarction. The ventricles and sulci are slightly prominent consistent with age-related parenchymal involution. The mastoid air cells and paranasal sinuses are clear. No fractures are identified. Soft tissue swelling is noted overlying the right temporal bone. Soft tissue swelling with underlying density is noted along the parietal bone and along the vertex, consistent with subgaleal hematoma. IMPRESSION: No acute intracranial process. Right-sided soft tissue swelling. Left-sided subgaleal hematoma. No acute fracture seen. . CT TORSO WITH CONTRAST Study Date of [**2141-2-15**] 2:14 PM FINDINGS: CT OF THE CHEST WITH INTRAVENOUS CONTRAST: The major airways are patent to subsegmental levels bilaterally. A 3-mm right upper lobe nodule (2:20), a 3-mm nodule within the left lower lobe (2:42), are seen in subpleural location, could represent atelectasis; however a followup is recommended as [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] criteria. There is mild emphysema in both lungs. Trace simple right pleural effusion is present. No pericardial effusion is seen. The thoracic aorta demonstrates atherosclerotic calcification, without evidence of acute traumatic injury or aneurysmal dilation. There is no mediastinal hemorrhage. No significant mediastinal, hilar or axillary lymphadenopathy is seen. Incidental note is made of coarse calcification in the right breast. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is no acute traumatic injury in the liver, spleen, adrenal glands, pancreas and both kidneys. A tiny subcentimeter hypodensity in the left lobe of liver (2:56) is too small to characterize. Lobulated iso to hyperdense areas in the fundus of the gallbladder, may represent adenomyomatosis or impacted fundal stone. There is no evidence of acute cholecystitis. A subcentimeter hypodensity in the lower pole of the left kidney (2:66) is too small to characterize. The stomach, small and large bowel are normal in appearance, without evidence of acute traumatic injury. There is no intra-abdominal free fluid or air. No significant retroperitoneal or mesenteric lymphadenopathy is seen. Calcification is seen in the abdominal aorta and iliac arteries, without aneurysmal dilation or acute traumatic injury. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is moderately distended. A calcified uterine fibroid is present. A temperature probe is seen within the rectum. No significant pelvic free fluid or adenopathy seen. BONES AND SOFT TISSUES: There is a subtle nondisplaced fracture involving the transverse process of L2 vertebra, with suggestion of surrounding soft tissue edema. No other fractures are identified. Mild degenerative changes are seen in the thoracolumbar spine. IMPRESSION: 1. No acute traumatic injury identified in the chest. 2. Non-displaced fracture of the right transverse processes of L2 vertebra, of indeterminate age, but could represent an acute fracture. 3. Sub-4-mm pulmonary nodules in both lungs. Based on [**Last Name (un) 8773**] criteria, if the patient has history of smoking or other known risk factors for lung cancer, followup chest CT at 12 months is recommended, if the patient is a low-risk patient, no followup is needed. Findings added to radiology critical findings dashboard on [**2141-2-15**]. 4. Trace right pleural effusion. 5. Adenomyomatosis and possible impacted stones of the gallbladder fundus. If clinically indicated, right upper quadrant ultrasound can be obtained. . SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Study Date of [**2141-2-15**] 2:39 PM FINDINGS: Three views of the right shoulder were obtained. No true external rotation view was obtained and the Y view is also slightly suboptimal. No evidence of acute fracture is seen, but it is difficult to exclude dislocation. There is likely at least anterior medial subluxation of the humeral head in relation to the glenoid fossa. Right acromioclavicular joint is intact with degenerative change seen. The visualized aspect of the very upper lateral right lung is clear. IMPRESSION: 1. No evidence of acute fracture. 2. Suboptimal examination due to inability to appropriately position patient. Suggestion of anterior medial subluxation of the right humeral head in relation to the glenoid fossa, of indeterminate age. Recommend clinical correlation. Consider repeat imaging when appropriate and patient able to be appropriate position. . SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT Study Date of [**2141-2-15**] 8:11 PM COMPARISON: [**2141-2-15**]. THREE VIEWS, RIGHT SHOULDER: On these three limited views of the shoulder there is a suggestion of anterior subluxation of the humeral head upon the glenoid fossa. Dedicated axillary views are recommended. There are moderate degenerative changes of the acromioclavicular joint. Visualized right hemithorax is clear. . GLENO-HUMERAL SHOULDER (W/O Y VIEW) RIGHT PORT Study Date of [**2141-2-15**] 9:10 PM COMPARISON: [**2141-2-15**]. SIX VIEWS, RIGHT SHOULDER: There is anterior subluxation of the humeral head upon the glenoid fossa. There is deformity of the humeral head laterally which could represent a [**Doctor Last Name **]-[**Doctor Last Name 3450**] deformity. There also may be a small osseous fragment inferior to the glenoid which could reflect Bankart injury. . . Cardiology: ECG Study Date of [**2141-2-15**] 5:25:06 PM Sinus rhythm. Baseline artifact. Normal tracing. No previous tracing available for comparison. TRACING #1 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 66 156 76 452/462 86 75 72 . ECG Study Date of [**2141-2-16**] 7:57:44 AM Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2141-2-15**] no diagnostic interim change. TRACING #2 Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 73 114 80 [**Telephone/Fax (2) 89456**] 61 Brief Hospital Course: 76-year-old woman with a past medical history significant for hypertension, previous rheumatic fever, chronic right arm weakness ? atypical ALS and frequent falls who presented after a mechanical fall down stairs and prolonged period on floor who was found to have a right transverse process L2 fracture and shoulder subluxation and had a brief MICU stay for hypothermia and rhabdomyolysis. There, she was stabilized and called out to the general medical floor the following day on [**2141-2-16**]. Patient was managed conservatively and improved and discharged to rehab on [**2141-2-18**]. Patient will likely require placement on discharge from rehab. . . # Fall/Pre-syncope: Per patient, fall was mechanical and has had many previous falls. She was unable to get up from floor and found by visiting PT. Given history of numerous falls, she will likely need placement in [**Hospital3 **] or other sheltered housing on discharge as she lives alone. Infectious work-up was negative. UA unremarkable, CXR was clear. ACS ruled out with serial cardiac biomarkers. She sustained possible acute right shoulder subluxation in addition to L2 transverse process fracture which were both managed conservatively. PT, OT and social work were consulted and she was discharged to rehab on [**2141-2-18**] and will likely need placement thereafter. . # Hypothermia: Body temperature was 32.3 C (rectal) on admission. The most likely etiology was felt to be environmental exposure given report of last contact being 3 days prior. She was treated with a warming blanket and fluid rescusitated, and body temperature normalized overnight. . # Rhabdomyolysis: CK on arrival was 3387 and was noted to trend down from that point with fluid rescusitation. Elevated CK was felt secondary to a prolonged period down following her fall. Creatinine was 0.7 on admission and remained stable following IVF. CK on discharge was 673. . # Likely acute on chronic right shoulder subluxation: Initial exam was concerning for anterior dislocation of right shoulder but XR showed right anterior subluxation of the humeral head upon the glenoid fossa. Per discussion with family, this may be a chronic or acute on chronic injury. Patient had recent shoulder dislocation [**2-8**] which was relocated at ED. She was evaluated by the vascular surgery team for concern over poor peripheral pulses in her right arm, but was felt to have adequate perfusion and good pulse was present. She was also evaluated by the orthopedic surgery team who recommended conservative with a right arm sling and follow-up in 4 weeks with appointment scheduled for [**2141-3-14**]. Pain control was initially with acetaminophen and morphine but quickly transitioned to tramadol on discharge. . # L2 FRACTURE: On CT Torso patient was found to have an undisplaced right L2 transverse process fracture. The patient was evaluated by the neurosurgery consult team, with recommendation for no limitation to activity and conservative management with pain control. Calcium and Vitamin D supplementation started at discharge. , # Anemia: Hct 41.6 on admission and fell to 27 after volume resuscitation. No evidence of bleeding. HD stable. Guaiac negative stools and latterly had iron studies, B12 and folate which were all normal and retics <3%. . R arm immobility: Patient could just move fingers of right hand and otherwise no significant movement in right UE. Per family this has been for approximately 2 years, gradual in onset, now has no use of R hand, extensive w/u without cause found, thought could be due to ? atypical ALS. In addition, had recent shoulder dislocation [**2-8**], relocated at ED. This remained at apparent baseline. . # HTN: Anti-hypertensives were initially held and slowly re-introduced initially with home atenolol and lisinopril. If persistent hypertension at rehab, can add diltiazem. . # Diarrhea: Patient developed frequent loose stools on [**2-17**]. Stools were sent for culture and c difficile toxin. . # Pulmonary nodule: Sub-4-mm pulmonary nodules in both lungs seen on CT-Thorax. Based on [**Last Name (un) 8773**] criteria, if the patient has history of smoking or other known risk factors for lung cancer, followup chest CT at 12 months is recommended, if the patient is a low-risk patient, no followup is needed per radiology. PCP to [**Name9 (PRE) 702**] as appropriate. Medications on Admission: Aspirin 81mg qd Diltiazem ER 240mg qd Atenolol 50mg qd Lisinopril 40mg qd Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6 hours) as needed for pain. 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] @ [**Hospital1 189**] Discharge Diagnosis: Mechanical fall in setting of frequent falls Likely acute on chronic right shoulder subluxation Undisplaced right transverse fracture of L2 Rhabdomyolysis Hypothermia Discharge Condition: Mental Status: Clear and coherent with likely chronic cognitive deficit Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented following a fall at home when you were unable to get up. You were found by PT and taken to the ED. There you had scans of your shoulder and hip in addition to a CT scan of your head, neck and body. The scans showed evidence of a possibly new worsening of a right shoulder injury in addition to a tiny fracture involving one of the vertebrae of your lower back. You were seen by vascular surgery who felt that blood supply to your shoulder was good. You were also seen by neurosurgery who felt that nothing needed to be done for your back injury and it will heal on its own. You were also seen by orthopaedics for your shoulder injury who recommended a sling and follow-up with them. You have an appointment on [**2141-3-14**] for review. You were discharged to rehab on [**2-17**] after assessment by PT. . Changes to medications: We HELD you diltiazem at present and can be restarted as necessary on discharge We STARTED tramdol 25-50mg as needed every 6 hours for pain We STARTED acetaminophen 650mg as needed every 6 hours for pain We STARTED laxatives We STARTED calcium and vitamin D Followup Instructions: Please make an appointment with your PCP on discharge. Department: ORTHOPEDICS When: TUESDAY [**2141-3-14**] at 10:20 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2141-3-14**] at 10:40 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

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19586, 19658

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19869, 19869

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14334

Discharge summary

report

Admission Date: [**2192-2-13**] Discharge Date: [**2192-2-16**] Service: CCU HISTORY OF PRESENT ILLNESS: This is an 82-year-old male with a history of known coronary artery disease status post myocardial infarction times two and history of diabetes mellitus who was admitted the morning of [**2192-2-13**] with substernal chest pain radiating to his neck. Patient ruled in for non-ST segment elevation MI with troponins greater than 50 and CKs peaking at 461 on [**2-14**] at 8 PM. The patient was taken to cardiac catheterization on the 14th and was found to have three vessel disease diffusely. He was found on hemodynamic measurements to have a pulmonary capillary wedge pressure of 33, PA pressure of 90/60 systolic and a low cardiac index of 1.3. While in the Cath lab he was treated with heparin bolus, Dobutamine drip at 5 mcg an hour, Lasix at 180 mg IV, Natrecor and Nitrodrip for his pump failure. These interventions improved his hemodynamics moderately giving him a PA pressure of 45/26, an index from 1.3 up to 1.5 and a PA saturation from 36 to 52. At this point, the patient was transferred to the CCU for further management of his pump failure and post MI state. On arrival to the CCU, the patient had no complaints of chest pain, shortness of breath, abdominal pain, back pain. He did complain of some posterior neck pain especially when he flexed his neck. He had no lower extremity loss of sensation or groin pain. PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI times two. The patient had received his previous cardiac care by Dr. [**Last Name (STitle) 19**], phone # [**Telephone/Fax (1) 2258**] at the [**Hospital 882**] Hospital. He did have a recent catheterization at the [**Hospital 882**] Hospital which has also showed three vessel disease. Patient had been evaluated at the [**Hospital6 1708**] and thought not to be a candidate or coronary artery bypass graft at that time. The patient did have an echocardiogram in [**Month (only) 956**] of last year that showed an ejection fraction of 40 to 45%. 2. Diabetes mellitus. 3. Gout. 4. Patient is on home O2 since [**Month (only) 1096**] for what he is says is "oxygen for his heart". 5. Chronic renal insufficiency. 6. Patient has a bullet wound to his head with a chronically dilated left pupil. ALLERGIES: Sulfa for which he gets a rash. MEDICINES AS AN OUTPATIENT: 1. Aspirin 325 p.o. q.d. 2. Lasix 40 p.o. b.i.d. 3. Metoprolol 12.5 p.o. t.i.d. 4. Imdur. 5. Lipitor. 6. NPH 40 in the AM, 28 in the PM. MEDICATIONS ON TRANSFER TO THE CCU: 1. Aspirin 325 mg p.o. q.d. 2. Lasix 40 mg p.o. b.i.d. 3. Mucomyst 600 mg p.o. b.i.d. 4. Integrilin 2 mcg per kilogram per minute. 5. Heparin GTT at 1000. 6. Nitro GTT. 7. Atorvastatin 10 mg p.o. q.d. 8. Metoprolol 12.5 mg p.o. t.i.d. 9. NPH 40 units in the AM, 28 in the PM. SOCIAL HISTORY: The patient lives in the [**Location (un) 686**] Senior Center. Has a remote history of tobacco with 10 pack years, quit 25 years ago. Occasional alcohol. PHYSICAL EXAMINATION: On admission to the CCU vital signs are afebrile, blood pressure 124/52, pulse 99, respirations 21, saturation 94% on a six liter nasal cannula, PA pressure 67/20. General: Patient is awake, alert, lying flat and comfortable with nasal cannula in place in no acute distress. Head, eyes, ears, nose and throat: Left greater than right pupil. Anicteric sclerae. Extraocular muscles are intact. Mucous membranes moist. Benign oropharynx. Neck: Patient lying flat, visible jugular venous pulsation. There is some increased neck pain with flexion. Chest: Basilar rales anterolaterally. Cardiac: Regular rate and rhythm, normal S1, S2, no murmurs, rubs, or gallops. Abdomen: Obese, nontender, nondistended with normoactive bowel sounds, no organomegaly. Extremities: Sheath in right groin clean, dry and intact. Chronic venostasis changes. Dorsalis pedis pulses to 1+ bilaterally equal. No edema or cyanosis. Neuro: No focal deficits. LABORATORIES ON TRANSFER TO CCU: White blood count 12.5 thousand increased from 11,000 on the previous day, hematocrit 33 decreased from 42 on the previous day, platelets 191 decreased from 209 on the previous day. Sodium 130, potassium 3.9, chloride 95, bicarbonate 20, BUN 53, creatinine 2.0, glucose 310. CK at 10 PM on [**2179-2-13**], at 8 AM [**566-2-14**], 7 PM [**567-2-13**], 8 PM [**2-14**] CK 461 and 8 AM [**2-15**] CK 424. MB have trended down since [**2-14**] at 8:45 AM when they were 56 and latest MB was 32 on [**2-15**] at 6:30 AM. Arterial blood gas: 7.46 / 76 O2, 30 CO2 on six liter nasal cannula. Calcium 8, magnesium 1.6, phosphorus 3.6. Cardiac index 3.2 on Dobutamine 5. Chest x-ray with improved pulmonary edema. Cardiac catheterization: Right coronary artery with 50% mid, 95% PDA, 70% posterior lateral. Proximal LAD with 90% mid, LAD 90%, distal 100%. Circumflex with proximal 90%, mid 90%. Left main with no flow limiting disease. Hemodynamics: Right atrium 20/17, right ventricle 90/20, pulmonary artery 90/58, wedge pressure 33, LV 129/40, aorta 129/89, Fick 1.3, SVR 2304, PVR 800, no aortic stenosis. Findings consistent with pump failure, three vessel disease and pulmonary hypertension. EKG: Pain free shows normal sinus rhythm at 94 with Q waves in II, III and aVF, [**Street Address(2) 4793**] elevation V4, V5, large R wave in V2. HOSPITAL COURSE: This is an 82-year-old male with a history of diabetes mellitus, coronary artery disease with known three vessel disease, MI times two admitted with non ST segment elevation MI. Known three vessel disease was confirmed by cardiac catheterization here without PCI performed. The patient shown to be in pump failure during cardiac catheterization. 1. CARDIOVASCULAR: Coronary artery disease / three vessel disease by catheterization today. Question reassessment for candidacy for coronary artery bypass graft versus selective PCI. Patient was given 18 hours worth of Integrilin, continued on aspirin and his statin. Beta blocker was held in the setting of pump failure and Dobutamine. His heparin was switched to Lovenox as no intervention was planned for today. He was continued on a Nitrodrip for angina control. His CK MB fractions peaked at 56 at 8 AM on [**2-14**] and his CKs peaked at 461 at 8 PM on the same date. Troponins were greater than 50. PUMP: Patient found to be in congestive heart failure during cardiac catheterization hemodynamic monitoring. He improved status post Dobutamine / diuresis / Nitroglycerin / Natrecor. He was negative 1.5 liters on the night of the 14th. The goal after that is to keep him even on ins and outs. He is saturating well on four liters by nasal cannula. His chest x-ray did look improved as well after the above treatment. He was weaned off his Dobutamine on the 15th. His blood pressures were in the 90s off of the Dobutamine with a pulse of 80. O2 saturations remained at 96% on four liters by nasal cannula. Echocardiogram was performed on [**2192-2-15**]. This shows a mildly dilated left atrium, left ventricular wall thickness and cavity size are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the entire inferior wall, hypokinesis of the distal half of the septum, lateral and anterior walls, akinesis of the apex. There is no aneurysm or thrombus seen. RV chamber size is normal. The aortic leaflets are normal with good leaflet excursion. There is trace AR seen, 1+ MR, no effusion. Ejection fraction was calculated at 25 to 30%. The patient was not on an ACE inhibitor and will defer to outpatient cardiologist, Dr. [**Last Name (STitle) 19**] for a question of starting ACE inhibitor. ELECTROPHYSIOLOGY: Patient EKG on [**2-15**] showed normal sinus rhythm with similar Q wave and ST changes as in previous days. EKG except now with a right bundle branch block with QRS of 126 milliseconds. Patient has an EKG showing similar right bundle branch block from [**2191-6-1**]. The rate when in regular rate and rhythm is 96 beats per minute. The rate of his previous EKG not in block was 94 making rate related changes less likely. The patient had short three to four second runs of SVT on telemetry without symptoms. 2. HEMATOLOGY: Patient's hematocrit was 42 on the day of admission trending down to 33 after catheterization and then 30 on the night of catheterization. A CT Scan of the belly was obtained at this time to evaluate for the possibility of retroperitoneal bleed in the setting of close catheterization state an anticoagulation. This shows no evidence of retroperitoneal hematoma. His hematocrit has been stable at 30 for the past 12 hours. We will transfuse for a hematocrit drop less than 30. We will change from heparin GTT to Lovenox as no immediately intervention is planned in this patient. 3. DIABETES MELLITUS: Blood sugars were increased in the mid 200s to mid 300s overnight as the patient was given half of his NPH dose while he was NPO. We will restart p.o. diabetic diet and restart his NPH as per his outpatient regimen. 4. RENAL: Patient with chronic renal insufficiency, creatinine stable at 2.0. Patient received Mucomyst in the peri-catheterization. Patient has good urine output. 5. FLUIDS, ELECTROLYTES AND NUTRITION: Patient has a mild respiratory alkalosis in the setting of his congestive heart failure. His electrolytes are stable. 6. NECK PAIN: This is unlikely to be an anginal equivalent as it is worsened with movement of the neck and is likely musculoskeletal. This is being treated with warm packs and Percocet. 7. PROPHYLAXIS: Protonix. 8. TUBES, LINES AND DRAINS: Patient has a Foley catheter. His right A line and sheath have been pulled. He has two peripheral IVs. The patient is a full code. DISPOSITION: We are current in contact with [**Hospital6 8866**] for the possibility of transferring the patient to the [**Hospital6 1708**] as this is where he receives most of his medical care and this is where his cardiologist, Dr. [**Last Name (STitle) 19**] is affiliated. If he is transferred, we will provide the films of his cardiac catheterization here. MEDICATIONS AT TIME OF DICTATION: 1. Lovenox 80 subcutaneous q. 12 hours. 2. Protonix 40 mg p.o. q.d. 3. Plavix 300 mg p.o. once and then 75 mg p.o. q.d. 4. Percocet one to two q. four to six hours p.r.n. 5. Folate 1 mg p.o. q.d. 6. Nesiritide 0.01 mcg per kilogram per minute started on [**2-14**]. 7. Insulin sliding scale. 8. NPH insulin 40 units at breakfast, 20 units at bedtime. 9. Atorvastatin 10 mg p.o. q.d. 10. Nitroglycerin GTT titrated to pain free. 11. Integrilin 2 mcg per kilogram per minute which will be stopped at 1 PM today. 12. Mucomyst 20% 600 mg p.o. b.i.d. 13. Aspirin 325 mg p.o. q.d. Any changes to the current medications will be added to this discharge summary at the time of discharge. DISCHARGE DIAGNOSIS: 1. Myocardial infarction. 2. Three vessel coronary artery disease. 3. Congestive heart failure. 4. Diabetes mellitus. 5. Anemia. CONDITION ON DISCHARGE: Fair. DISPOSITION: Likely to [**Hospital6 1708**], CCU. Any changes will be dictated at time of discharge. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 7783**] MEDQUIST36 D: [**2192-2-15**] 14:09 T: [**2192-2-15**] 14:23 JOB#: [**Job Number 42522**]

[ "250.40", "428.0", "276.4", "410.71", "790.01", "274.9", "583.81", "728.85", "785.51" ]

icd9cm

[ [ [] ] ]

[ "00.13", "37.23", "99.20", "88.56" ]

icd9pcs

[ [ [] ] ]

10933, 11068

5419, 10912

3061, 5401

117, 1456

1478, 2863

2880, 3038

11093, 11497

67,101

191,389

53225

Discharge summary

report

Admission Date: [**2116-3-4**] Discharge Date: [**2116-3-9**] Date of Birth: [**2061-9-10**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[**First Name3 (LF) 4679**] Chief Complaint: Right upper lobe FDG avid lung nodule Major Surgical or Invasive Procedure: [**2116-3-4**] OPERATION: 1. Right thoracoscopy converted to right thoracotomy. 2. Right upper lobectomy. 3. Mediastinal lymph node dissection. History of Present Illness: Ms. [**Known lastname 8814**] is here for surgical resection of her right upper lobe lung nodule which is clinically stage IIA (+ 10R, 11R lymph nodes, clean cervical mediastinoscopy). She has history of cardiomyopathy with reported clean cardiac catheterization. Past Medical History: Cardiomyopathy, followed by Dr. [**Last Name (STitle) **] at [**Hospital1 **] asthma GERD Cholecystectomy Social History: 40 pack year hx of smoking, denies ETOH, illicit drugs Lives with [**Doctor Last Name **], significant other. [**Name (NI) 1403**] for meals on wheels, driver and deliverer No known exposures Family History: Father died age 49 died of metastatic liver CA to lung Mother alive at 84, has epilepsy. Siblings reported healthy. Physical Exam: Discharge Vital signs: T 97.6, HR 66, BP 108/60, RR 20, 95% RA Physical Exam on discharge: Gen: pleasant in NAD, Alert and oriented x 4 without deficit Lungs: wheeze t/o. Left thoracotomy healing with slight erythema, but no drg CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [**2116-3-8**] 07:35AM BLOOD WBC-8.0 RBC-3.75* Hgb-10.6* Hct-32.3* MCV-86 MCH-28.3 MCHC-32.8 RDW-13.4 Plt Ct-241 [**2116-3-4**] 08:48AM BLOOD WBC-5.9 RBC-4.99 Hgb-14.5 Hct-42.2 MCV-85 MCH-29.1 MCHC-34.4 RDW-14.0 Plt Ct-187 [**2116-3-8**] 07:35AM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-144 K-3.7 Cl-102 HCO3-38* AnGap-8 [**2116-3-4**] 08:48AM BLOOD Glucose-107* UreaN-14 Creat-0.7 Na-142 K-4.1 Cl-106 HCO3-27 AnGap-13 [**2116-3-8**] 07:35AM BLOOD Calcium-8.5 Phos-3.9# Mg-1.9 [**2116-3-4**] 08:48AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2 CXR [**2116-3-9**]: MPRESSION: PA and lateral chest compared to [**3-6**] through 13: Focal pleural thickening in the region of a large vascular clip in the right hemithorax has increased slightly since [**3-7**], and the apical pneumothorax has not appreciably changed. On the left, the large lower lobe mass is stable. Small left pleural effusion may have developed over the past 24 hours. Mild cardiomegaly stable. Brief Hospital Course: Mrs. [**Known lastname 8814**] was taken to the operating room on [**2116-3-4**] by Dr. [**First Name (STitle) **] for a right thoracoscopy converted to right thoracotomy, right upper lobectomy, mediastinal lymph node dissection, for a concerning right upper lobe nodule. She came out of the OR with a right chest, foley and IV dilaudid for pain. On [**2116-3-5**] she was successfully extubated. The patient transfered to the floor on [**2116-3-6**]. Below is a systems review of the [**Hospital 228**] hospital course: Neuro/Pain: The acute pain service was consulted postoperatively and placed a Paravertebral catheter with Bupivacaine 0.25% infusing and Dilaudid PCA. This was dc'd [**2116-3-8**]. The patient was placed on morphine IR, with good effect. Respiratory: Aggressive pulmonary toilet was encouraged. Nebulizers continued. Secretions were not an issue. The patient's oxygen saturation decreased to 87% while ambulating therefore she was sent home on 2L NC oxygen. The patient's resting oxygen saturations were >92%. The right chest tube from surgery did not have a leak and was dc'd [**2116-3-6**] with stable postpull right apical pneumothorax. CV: The patient remained hemodynamically stable without arrythmia. She was started on metoprolol 12.5 mg po bid for both EF 40% (echo done on ICU admission at bedside to evaluate true cardiac function), and to prevent atrial fibrillation as the patient was tachycardic (Initiating beta blockade discussed with Dr. [**Name (NI) **], pt outpt cardiologist). The patient's I and O, and daily weights were watched. She was given lasix [**2116-3-6**]. Her dc weight was 100kg. There were no issues with heart failure. Abd: Diet was advanced and tolerated on dc. Stool softeners given to prevent constipation while on narcotics. Renal: Foley was dc'd [**2116-3-6**] with good urine output following such. Electrolytes were followed and replaced as necessary. ID: CBC and fever curves were watched, without infectious issues during this stay. Lines: A right AC peripheral IV was continued on the floor and dc'd prior to discharge. There was a small area of erythema surrounding this site. It was seen by Dr. [**First Name (STitle) **] on date of discharge, and pt told to take ibuprofen with arm elevation and warm compresses. No antibiotics were needed at this time. Proph: DVT proph: SCD's and heparin SQ. Ulcer proph: PPI. Dispo: The patient was seen by Physical Therapy who cleared her for home with home PT. She cleared stairs and was deemed stable for discharge home by Dr. [**First Name (STitle) **] on [**2116-3-9**]. Medications on Admission: Citalopram 40 mg daily, Advair 500/50 [**Hospital1 **], Omeprazole 20 mg daily, Albuterol IH prn, lasix 20mg po daily Discharge Medications: 1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): will need to cut the tab in half. Disp:*30 Tablet(s)* Refills:*2* 6. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 8. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*150 Tablet(s)* Refills:*0* 9. home oxygen 2 Liters Nasal cannula, continuous pulse dose for portability. ICD-9 162.9. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: take as you were taking before surgery. F/U withPCP in one week to check electrolytes. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Right upper lobe lung nodule- FDG avid Left lower lobe FDG negative, ground glass lung nodule Cardiomyopathy EF 40% Asthma Depression GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2348**] if you experience: -Fevers greater than 101.5 or chills -Increased shortness of breath, cough, or chest pains -Right incisions develops drainage, redness, purulence. Chest tube site: change daily with bandaid -Should chest tube site have drainage cover with a clean, dry dressing, change as needed to keep site clean and dry. -You may shower. Wash incisions with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs -No driving while taking narcotics. Take stool softners with narcotics -Walk 4-5 times a day day for 10-15 minutes increase to a goal of 30 minutes daily Check daily weights and record. Call your cardiologist if weight up 2# in a day or 3# in a week. Followup Instructions: Followup with Dr. [**First Name (STitle) **] Phone:[**0-0-**] Date/Time:[**2116-3-19**] 4:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your appointment Completed by:[**2116-3-10**]

[ "425.4", "278.01", "V64.42", "162.3", "311", "493.90", "530.81", "512.8", "305.1", "786.09" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6477, 6552

2542, 5136

314, 460

6735, 6735

1565, 2519

7669, 7977

1109, 1227

5305, 6454

6573, 6714

5162, 5282

6886, 7646

1242, 1306

1334, 1546

237, 276

488, 753

6750, 6862

775, 883

899, 1093

70,026

165,686

42158

Discharge summary

report

Admission Date: [**2155-9-13**] Discharge Date: [**2155-9-16**] Service: NEUROLOGY Allergies: Keflex / Penicillins / Coumadin Attending:[**First Name3 (LF) 2569**] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 86 y/o RHW with a history of Afib and Right MCA CVA in [**2152**], who initially presented to [**Hospital6 **] with new onset left hemiparesis, was found to have a right MCA occlusion, and given t-PA. History gathered from daughter who states that she was driving with her mom in the passenger seat after a day of shopping. All of a sudden, the patient went limp on the left side. She was leaning over and when her daughter called over to pull herself up she had to use her right hand but was unable to keep upright. They drove to a local fire department and the patient was quickly taken to [**Hospital6 4287**]. There she was seen by neurology who noted an NIHSS of 24 with full left hemiparesis and left neglect. A CT scan demonstrated right MCA occlusion. She was given t-Pa bolus about an hour post event and then placed on a gtt over here. Here she had a NIHSS of 8. She had no acute complaints herself except her belly ached a little as she has been wanting to go to the rest room. She was unable to state what exactly occurred. Does not know exactly why she is at the hospital. She does not endorse any visual changes or weakness. Daughter states that she made a full recovery post stroke in [**2152**] with minor weakness of the left hand and no visual issues. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: R CVA [**2152**] GI bleed [**2152**] on Coumadin (multiple times) CAD s/p stent x2 in [**3-/2155**] A-fib HTN TAH Cardiac pacemaker in place Lung Cancer s/p RU lobectomy in [**2145**] Social History: Very independent, lives with family in [**Hospital1 8**], MA. Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98 P:93 R: 16 BP:150/93 SaO2:97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally Cardiac: Irregular S1S2 Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x to person, time and [**Hospital1 **]. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Pt. was able to register 3 objects and recall [**1-30**] at 5 minutes 1 more with cues. The pt. had good knowledge of current events. Does not spontaneously look to the left when spoken to on that side, denies visual loss. -Cranial Nerves: I: Olfaction not tested. II: Pupils surgical b/l, sluggish reactivity. Left homnymous hemianopsia. III, IV, VI: Can get eyes to look to the left with effort. V: Facial sensation intact to light touch. VII: Left facial droop with weak eye closure on the left. VIII: Not tested. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Left drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 4 5 4 4 5 4 - 4 5 4 4 5 4 R 5 5 5 5 5 5 - 5 5 5 5 5 5 -Sensory: extinction to DSS on the left with light touch. intact to light touch b/l in upper and lower ext. Pinprick and vibration not tested. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 0 0 0 1 0 R 0 0 0 1 0 Plantar response was upgoing on the left and equivocal on the right. -Coordination: No ataxia on right on FNF. Left not tested. -Gait: Not tested. Physical Examination on Admission: Vitals: T: 98 P:93 R: 16 BP:150/93 SaO2:97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally Cardiac: Irregular S1S2 Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x to person, time and [**Hospital1 **]. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Pt. was able to register 3 objects and recall [**1-30**] at 5 minutes 1 more with cues. The pt. had good knowledge of current events. Does not spontaneously look to the left when spoken to on that side, denies visual loss. -Cranial Nerves: I: Olfaction not tested. II: Pupils surgical b/l, sluggish reactivity. Left homnymous hemianopsia. III, IV, VI: Can get eyes to look to the left with effort. V: Facial sensation intact to light touch. VII: Left facial droop with weak eye closure on the left. VIII: Not tested. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Left drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 4 5 4 4 5 4 - 4 5 4 4 5 4 R 5 5 5 5 5 5 - 5 5 5 5 5 5 -Sensory: extinction to DSS on the left with light touch. intact to light touch b/l in upper and lower ext. Pinprick and vibration not tested. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 0 0 0 1 0 R 0 0 0 1 0 Plantar response was upgoing on the left and equivocal on the right. -Coordination: No ataxia on right on FNF. Left not tested. -Gait: Not tested. DISCHARGE PHYSICAL EXAM: Vitals: T: 97.9 P:60 R: 18 BP:150/84 SaO2:99% RA General: Awake, cooperative, NAD. Dyspnea upon muscle strength testing and gait testing. HEENT: NC/AT, MMM, no lesions noted in oropharynx. Neck: Supple, no lymphadenopathy, no carotid bruits appreciated. Pulmonary: Lungs CTA bilaterally. Cardiac: Irregular S1S2. Abdomen: Soft, nontender, nondistended. Extremities: No C/C/E bilaterally. Skin: Multiple new ecchymoses on upper extremities from tPA. Neurologic: -Mental Status: Alert, oriented to person, date and [**Hospital1 **]. Attentive, able to name DOW backward without difficulty. Language is fluent with intact repetition and comprehension. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Pt. was able to register 3 objects and recall [**2-27**] at 5 minutes with prompting. No gaze deviation. Spontaneously looks to both sides when spoken to from different directions. Denies visual loss. -Cranial Nerves: I: Olfaction not tested. II: Pupils surgical b/l, sluggish reactivity. Left inferior quadrantinopia. III, IV, VI: EOMI, delayed saccades, saccadic intrusion to smooth pursuit. V: Facial sensation intact to light touch. VII: Mild left facial droop, facial movements full throughout. VIII: Hearing slightly diminished bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Left drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 4 4 5 5 5 4 4 5 5 4 4 5 4 R 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Extinction to DSS on the left with light touch on face, arms, and legs. Intact sensation to light touch b/l in upper and lower extremities. Pinprick and vibration not tested. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 0 0 0 1 0 R 0 0 0 1 0 Plantar response was upgoing on the left and equivocal on the right. -Coordination: No ataxia bilaterally but slow movements on FNF. -Gait: Good initiation, shortened stride, shuffling, dyspnea upon standing and when taking a few steps. Negative Romberg. Pertinent Results: Labs on Admission: [**2155-9-14**] 08:41AM BLOOD WBC-10.6 RBC-4.32 Hgb-12.8 Hct-37.2 MCV-86 MCH-29.7 MCHC-34.5 RDW-14.0 Plt Ct-206 [**2155-9-14**] 08:41AM BLOOD Glucose-110* UreaN-16 Creat-1.0 Na-142 K-4.2 Cl-107 HCO3-23 AnGap-16 [**2155-9-14**] 08:41AM BLOOD Calcium-8.9 Mg-2.1 Cholest-118 [**2155-9-15**] 05:31AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0 [**2155-9-14**] 08:41AM BLOOD %HbA1c-5.7 eAG-117 [**2155-9-14**] 08:41AM BLOOD Triglyc-86 HDL-57 CHOL/HD-2.1 LDLcalc-44 [**2155-9-14**] 08:41AM BLOOD TSH-2.7 Imaging: NCHCT [**2155-9-13**]: No hemorrhage. Old right MCA infarct. NCHCT [**2155-9-14**]: No acute change, stable from previous study. EKG: A-fib. No significant ST changes. Brief Hospital Course: Ms. [**Known lastname 4643**] is an 86 y/o woman with a history of right MCA ischemic stroke and atrial fibrillation (off of coumadin, [**1-29**] history of hemodynamically significant GI bleeds), who presents with new onset left sided weakness on [**2155-9-13**]. 1) Neurologic: The patient was brought to an OSH where her NIHSS was 24 and was subsequently given IVTPA for a presumed "left M1 occlusion" per report. She was transferred to the [**Hospital1 18**] where our neurology team assessed her to be much improved with an NIHSS of 8. Her current deficits were thought to be residual from her old right MCA infarction, and it is assumed that she must have recanalized a new right M1 occlusion with the IV TPA. Given her residual minimal deficits, she was not transferred to the neuro-IR suite. She was admitted to the ICU for post-TPA monitoring, and later transferred to the floor. While in the ICU she remained hemodynamically stable and afebrile. Over the following days, her examination improved. At the time of her [**Hospital **] transfer to the floor, her physical examination was significant for a left sided forehead sparing facial droop, mild left iliopsoas weakness, left pronator drift and a left inferior quadrantanopsia. Her appreciation of her left sided weakness was taken as a sign of recovery. Upon discharge, her physical examination was notable for mild left sided forehead sparing facial droop, mild left deltoid and iliopsoas weakness, improving left inferior quadrantonopsia, and extinction to double simultaneous stimuli. 2) Cardiac: She was monitored on telemetry and had a 12-lead EKG which showed atrial fibrillation and non-specific ST T wave changes. Her admission INR was 1.1. Her A1c is 5.7% and lipid panel has LDL of 118 which are at goal. She was kept on simvastatin 10mg daily. We discussed the option of anticoagulation with her PCP, [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 8079**], who conveyed that she had two episodes of symptomatic GI bleeding during which she presented to her PCP's office for symptoms of lightheadedness. Her Hct at the time was as low as 21. The second episode of bleeding occurred in the setting of an elevated INR (~6). Endoscopic studies revealed no active sources of bleeding; EGDs showed nonbleeding gastritis and colonoscopy/capsule endoscopy showed only evidence for AVMs not actively bleeding. Following these two episodes, she was stopped on coumadin and Dr. [**Last Name (STitle) 8079**] emphasized that the decision to stop coumadin was not taken lightly. Ultimately, the decision was made now to continue the patient on ASA 325 bridge to anticoagulation with warfarin (goal INR 2.0 to 3.0). She was kept on verapamil and her atenolol was held with goal 120s-160s. 3) Infectious disease: She was afebrile throughout her admission with no leukocytosis. 4) Pulmonary: She was frequently dyspnic upon muscle strength and gait testing, but had no episodes of desaturation. She was restarted on her home Symbicort for her respiratory symptoms. 6) GI: She was kept on a heart healthy diet with senna/colace as needed. Her omeprazole was increased to 40mg daily given her past history of gastritis in the setting of GI bleeds on coumadin. 7) Hematologic: She was kept on an aspirin bridge to coumadin with a goal therapeutic INR of 2.0-3.0. Discharge Condition: She was assessed by our physical therapists who would like for her to go to acute rehab for 1-2 weeks to improve her left sided weakness. She was clinically stable at discharge and will continue on aspirin and warfarin until INR is therapeutic ([**1-30**]) Medications on Admission: Atenolol 50mg PO QD Verapamil 90mg QHS Crestor 20 mg PO QD ASA 325 mg PO QD Prilosec Colace Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. budesonide 0.25 mg/2 mL Suspension for Nebulization Sig: One (1) ML Inhalation [**Hospital1 **] (2 times a day). 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: at 4PM. 5. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO once a day: Continue taking until INR btw [**1-30**] . Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left sided weakness with right-sided M1 occlusion. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent with recommendation for further PT. Discharge Instructions: You were admitted to the Neuro-ICU of the [**Hospital1 827**] for the management of a new stroke that occurred. Incidentally, this happened to occur in the same region of your brain as your old stroke and caused you to have new left sided weakness and problems looking to the left. You were given t-[**MD Number(3) 91427**] is a medicine to break up the blood clot which was blocking that area. After being given that medicine, your left-sided weakness has much improved. The following medication changes were made: STARTED Coumadin 2.5 mg PO QD We are restarting you on Coumadin given your irregular heartbeat (atrial fibrillation) to prevent the development of blood clots which may cause further strokes in the future. If you notice any of the warning signs listed below please call your PCP or go to the nearest ED for further evaluation. Followup Instructions: - Please follow up with our Stroke Neurologist Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] on: [**2155-12-16**] 11:30AM [**Hospital Ward Name 23**] Building ([**Location (un) 830**], [**Location (un) **] MA) Ph: [**Telephone/Fax (1) 3767**] - Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8079**], in 1 week. - Please call the [**Hospital1 18**] Patient Registration Office at [**Telephone/Fax (1) 91428**] to update your personal and demographic information. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "728.87", "427.31", "V45.82", "496", "V45.88", "401.9", "438.83", "V45.01", "438.89", "434.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14007, 14077

9735, 13084

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Discharge summary

report+addendum

Admission Date: [**2153-11-12**] Discharge Date: [**2153-11-16**] Date of Birth: [**2081-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Oxycodone / Codeine / Avandia / Adhesive Tape Attending:[**First Name3 (LF) 1283**] Chief Complaint: angina Major Surgical or Invasive Procedure: CABG x2 [**2153-11-12**] (LIMA to LAD, SVG to OM) History of Present Illness: 71 yo female with angina for several weeks, with know history of CAd and prior stents. Cath revealed 70% LM, 50% LAD with 40% ISR, RCA diffuse dz, EF 61%, LVEDP 25. Referred for CABG. Past Medical History: IDDM MI [**2132**] CAD with LAD/RCA PTCA [**2133**], DES [**9-27**] to LAD elev. lipids right bronchial Ca with resection/XRT [**2137**] PVD with bil. iliac stents [**1-28**] TIA x [**Numeric Identifier 4719**] PSH: appy cholecystectomy tonsillectomy TAH Social History: lives with husband not employed quit smoking 20 years ago ETOH very rarely Family History: brother with CAD in 60's Physical Exam: HR 80 RR 20 right 140/60 left 144/66 5'5" 165# NAD,well-appearing skin/HEENT unremarkable neck supple with full ROM, no carotid bruits appreciated CTAB RRR no murmur warm, well-perfused with no peripheral edema mild RLE superficial varicosities neuro grossly intact 2+ bil. fem/DP/PT/radials Pertinent Results: [**2153-11-14**] 06:00AM BLOOD WBC-11.6* RBC-3.66* Hgb-11.1* Hct-32.9* MCV-90 MCH-30.5 MCHC-33.9 RDW-14.8 Plt Ct-175 [**2153-11-12**] 06:31PM BLOOD PT-14.2* PTT-40.5* INR(PT)-1.3* [**2153-11-14**] 06:00AM BLOOD Plt Ct-175 [**2153-11-14**] 06:00AM BLOOD Glucose-155* UreaN-19 Creat-0.7 Na-135 K-4.4 Cl-103 HCO3-27 AnGap-9 [**2153-11-14**] 06:00AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.9 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 67576**] (Complete) Done [**2153-11-12**] at 3:11:05 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2081-12-21**] Age (years): 71 F Hgt (in): 65 BP (mm Hg): 110/70 Wgt (lb): 174 HR (bpm): 63 BSA (m2): 1.87 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 410.91, 786.51, 440.0 Test Information Date/Time: [**2153-11-12**] at 15:11 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW1-: Machine: 1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 1.7 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. No other changes from the preCPB. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician ?????? [**2149**] Brief Hospital Course: Admitted [**11-12**] and underwent cabg x2 with Dr. [**Last Name (STitle) 1290**]. Transferred to the CVICU in stable condition on phenylephrine,nitroglycerin, and propofol drips.Extubated the next morning, and transferred to the floor on POD #1 to begin increasing her activity level. She conitnued to do well and was gently diuresed. She was ready for discharge to rehad on postoperative day 4. She is to remain on a nitrate for three months per Dr. [**Last Name (STitle) 1290**]. Medications on Admission: plavix 75 mg daily lipitor 20 mg daily atenolol 50 mg daily lasix 20 mg daily metformin 500 mg TID ASA 325 mg daily diovan 160 mg daily amlodipine 5 mg daily calcium with Vit. D 500 mg daily Humulin NPH 75/25 18 units QAM, 14 units QPM Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day. 4. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: 18 units Subcutaneous before breakfast. 8. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: Fourteen (14) units Subcutaneous before dinner. 9. insulin sliding scale see page 1 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**] Discharge Diagnosis: CAD s/p CABG Diabetes Mellitus HTN MI [**2132**] PTCA LAD/RCA [**2133**], Cypher stent LAD [**9-27**] elev. lipids right bronchial cancer with resection [**2137**]/XRT [**Doctor First Name **] x 2 [**2142**] PVD with bil. iliac stents [**1-28**] Discharge Condition: good Discharge Instructions: SHOWER DAILY and pat incisions dry no lotions, creams or powders on any incision no driving for one month do lifting greater than 10 pounds for 10 weeks call surgeon for fever greater than 100.5, redness or drainage [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr. [**Last Name (STitle) 10755**] after discharge from rehab [**Telephone/Fax (1) 46461**] Dr. [**Last Name (STitle) 1655**] after discharge from rehab Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2153-11-16**] Name: [**Known lastname **],[**Known firstname 11693**] P Unit No: [**Numeric Identifier 11694**] Admission Date: [**2153-11-12**] Discharge Date: [**2153-11-16**] Date of Birth: [**2081-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Oxycodone / Codeine / Avandia / Adhesive Tape Attending:[**First Name3 (LF) 674**] Addendum: medication changes Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day. 4. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: 18 units Subcutaneous before breakfast. 8. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: Fourteen (14) units Subcutaneous before dinner. 9. insulin sliding scale see page 1 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Tablet Sustained Release 24 hr(s) 14. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 4887**] [**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**] Completed by:[**2153-11-16**]

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7375, 7626

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7678, 7923

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1032, 1330

290, 298

418, 603

625, 883

899, 975

74,230

160,836

20968

Discharge summary

report

Admission Date: [**2118-6-26**] Discharge Date: [**2118-7-8**] Date of Birth: [**2041-5-17**] Sex: F Service: NEUROLOGY Allergies: Plavix / Sulfa(Sulfonamide Antibiotics) / Codeine Attending:[**First Name3 (LF) 2569**] Chief Complaint: right sided weakness and aphasia Major Surgical or Invasive Procedure: PICC placement neurointervention (cerebral angio and clot retrieval) intubation History of Present Illness: Ms. [**Known lastname 55729**] is a 77 yo RH woman with PMH of PAF, HTN, DLP, tobacco use and is now 9 days post 2-vessel CABG with tissue St. [**Male First Name (un) 923**] MVR (at [**Hospital3 **]) who developed acute onset of right sided weakness and difficulty speaking. She was maintained on ASA only. She had been previously well and was seen to be walking and talking by her nurse at 19:25. However, she subsequently developed right sided weakness and aphasia. Concerned about a stroke, a STAT NCHCT at [**Hospital3 **] showed no hypodensity but was significant for a distal left M1/M2 clot.Given her recent CABG, she was not a tPA candidate. She was then transferred to the [**Hospital1 18**] ED for urgent evaluation and possible neuroIR intervention. Upon arrival, she was noted to have a L MCA syndrome with a NIHSS of 21. A repeat CT/CTA/CTP showed some evolution of her left MCA stroke and no major change in her MCA-occlusion in the setting of a large mismatch. Given that, she was sent for a MERCI clot retrieval. ROS: Unable as patient globally aphasic. Past Medical History: 1. Hypertension. 2. Hypercholesterolemia. 3. Coronary artery disease. 4. Osteoarthritis. 5. Osteopenia. 6. Anxiety. 7. Macular degeneration. 8. Retinal vein thrombosis. 9. Vertigo. Social History: Positive for cigarette smoking. She has a 40-pack-year history and currently smokes [**1-27**] cigarettes per day. Negative for alcohol use. Negative for illicit drugs or IV drug use. She lives in [**Location 8985**] with her husband. She has 2 children and 2 grandchildren. Family History: Negative for coronary artery disease. Her mother had a platelet dysfunction. Physical Exam: Physical Exam on Admission: Vitals: T:afebrile P:100s-140s Afib R:13 BP:149/78 SaO2:98% General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: irregularly irregular, tachy Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: post-CABG scar, well healing Neurologic: Mental Status: Alert, Global aphasia Cranial Nerves: PERRL 3 to 2mm and brisk. No reaction to threat. eyes deviated to left, not overcome by OCR. right facial droop Palate elevates symmetrically. Tongue protrudes in midline. Motor: Apparent full strength of LUE and LLE. RUE able to keep upright for 7 seconds, but then falls to the bed. RLE has triple flexion to pain. Sensory: Grimaces to noxious stimuli on left only DTRs: [**Name2 (NI) **] toe left, upgoing on right Coordination: deferred Gait: deferred . . Physical Exam on Transfer: General: Awake and alert, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, No nuchal rigidity Pulmonary: Lungs CTA bilaterally, +crackles at R base Cardiac: irregularly irregular Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: post-CABG scar, well healing Neurologic: Mental Status: Awake and alert, makes good eye contact and tracks well, globally aphasic, not following commands, no verbal output Cranial Nerves: PERRL 3 to 2mm and brisk. Blinks to threat from L but not from R. Left gaze preference. R facial droop. Motor: Moving L side purposefully with full strength. RUE flaccid with no withdrawal to noxious. RLE triple flexes to noxious. Sensory: Withdraws L to noxious, triple flexes RLE, grimaces but does not withdraw RUE DTRs: [**Name2 (NI) **] toe left, upgoing on right Coordination: deferred Gait: deferred . . Physical Exam on Discharge: VS: 98.1, 116/66, 99, 18, 100% on 2L GEN: lying in bed in NAD HEENT: OP clear CV: irreg. irreg. PULM: CTAB ABD: soft, NT, mildly distended, PEG c/d/i EXT: trace edema at ankles bilaterally NEURO: MS - looks to voice, possibly follows commands to open/close eyes but may be coincidental only, non-verbal CN - looks minimally past midline to R, R pupil 3->2 and sluggish, L pupil 2->1 and sluggish, R facial droop MOTOR - R side flaccid with triple flexion to noxious in RLE and no response to noxious in RUE, moves L side spontaneously SENSORY - intact to noxious except in RUE as above COORDINATION - reaches accurately for examiners hand with LUE REFLEXES - R toe upgoing, L toe mute Pertinent Results: ADMISSION LABS: [**2118-6-26**] 06:16PM CK(CPK)-39 [**2118-6-26**] 06:16PM CK-MB-1 [**2118-6-26**] 04:21PM TYPE-ART PO2-154* PCO2-25* PH-7.47* TOTAL CO2-19* BASE XS--2 [**2118-6-26**] 04:21PM freeCa-0.98* [**2118-6-26**] 10:18AM CK(CPK)-36 [**2118-6-26**] 10:18AM CK-MB-2 [**2118-6-26**] 04:07AM TYPE-ART PO2-127* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 [**2118-6-26**] 04:07AM freeCa-1.09* [**2118-6-26**] 03:55AM GLUCOSE-139* UREA N-10 CREAT-0.6 SODIUM-135 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [**2118-6-26**] 03:55AM ALT(SGPT)-58* AST(SGOT)-54* CK(CPK)-32 ALK PHOS-163* TOT BILI-0.5 [**2118-6-26**] 03:55AM CK-MB-2 cTropnT-0.13* [**2118-6-26**] 03:55AM TOT PROT-5.0* ALBUMIN-2.6* GLOBULIN-2.4 CALCIUM-7.2* PHOSPHATE-4.2 MAGNESIUM-1.8 CHOLEST-57 [**2118-6-26**] 03:55AM %HbA1c-6.0* eAG-126* [**2118-6-26**] 03:55AM TRIGLYCER-87 HDL CHOL-28 CHOL/HDL-2.0 LDL(CALC)-12 [**2118-6-26**] 03:55AM WBC-19.0* RBC-3.36* HGB-9.1* HCT-29.5* MCV-88 MCH-27.0 MCHC-30.9* RDW-15.3 [**2118-6-26**] 03:55AM PT-14.2* PTT-25.8 INR(PT)-1.3* [**2118-6-26**] 03:55AM PLT COUNT-377 [**2118-6-26**] 02:49AM PO2-287* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS--2 [**2118-6-26**] 02:49AM GLUCOSE-131* LACTATE-1.0 NA+-131* K+-3.5 CL--104 [**2118-6-26**] 02:49AM HGB-8.3* calcHCT-25 [**2118-6-26**] 02:49AM freeCa-0.99* [**2118-6-26**] 12:15AM GLUCOSE-136* UREA N-13 CREAT-0.7 SODIUM-133 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-19* ANION GAP-17 [**2118-6-26**] 12:15AM estGFR-Using this [**2118-6-26**] 12:15AM WBC-15.2* RBC-3.67* HGB-10.1* HCT-32.0* MCV-87 MCH-27.4 MCHC-31.4 RDW-15.2 [**2118-6-26**] 12:15AM NEUTS-78* BANDS-2 LYMPHS-6* MONOS-11 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2118-6-26**] 12:15AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2118-6-26**] 12:15AM PLT SMR-NORMAL PLT COUNT-292 [**2118-6-26**] 12:15AM PT-13.8* PTT-24.5* INR(PT)-1.3* DISCHARGE LABS: [**2118-7-8**] 08:47AM BLOOD WBC-13.1* RBC-2.96* Hgb-8.2* Hct-25.8* MCV-87 MCH-27.6 MCHC-31.7 RDW-16.2* Plt Ct-282 [**2118-7-8**] 08:47AM BLOOD PT-16.1* PTT-94.1* INR(PT)-1.5* [**2118-7-8**] 08:47AM BLOOD Glucose-126* UreaN-23* Creat-1.0 Na-142 K-3.7 Cl-103 HCO3-29 AnGap-14 [**2118-7-7**] 05:42AM BLOOD ALT-43* AST-32 AlkPhos-128* TotBili-0.4 [**2118-7-8**] 08:47AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.3 [**2118-7-7**] 05:42AM BLOOD Vanco-35.9* ECG [**2118-6-25**]: Atrial fibrillation with rapid ventricular response. Non-specific intraventricular conduction delay. Probable inferior myocardial infarction, age indeterminate. Non-specific ST-T wave changes CT head [**2118-6-25**]: 1. CT head shows dense left middle cerebral artery in the bifurcation region with loss of [**Doctor Last Name 352**]-white matter differentiation in the left insular cortex. Small vessel disease and brain atrophy. No hemorrhage. 2. CT perfusion demonstrates large area of ischemia with probable small infarct in the left MCA territory. 3. CT angiography of the neck demonstrates mild atherosclerotic disease at the left carotid bifurcation. 4. CT angiography of the head demonstrates likely thrombus at the left middle cerebral artery bifurcation with markedly diminished flow in the superior division and some decrease in flow in the inferior division of the left middle cerebral artery. Cerebral angiogram [**2118-6-26**]: IMPRESSION: [**Known firstname 1494**] [**Known lastname 55729**] underwent cerebral angiography and both mechanical and pharmacological thrombectomy of the left middle cerebral artery which was unsuccessful. We were however able to restore fully restore flow to the inferior division which was initially only partially filling. CXR [**2118-6-26**]: The ET tube is 3.3 cm above the carina. There are bilateral pleural effusions, left greater than right, with bilateral lower lobe volume loss. Given dense retrocardiac opacity, an infiltrate in this region cannot be excluded. There is pulmonary vascular re-distribution and alveolar infiltrates. The overall impression is that of CHF that has worsened in the interval. CT head [**2118-6-26**]: IMPRESSION: Unchanged loss of [**Doctor Last Name 352**]-white matter differentiation along the left insula, in keeping with known acute left MCA-territory ischemia. MRI brain [**2118-6-27**]: IMPRESSION: Acute infarct in the left MCA distribution. In addition, there are multiple tiny foci of slow diffusion in bilateral cerebral hemispheres and the right cerebellum consistent with embolic infarcts. CXR [**2118-6-30**]: FINDINGS: Compared to the previous radiograph, there is no relevant change. The endotracheal tube and the other monitoring and support devices are constant. Pre-existing pleural effusions have minimally decreased in extent, so that the lung parenchyma has increased in transparency. However, bilateral pleural effusions are still present. Unchanged signs of mild-to-moderate pulmonary edema and bilateral basal areas of atelectasis. Mild cardiomegaly persists. No newly appeared parenchymal opacities. No pneumothorax. LUE US [**2118-7-4**]: IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity deep veins. VIDEO SWALLOW [**2118-7-4**]: IMPRESSION: Gross aspiration with nectar and thin liquids, with most being silent. For full details, please see the speech and swallow division note in OMR. CT ABD/PELVIS [**2118-7-5**]: IMPRESSION: 1. Normal anatomic course of the stomach without colonic interposition. 2. Moderate-to-severe atherosclerosis. CXR [**2118-7-7**]: IMPRESSION: AP chest compared to [**6-27**] through [**7-2**]: Tip of the new right PIC line lies in the right brachiocephalic vein at or just before its junction with the left. Right internal jugular line ends low in the SVC, feeding tube ends in the stomach. Lung volumes have improved since [**7-2**] and previous mild pulmonary edema is receding. Left lower lobe atelectasis has improved substantially. Small bilateral pleural effusions have not changed much. Mild cardiomegaly stable. No pneumothorax. Brief Hospital Course: 77 yo woman with hx of HTN, HL, paroxysmal a fib, CAD s/p CABG 9 days PTA who presented as a code stroke with dense R sided weakness and global aphasia. Initial CT relatively unremarkable with subtle hypodensities in L MCA distribution but CTP showed large perfusion deficit. Not a candidate for IV tPA due to recent CABG. Neurointervention was attempted toward end of time window with partial recanalization of the L MCA inferior division. She was admitted to the neuro ICU for post-intervention care. . # Neuro: She remained stable s/p intervention. Repeat head CT [**6-26**] was stable. She was started on a heparin drip for anticoagulation. Subsequent MRI showed a large L MCA territory infarct in addition to several small scattered infarcts (R cerebellum, R corona radiata). BP was allowed to autoregulate. She was continued on atorvastatin 10mg. Lipid panel revealed LDL of 12, HbA1c was 6.0%. Her exam remained stable with global aphasia and dense R sided weakness. She did improve her level of alertness throughout this admission, but remained non-verbal. . # Cardiovascular: She was maintained on tele monitoring. BP was allowed to autoregulate with goal SBP 120-180. She had several episodes of a fib with RVR and was started on an amiodarone drip with resolution. She was transitioned to Amiodarone 400mg [**Hospital1 **] and Metoprolol 25mg [**Hospital1 **] with good rate control. She was continued on Atorvastatin 10mg daily. Later in her hospital course she was transitioned to amiodarone 400mg QD and then 200mg QD. Her outpatient cardiologist was contact[**Name (NI) **] and he recommended that she remain on 200mg QD until she sees him as an outpatient at which point he may then stop it. . # Pulmonary: She was successfully extubated on [**6-30**] and weaned to nasal cannula. She received a few doses of lasix due to concerns for pulmonary edema and was subsequently started on 20mg IV BID, which was then changed to 20mg IV QD and then switched back to 20mg PO BID once she had her PEG in place. . # Infectious disease: She remained afebrile, but with a fluctuating leukocytosis up to 22. CXR showed evidence of volume overload but no focal infiltrates. UA was mildly positive but cx grew yeast. Her foley was exchanged and a repeat UCx was negative for growth. Her leukocytosis gradually began to trend down without intervention, but then increased again. She then spiked a fever and her CXR showed an infiltrate, so she was started on vanc and zosyn on [**7-3**] for a presumed ventilator associate PNA with plans to complete an 8 day course on the morning of [**7-11**]. . # Endo She was maintained on fingersticks and ISS with a goal of euglycemia. HbA1c was 6.0%. . # FEN: A Dobhoff was placed and she was stated on tube feeds. A swallow eval was performed on [**7-1**] and she failed, so therefore a PEG was placed on [**7-6**] without complication. She was restarted successfully on tube feeds thereafter. . # Prophylaxis: She was maintained on a heparin gtt and pneumoboots for DVT prophylaxis now with a planned bridge to coumadin, goal INR [**2-25**]. She was maintianed on famotidine and a bowel regimen for GI prophylaxis. Fall and aspiration precautions were maintained. . # CODE: She was initially full code upon admission but after discussion with her family she was made DNR but not DNI. Ok to reintubate if necessary but no compressions/shocks. . [ AHA/ASA Core Measures for Ischemic Stroke ] 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? (X) Yes - () No 4. LDL documented? (X) Yes (LDL = 12 ) - () No 5. Intensive statin therapy administered? (for LDL > 100) () Yes - (X) No - LDL < 100 6. Smoking cessation counseling given? () Yes - (X) No (Reason () non-smoker - (X) 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 anti-thrombotic therapy? (x) Yes (Type: () Antiplatelet - (x) Anticoagulation) - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No Medications on Admission: Home Medications: 1. Atenolol 100 mg p.o. b.i.d. 2. Aspirin 81 mg p.o. daily. 3. Lasix 20 mg p.o. b.i.d. 4. Felodipine 10 mg p.o. daily. 5. Diovan 320 mg p.o. daily. 6. Lipitor 10 mg p.o. daily. 7. Atorvastatin 10 mg p.o. daily. 8. Nitroglycerin 0.3 mg sublingual p.r.n. 9. Ativan 1 mg p.o. q. a.m. and 0.5 mg at bedtime p.r.n. anxiety. Recent discharge Meds ([**6-23**] from [**Hospital3 **]): Aspirin 81 mg p.o. daily, Lipitor 10 mg p.o. daily, Lasix 20 mg p.o. daily, potassium chloride 20 mEq p.o. daily, Lopressor 50 mg p.o. t.i.d., digoxin 0.25 mg p.o. daily. Apparently is now on Amiodarone 400 mg tid. Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN pain, fever 3. Amiodarone 200 mg PO DAILY Start: In am 4. Bisacodyl 10 mg PO DAILY 5. Docusate Sodium (Liquid) 100 mg PO BID 6. Furosemide 20 mg PO BID 7. Metoprolol Tartrate 25 mg PO BID 8. Miconazole Powder 2% 1 Appl TP TID:PRN groin skin irritation 9. Piperacillin-Tazobactam 4.5 g IV Q8H Day 1 = [**7-3**] 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 1 TAB PO BID 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 13. Vancomycin 750 mg IV Q 12H Start: PM of [**7-7**] Day 1 = [**7-3**] 14. Warfarin 5 mg PO DAILY16 15. Heparin IV No Initial Bolus Initial Infusion Rate: 1300 units/hr Please check Q6H PTTs goal 50-70 16. Nitroglycerin SL 0.3 mg SL PRN chest pain Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Left MCA stroke Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound, but will be able to get up to chair soon. NEURO EXAM: Non-verbal, looks to examiner, moves L-side spontaneously, plegic in R side with triple flexion to noxious in RLE and no movement to noxious in RUE Discharge Instructions: Dear Ms. [**Known lastname 55729**], You were seen in the hospital for a stroke. While you were here, you were closely monitored with some improvement in your alertness and ability to move your extermities. We made the following changes to your medications: 1) We STARTED you on TYLENOL 650mg every 6 hours as needed for pain or fever 2) We STARTED you on AMIODARONE 200mg once a day. 3) We STARTED you on BISACODYL 10mg once a day. 4) We STARTED you on DOCUSATE 100mg twice a day. 5) We STARTED you on a HEPARIN DRIP. 6) We STARTED you on METOPROLOL TARTRATE 25mg twice a day. 7) We STARTED you on MICONAZOLE POWDER as needed for itchy rash. 8) We STARTED you on ZOSYN 4.5grams every 8 hours. This will finish on [**7-11**]. 9) We STARTED you on MIRALAX 17 grams as needed for constipation. 10) We STARTED you on SENNA 8.6mg twice a day. 11) We STARTED you on VANCOMYCIN 750mg every 12 hours to stop on [**7-11**]. 12) We STARTED you on WARFARIN 5mg once a day. This dose will be adjusted as needed to maintain your INR within [**2-25**]. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: You have an appointment with your cardiologist, Dr. [**Last Name (STitle) 55730**] on [**9-13**]. Please call [**Telephone/Fax (1) 5985**] to confirm the details prior to the day of your appointment. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2118-8-24**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: MONDAY [**2118-9-5**] at 1 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

[ [ [] ] ]

[ "88.41", "96.6", "96.72", "99.10", "00.40", "39.74", "43.11" ]

icd9pcs

[ [ [] ] ]

16719, 16791

10928, 15180

343, 425

16851, 16851

4812, 4812

18516, 19433

2060, 2139

15850, 16696

16812, 16830

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3667, 4078

4828, 6773

2182, 2610

16866, 17167

1557, 1749

1765, 2044

5,569

183,684

2272

Discharge summary

report

Admission Date: [**2126-10-24**] Discharge Date: [**2126-10-28**] Date of Birth: [**2072-7-4**] Sex: F Service: [**Doctor Last Name **] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 7860**] is a 54-year-old Ukranian woman, mostly Russian-speaking, who has a past medical history of hepatitis C cirrhosis and a recent diagnosis of hepatoma with an AFP of 340,000. She had a recent paracentesis about one week prior to admission which removed about 3 liters of fluid without complications. Since then, she complains of malaise and nausea. On the morning of admission, she experienced seven episodes of emesis that were nonbloody followed by two episodes of hematemesis. She presented to the Liver Clinic where she had an additional episode of hematemesis. She also noted that she has had one week of diarrhea and melena with decreased appetite. She denied lightheadedness, loss of consciousness, dizziness, headache, chest pain, shortness of breath, abdominal pain, urinary symptoms, or dyspepsia. She has not used aspirin or nonsteroidal antiinflammatory drug, and she denied fevers, chills, travel history, or changes in food. She does not drink alcohol. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Schizophrenia. 4. Hepatitis C diagnosed within the last month, complicated by cirrhosis with ascites. 5. Hepatoma. MEDICATIONS ON ADMISSION: Medications on admission included Aldactone 100 mg p.o. q.d., Lasix 40 mg p.o. q.d., Glucotrol 5 mg p.o. q.d., Ativan 1 mg p.o. q.h.s., moexipril 7.5 mg p.o. q.d., Zoloft 100 mg p.o. q.d., and Prolixin 25 mg p.o. every six weeks. ALLERGIES: PENICILLIN causes a rash. SOCIAL HISTORY: She lives with her husband and does not smoke or drink. PHYSICAL EXAMINATION ON ADMISSION: Ms. [**Known lastname 7860**] was a well-appearing woman in no acute distress. Her blood pressure lying down was 140/80 with a pulse of 88, upon standing up she went to a blood pressure of 137/80 with a pulse of 120. Her HEENT examination was unremarkable. Her neck was supple with no jugular venous distention. Her lungs were clear. Her heart was regular in rate and rhythm and had a 3/6 systolic murmur loudest at the right upper sternal border with no radiation to the neck. Her abdomen was soft and distended with no clear fluid wave. Her neurologic examination showed no asterixis. LABORATORY DATA ON ADMISSION: Laboratories on admission included a hematocrit of 33.8 which was down from 37.3 on [**10-15**]. Her electrolytes showed a sodium of 128, a potassium of 5.5, a chloride of 93, a bicarbonate of 23, a BUN of 27, and a creatinine of 1.2. Her baseline creatinine is 0.6. Her AST was 119. Her ALT was 68. Her alkaline phosphatase was 94. Her amylase and lipase were 26 and 45, respectively. Her total bilirubin was 1.8. Her albumin was 3.1. Her hepatitis C virus viral load was 29,700. HOSPITAL COURSE: In the Emergency Room Ms. [**Known lastname 7860**] [**Last Name (Titles) 1834**] a nasogastric lavage of 700 cc without complete clearing. She was immediately sent to esophagogastroduodenoscopy which showed grade III varices in the lower third of her esophagus with no active bleeding. A nonbleeding varix was noted in the cardia of her stomach as well as clotted blood in her fundus. She had a normal duodenum. Therapy was undertaken with sodium morrhuate at that time. She was then transferred to the Medical Intensive Care Unit where she was closely watched. She was started on Octreotide, Protonix, and ciprofloxacin for spontaneous bacterial peritonitis prophylaxis. Serial hematocrits were watched which were suggestive a second bleed, so she was sent back for another esophagogastroduodenoscopy, where upon her varices were banded. During her stay she received 6 units of packed red blood cells and 2 units of fresh frozen plasma. She was also started on Carafate after her second esophagogastroduodenoscopy. Nadolol and Imdur were begun for her varices. She completed three days of ciprofloxacin and five days of Octreotide during her stay. After her hematocrit was stable for 12 hours she began to have her diet advanced which she tolerated with minimal nausea. Her hematocrit remained stable at about 36.5 to 36.7 after her second esophagogastroduodenoscopy. As she had tense ascites, she [**Last Name (Titles) 1834**] a large volume therapeutic paracentesis which removed about 5 liters of straw-colored fluid. She tolerated the procedure without any immediate complications. CONDITION AT DISCHARGE: Condition on discharge was improved. DISCHARGE STATUS: To home. DISCHARGE FOLLOWUP: To follow up with her primary care physician, [**Name10 (NameIs) 151**] the Liver Clinic on Tuesday, [**11-5**], and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Hematology/Oncology. DISCHARGE DIAGNOSES: 1. Hepatitis C complicated by cirrhosis with ascites, esophageal varices, status post a bleed, status post esophagogastroduodenoscopy times two with sclerotherapy and banding. 2. Hepatoma. 3. Type 2 diabetes. 4. Hypertension. 5. Schizophrenia. MEDICATIONS ON DISCHARGE: 1. Glucotrol 5 mg p.o. q.d. 2. Prolixin 25 mg p.o. every six weeks. 3. Zoloft 100 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Nadolol 40 mg p.o. q.d. with a goal heart rate of 60. 6. Lasix 20 mg p.o. q.d. 7. Aldactone 50 mg p.o. q.d. 8. Imdur 30 mg p.o. q.d. 9. Carafate 1 g q.i.d. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Name8 (MD) 1552**] MEDQUIST36 D: [**2126-10-29**] 15:45 T: [**2126-11-3**] 10:55 JOB#: [**Job Number 11965**]

[ "070.54", "571.5", "401.9", "155.0", "295.90", "250.00", "456.8", "789.5", "456.20" ]

icd9cm

[ [ [] ] ]

[ "54.91", "42.33" ]

icd9pcs

[ [ [] ] ]

4866, 5116

5142, 5711

1395, 1665

2911, 4524

4539, 4607

4628, 4845

182, 1185

2402, 2893

1207, 1368

1682, 1760

15,283

165,728

7126

Discharge summary

report

Admission Date: [**2165-10-7**] Discharge Date: [**2165-10-11**] Date of Birth: [**2092-8-17**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 73-year-old gentleman who presented with a right lower lobe tumor on a recent CT scan. The scarring of his lung had been followed two years prior from a chest x-ray. He had some complaints of back pain this year with loss of balance. Occasionally, his ambulation had been reduced to approximately one-half mile which brought on angina in addition to any exertion like walking up a [**Doctor Last Name **]. He had a recent cardiac catheterization which showed an ejection fraction of approximately 20% with multiple blocked arterial vessels. PAST MEDICAL HISTORY: 1. Myocardial infarction in [**2139**]. 2. Coronary artery bypass graft in [**2145**]. 3. Redo coronary artery bypass graft in [**2152**]. 4. Angioplasty in [**2163**]; the patient still occasionally has angina; he had several angioplasties in [**2163**]. 5. A very recent smoking history. 6. Chronic obstructive pulmonary disease. ALLERGIES: PENICILLIN which caused a question of hyperthermia and STATINS which cause leg cramps. He also listed METHANOL as giving him a rash. MEDICATIONS ON ADMISSION: His medications prior to admission were aspirin, Colestid, captopril, and Lopressor. PHYSICAL EXAMINATION ON ADMISSION: On examination, his lungs were clear bilaterally. His heart was regular in rate and rhythm. His abdominal examination was soft. LABORATORY DATA ON ADMISSION: Preoperative laboratory work showed a white blood cell count of 8.3, a hematocrit of 37.3, platelet count of 356,000. Glucose 67, BUN 22, creatinine 1.3, sodium 138, potassium 4.6, chloride 99, bicarbonate 25. Anion gap of 19. RADIOLOGY/IMAGING: Preoperative chest x-ray showed calcified mediastinal lymph nodes and a vague opacity only seen on the AP view. The ill-defined opacity was in the right base. The examination was otherwise unremarkable. Please refer to his final chest x-ray report. Electrocardiogram showed sinus bradycardia with some supraventricular extra systoles and a left bundle-branch block. PLAN: The plan was for him to have a mediastinoscopy and thoracoscopy with a question of a right lower lobectomy. Dr. [**Last Name (STitle) 175**] did note his increased risk of operation and discussed it with Dr. [**Last Name (STitle) **] of Cardiology who recommended that it would reasonable to go ahead with monitoring, although the risk was increased. HOSPITAL COURSE: On [**10-7**] he underwent a bronchoscopy mediastinal thoracoscopy and a right left lower lobectomy by Dr. [**Last Name (STitle) 175**]. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition. He was seen by the Acute Pain Service for follow up of his epidural. On postoperative day one, he was extubated. He had been on a little bit of Neo-Synephrine. His central venous pressure line was changed. He was in sinus rhythm with premature contractions in the 60s with a temperature maximum of 99.7. He was satting reasonably well on 3 liters of nasal cannula. He had no pleural leak and had 80 cc from his chest tube. His hematocrit was 31.8. He was neurologically intact. He had decreased breath sounds at the right lower lobe, but was clear on the left. His examination was otherwise unremarkable. He started pulmonary toilet. His epidural remained in place. His calcium and magnesium were down slightly. His electrolytes were repleted. His Neo-Synephrine was weaned to off. He started p.o. as tolerated. His Foley remained in place. He was transferred to the floor after weaning of his Neo-Synephrine. He was followed by the Acute Pain Service for his epidural. He was seen by Physical Therapy for help with his ambulation. He was seen by Case Management. On postoperative day two, he was hemodynamically stable. His lungs were clear. His heart was irregularly irregular. His chest tubes had a small air leak. His abdominal was benign. His extremities were warm. A chest x-ray was checked to see if there was a pneumothorax with plans to pull his chest tubes if there was no pneumothorax as there was minimal chest tube output. He continued to work with Physical Therapy on the floor. On postoperative day three, he was sitting up comfortably. He was afebrile with good vital signs. His urine output was good. His lungs were clear. His heart was regular in rate and rhythm. His abdominal examination benign with minimal swelling in his extremities. His chest tubes had been pulled the evening prior. His Foley catheter was removed in the morning. His epidural was removed. He was ambulating well. His central line was discontinued with plans for discharge in the morning, and he was discharged to home on [**10-11**] with the following discharge diagnoses. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Status post right lower lobectomy, bronchoscopy, mediastinoscopy, mediastinal fluoroscopy. 3. Status post myocardial infarction. 4. Status post coronary artery bypass graft. 5. Status post redo coronary artery bypass graft. 6. Status post multiple angioplasties in [**2163**]. 7. Angina. MEDICATIONS ON DISCHARGE: 1. Captopril 6.25 mg p.o. q.d. 2. Lopressor 25 mg p.o. b.i.d. 3. Aspirin 81 mg p.o. q.d. 4. Tylenol p.r.n. 5. Percocet one to two tablets p.o. q.4-6h. p.r.n. for pain. 6. Milk of Magnesia p.o. q.d. p.r.n. 7. Albuterol meter-dosed inhaler p.r.n. DISCHARGE STATUS: The patient was discharged to home on [**2165-10-11**]. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (NamePattern1) 76**] MEDQUIST36 D: [**2165-11-1**] 12:01 T: [**2165-11-2**] 05:01 JOB#: [**Job Number 26534**] (cclist)

[ "162.5", "V45.81", "492.8" ]

icd9cm

[ [ [] ] ]

[ "32.3" ]

icd9pcs

[ [ [] ] ]

4892, 5233

5259, 5876

1266, 1373

2550, 4871

181, 731

1551, 2531

753, 1239

30,262

161,506

54490

Discharge summary

report

Admission Date: [**2185-8-18**] Discharge Date: [**2185-8-26**] Service: NEUROLOGY Allergies: Naprosyn / Vicodin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: TEE History of Present Illness: The pt is a 83 year-old right-handed woman with a PMH of HTN, HLD and newly diagnosed paroxysmal afib who was transferred from an OSH today as a code stroke. This history is obtained from her daughter as she is unable to provide a history. Reportedly, she was in her USOH until 6 days ago when her daughter noticed that she as having difficulty making a phone call (although the details of this are not known) and had difficulty putting a belt on. The next day, she complained of abdominal pain and was "confused". This confusion was characterized by speech that was intelligible but non-nonsensical. There was no slurring however and no weakness or facial droop. She was taken to Cape Code hospital where she was found to be in afib. She was also noted to have a transaminitis. It appears that there may have been a head CT at the time, although there is neither a report nor a disc of this image. A CT of the abdomen showed reported liver and kidney lesions. She was d/c'd on a clear liquid diet and advised to start Coumadin. The following day, the patient was seen by a cardiologist and advised to start Coumadin. She went to see her PCP the next day and she was not stared on Coumadin given that she would probably need a biopsy of the liver or kidney lesions. She was actually also taken off all of her meds including aspirin except for atenolol and Colace. Today, she was in her USOH at 7am and her last known well time was 7:30. At 7:40am her daughter found her lying on her R side screaming. She was taken to an OSH where she was found to have a R parietal-occipital infarct and transferred here. Timing of her arrival and decision for thrombolysis at the OSH are not listed in her transfer documentation. At the OSH, her BP's were recorded ranging in the 130's-170's On arrival here, her NIHSS is 17. She is globally aphasic and appears to have severe visual impairment (not tracking, no blink to threat bilaterally and a L gaze preference). She was initially in SR. Her CT showed bilateral occipital-parietal infarcts, a possible bleed in the R infarct and a fetal circulation, no basilar thrombosis. During her course in the ED, she converted to afib with RVR (rate 120's). FS on arrival was 106. ROS: unable to obtain Past Medical History: - paroxysmal afib - OA - HTN - HLD - depression - C7 compression fracture - schmorals node - transient global amnesia - memory impairments - macular degeneration - BSO Social History: former tobacco (remote) -no EtOH or tobacco Lives with daughter. [**Name (NI) **] ETOH. 2 glasses of wine/night. Family History: -mother: died of stroke Physical Exam: General: Awake, agitated, screaming at times HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: regular, nl S1,S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema Skin: no rashes or lesions noted. Neurologic: -Mental Status: awake, fluent speech that does not make sense but is syntactic ally intact and uses normal prosody. The speech has intermittent preserved phrases "I want milk", "where is [**Doctor First Name **]" but neither these responses nor the remainder of her speech appears to be logical and she does not follow commands, answer questions (even Y/N). She does not read or repeat. There is no dysarthria but there are frequent paraphasic errors "climy" "tookal much". CN I: not tested II,III: no blink to threat. patient does not track, even to familiar faces, Pupil 3mm->2.5mm bilaterally, fundi normal although this is a very limited exam III,IV,V: L gaze preference but able to look in all directions with oculocephalic V: says "ouch" with pinprick in V1-V3 VII: face appears symmetrical VIII: UA to formally test IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: UA to formally test XII: tongue protrudes midline Motor: Normal bulk, slightly increased tone in the legs; or myoclonus. patient is unable to follow commands for formal strength testing, however her arms are spontaneously antigravity. She has a grasp reflex on the L which is full but the R side has a weaker grasp. She is able to pick at the BP cuff without difficulty. She will not take objects in her hand, saying "what is this" and then putting them down but not dropping them. Her legs withdraw symmetrically to nox stim but she does not raise them off the bed, despite nox stim, holding them up and repeated coaching. Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 2 0 Extensor R 2 2 2 2 0 Extensor -Sensory: says "ouch" to nox stim in all extremitiesm. unable to test DDS due to patient cooperation -Coordination: UA to assess formally -Gait: deferred given mental status of agitation and confusion Pertinent Results: [**2185-8-18**] 02:00PM PT-13.3 PTT-39.9* INR(PT)-1.1 [**2185-8-18**] 02:00PM PLT COUNT-295 [**2185-8-18**] 02:00PM NEUTS-77.9* LYMPHS-17.2* MONOS-4.3 EOS-0.3 BASOS-0.3 [**2185-8-18**] 02:00PM WBC-9.2 RBC-3.50* HGB-11.1* HCT-32.1* MCV-92 MCH-31.6 MCHC-34.5 RDW-12.8 [**2185-8-18**] 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-8-18**] 02:00PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-2.4 [**2185-8-18**] 02:00PM CK-MB-NotDone cTropnT-<0.01 [**2185-8-18**] 02:00PM CK(CPK)-60 [**2185-8-18**] 02:00PM estGFR-Using this [**2185-8-18**] 02:00PM GLUCOSE-107* UREA N-21* CREAT-0.8 SODIUM-140 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [**2185-8-18**] 03:35PM URINE MUCOUS-FEW [**2185-8-18**] 03:35PM URINE HYALINE-0-2 [**2185-8-18**] 03:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2185-8-18**] 03:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2185-8-18**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2185-8-18**] 03:35PM URINE GR HOLD-HOLD [**2185-8-18**] 03:35PM URINE HOURS-RANDOM [**2185-8-18**] 04:48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2185-8-18**] 04:48PM URINE HOURS-RANDOM [**2185-8-18**] 08:58PM PT-12.6 PTT-35.9* INR(PT)-1.1 [**2185-8-18**] 08:58PM PLT COUNT-321 [**2185-8-18**] 08:58PM WBC-8.9 RBC-3.62* HGB-11.1* HCT-33.8* MCV-93 MCH-30.5 MCHC-32.7 RDW-12.7 [**2185-8-18**] 08:58PM TSH-1.2 [**2185-8-18**] 08:58PM HDL CHOL-50 CHOL/HDL-3.0 [**2185-8-18**] 08:58PM %HbA1c-6.0* [**2185-8-18**] 08:58PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-2.2 CHOLEST-151 [**2185-8-18**] 08:58PM CK-MB-NotDone cTropnT-<0.01 [**2185-8-18**] 08:58PM ALT(SGPT)-56* AST(SGOT)-45* LD(LDH)-472* CK(CPK)-75 ALK PHOS-94 TOT BILI-1.0 [**2185-8-18**] 08:58PM GLUCOSE-116* UREA N-17 CREAT-0.7 SODIUM-140 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15 [**2185-8-18**] 11:13PM URINE RBC->50 WBC-0-2 BACTERIA-MOD YEAST-MOD EPI-0 [**2185-8-18**] 11:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2185-8-18**] 11:13PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.040* CT: b/l parietal infarcts w/ early hypodensity and possible hemorrhagic transformation within RIGHT parietal lesion CTA: no major vessel occlusion; b/l fetal origin to PCAs. MRI/ DWI: Bilateral ischemic parietal infarcts with a single hemorrhagic stroke of the right parietal lobe. Brief Hospital Course: Pt was admitted s/p transferred from OSH for a Code Stroke. Pt was managed on in the ICU initially then transferred to StepDown on DOA #2. She had bilateral parietal infarcts and bilateral smaller infarcts of the frontal lobes. The etiology is probably from cardioembolism due to her atrial fibrillation. Another possibility is that this was a hypoperfusion event. Although, no hypotensive episode was noted. Pt was started on NGT tube feeds secondary to poor mental status. Aspirin 81mg PO qday and Heparin SC was started on [**8-20**]. Antcoagulation was held throughout hospitalization secondary to hemorrhagic component of stroke. Anticoagulation is planned to restart [**2185-8-31**]. Antihypertensive were initially held and then later restarted, i.e Lopressor 25mg [**Hospital1 **] started on [**2185-8-21**]. Pt obtain Speech and Swallow study on [**2185-8-22**]. Pt passed and pt was switch to po nutrition. Pt scheduled to obtain TEE on [**2185-8-22**]. Metoprolol started at 25mg PO BID. PMD office contact[**Name (NI) **] via fax regarding liver and kidney lesions. These lesions are actually cysts. On [**2185-8-23**], Pt restarted on lisinopril and switched to TID, Records faxed over on [**2185-8-24**]. Pt physically continued to improve. Severe visual impairment noted. Patient does not track or blink to threat with either eye. She correctly counts fingers only part of the time and may be confabulating. She speaks in phrases with many paraphasic errors and does not answer questions appropriately. She follows one step commands. Family aware of progress. Medications on Admission: atenolol 12.5 mg PO BID - Colace Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): sliding scale. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Fever and pain. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for agitation. Discharge Disposition: Extended Care Facility: Rehab of [**Location (un) **] and Islands Discharge Diagnosis: Bilateral parietal Strokes, bilateral frontal infarcts Discharge Condition: Cortical blindness. Wernicke's aphasia. Discharge Instructions: Take all medications as prescribed. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2185-10-3**] 3:00 Please call [**Telephone/Fax (1) 111503**] to make an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]

[ "593.9", "573.8", "362.50", "294.9", "351.8", "377.75", "434.11", "733.00", "437.7", "272.4", "311", "427.31", "715.90", "784.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "88.72" ]

icd9pcs

[ [ [] ] ]

10202, 10270

7818, 9396

247, 253

10368, 10410

5217, 7795

10494, 10821

2860, 2886

9480, 10179

10291, 10347

9422, 9457

10434, 10471

2901, 3311

196, 209

281, 2520

3326, 5198

2542, 2712

2728, 2844

25,882

179,474

51644

Discharge summary

report

Admission Date: [**2122-10-1**] Discharge Date: [**2122-10-6**] Service: CCU IDENTIFICATION/CHIEF COMPLAINT: The patient is a 78-year-old male with a history of coronary artery disease and is status post coronary artery bypass graft times two with a porcine mitral valve replacement and congestive heart failure, with an ejection fraction of less than 20%. HISTORY OF PRESENT ILLNESS: The patient had been in his usual state of health at home until two weeks prior to admission. At that time, the patient began noticing increased shortness of breath and dyspnea on exertion. Typically, he was able to walk half a mile without any problems. [**Name (NI) **] also states that he had a 3-pound weight gain over that period of time. During the week prior to admission the patient had his Lasix dose doubled to 40 mg once a day. He had some laboratory work drawn on [**Hospital3 4298**] which showed an increase of his creatinine to 3 from a baseline of 2.3 to 2.5. The patient was subsequently seen in the Congestive Heart Failure Clinic by Dr. [**Last Name (STitle) **] where he was noted to be in worse condition compared to his previous office visit in [**2122-7-26**]. The patient has also had previous admissions for congestive heart failure requiring milrinone to aid in his diuresis. His most recent admission was in [**2122-3-26**]. PAST MEDICAL HISTORY: 1. Coronary artery disease; the patient is status post coronary artery bypass graft in [**2102**] and a redo coronary artery bypass graft in [**2121-3-26**]. The patient has also undergone a cardiac catheterization and stenting of his vein graft to his left anterior descending artery in [**2122-1-26**]. 2. [**State 531**] Heart Association class III congestive heart failure. The patient was found on echocardiogram to have an ejection fraction of less than 20%. 3. Mitral valve replacement with a porcine mitral valve. 4. DDD pacemaker for complete heart block following his redo coronary artery bypass graft. 5. Hypercholesterolemia. 6. History of atrial fibrillation, post redo coronary artery bypass graft that was initially treated with Coumadin but subsequently discontinued secondary to hemoptysis in [**2121-7-26**]. 7. Chronic renal insufficiency. MEDICATIONS ON ADMISSION: 1. Amiodarone 100 mg p.o. q.d. 2. Carvedilol 3.125 mg p.o. b.i.d. 3. Losartan 25 mg p.o. q.d. 4. Digoxin 0.125 mg on Monday and Thursday. 5. Erythropoietin 10,000 units every week on Wednesday. 6. Lipitor 10 mg p.o. every Monday, Wednesday and Friday. 7. Lasix 40 mg p.o. q.d. 8. Prilosec 20 mg p.o. q.d. 9. Vitamin E. 10. Flonase. ALLERGIES: PENICILLIN, DOXYCYCLINE. SOCIAL HISTORY: The patient is a retired architect and denies a smoking or alcohol history. PHYSICAL EXAMINATION ON ADMISSION: The patient was in mild respiratory distress. His temperature on admission was 97, blood pressure 103/45, heart rate was 76 and regular, and a respiratory rate of 20. On head and neck examination, the patient's mucous membranes were moist, and his oropharynx was clear. His pupils were equal and reactive to light. On cardiovascular examination, the patient's jugular venous pressure was noted to be at 14 cm above the sternal angle. He had a normal S1 and S2, and he had an audible S3 and S4. He also had a 2/6 systolic murmur at his left sternal border radiating to his right second intercostal space and to his apex. On respiratory examination, the patient had a few scattered inspiratory crackles at the bases. His abdominal examination showed him to have bowel sounds present with no abdominal distention or pain on palpation. His liver was palpable 4 cm below the costal margin. On musculoskeletal examination, the patient was noted to have a slight amount of edema in his ankles at 1+. RADIOLOGY/IMAGING: The patient's electrocardiogram showed him to be AV-paced at a rate of 70. LABORATORY DATA ON ADMISSION: The patient's Chem-7 revealed a sodium of 129, potassium of 5.2, chloride 92, bicarbonate 26, BUN 65, and creatinine of 2.5; in comparison to [**9-15**], where his BUN was 58 and creatinine was 2.5. His complete blood count showed a white blood cell count of 3.2, hematocrit of 34.8, and platelet count of 84. His PT was 14.5, PTT of 29.2, and INR of 1.4. His urinalysis was negative. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit and was initiated on a milrinone infusion with a 50-mcg/kg bolus, followed by a 0.28-mg/kg/min. infusion. He was also given an intravenous dose of Lasix 40 mg. The patient remained on his baseline medications and continued with the milrinone until the day before discharge. He was completely stable during his hospital course. He was transferred to the floor on [**2122-10-5**]. His milrinone infusion was continued for a total duration of four days. During that time, the patient's net total body fluid balance was minus approximately 4 liters. The patient was restarted on his p.o. Lasix dose on [**10-5**] and was diuresing well following the discontinuation of his milrinone infusion. Symptomatically, the patient was improved and felt less short of breath. He was able to go for short walks without any difficulty. The patient was discharged to home on [**10-6**]. He was given a dose of Epogen 10,000 units subcutaneous times one to save him an additional trip to get Epogen tomorrow. He also had his iron preparation changed to an elixir to see if the patient would have better tolerance of the iron. CONDITION AT DISCHARGE: The patient was in stable condition. DISCHARGE STATUS: Discharged to home. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. q.d. 2. Amiodarone 100 mg p.o. q.d. 3. Carvedilol 6.125 mg p.o. q.d. 4. Digoxin 0.125 mg on Monday and Thursday. 5. Prevacid 20 mg p.o. q.d. 6. Cozaar 25 mg p.o. q.d. 7. Lipitor 10 mg p.o. every Monday, Wednesday and Friday. 8. Lasix 20 mg p.o. b.i.d. 9. Vitamin E 400 units p.o. q.d. 10. Multivitamins 1 tablet p.o. q.d. 11. Ferrous fumarate 100 mg p.o. b.i.d. elixir. DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with Dr. [**Last Name (STitle) 7626**] and also had an appointment arranged to be seen in the Congestive Heart Failure Clinic. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 26201**] MEDQUIST36 D: [**2122-10-6**] 13:26 T: [**2122-10-6**] 12:35 JOB#: [**Job Number **]

[ "414.8", "428.0", "414.01", "V42.2", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5634, 6047

2277, 2666

4331, 5513

6072, 6498

5528, 5607

122, 371

400, 1359

3925, 4313

1381, 2250

2683, 2781

25,848

140,820

13655

Discharge summary

report

Admission Date: [**2136-11-22**] Discharge Date: [**2136-11-28**] Date of Birth: [**2072-5-19**] Sex: M Service: [**Hospital Unit Name 196**]/BLUE HISTORY OF PRESENT ILLNESS: This is a 64 year-old gentelman with known coronary artery disease status post an inferoposterior myocardial infarction in [**2116**] who is status post redo-CABG times six and bovine AVR in [**2135-2-8**] who was transferred from the Neurosurgical Service on nerve decompression with a posterior fossa approach. The patient's postoperative course was complicated by his typical angina and atrial flutter with variable block. The patient's prior cardiac history is as follows: 1. Status post inferior myocardial infarction in [**2116**]. 2. Status post coronary artery bypass graft times four in [**2116**], descending coronary artery with jumps to the diagonal, left circumflex and posterior descending coronary artery. 3. Status post catheterization in 12/99 showing all four grafts were 80 to 100% stenosed. 4. Status post coronary artery bypass graft times six with AVR in [**2135-2-8**] done at [**Hospital3 41191**] Center. The following grafts reverse saphenous vein graft to diagonal one and distal left anterior descending coronary artery sequential, reverse saphenous vein graft to the ramus intermedius and obtuse marginal one sequential and reverse saphenous vein graft to the posterolateral and posterior descending coronary artery branches of the right coronary artery. AVR was with 27 mm bovine paracardial bioprosthesis. 5. Echocardiogram on [**11-8**] at [**Hospital 41192**] Hospital shows an EF of 40%, concentric left ventricular hypertrophy and mild MR. PAST MEDICAL HISTORY: 1. See above for cardiac history. 2. Gout. 3. Hypercholesterolemia. 4. Right trigeminal neuralgia status post prior surgery in [**2132**], status post right trigeminal nerve decompression on [**2136-11-22**]. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER FROM NEUROSURGERY TO MEDICINE: 1. Morphine sulfate for pain. 2. Zofran prn nausea. 3. Metoprolol 25 mg po b.i.d. 4. Aspirin 325 mg po q.d. 5. Lisinopril 10 mg po q.d. 6. Lasix 40 mg po q.d. 7. Allopurinol 500 mg po q.d. 8. Trazodone 50 mg po q.h.s. 9. Prednisone 5 mg po q.d. 10. Celecoxib 200 mg po q.d. SOCIAL HISTORY: There is a sixty pack year history of tobacco use and two to three glasses of wine per day none in the last two weeks by his report. The patient works in the meat packing industry and lives with his wife and kids. FAMILY HISTORY: Coronary artery disease is present in both the brother and the father. The father died at age unknown. ADMISSION PHYSICAL EXAMINATION: Vital signs temperature 38?????? Celsius. Pulse 79. Blood pressure 130/67. Respiratory rate 12. O2 saturation 94% on 2 liters nasal canula oxygen. General awake and in no acute distress. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Mild droop of the left upper eyelid is noted, which the patient can abduct when asked. Mucous membranes are moist. Oropharynx clear. Neck no jugulovenous distention. No carotid bruits. Cardiovascular regularly irregular rhythm. 3 out of 6 systolic ejection murmur best heard at the right upper sternal border with diffuse radiation. Pulmonary inspiratory crackles one third of the way up bilaterally with the occasional expiratory wheeze. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities no clubbing, cyanosis or edema. Neurological examination alert and oriented times three. Cranial nerves II through XII intact. Strength 5 out of 5 in all the major muscles groups of the extremities. Reflexes are 1+ in the knees and ankles. No clonus. HOSPITAL COURSE: The patient was admitted status post craniotomy to [**Hospital Unit Name 196**] for management of multiple cardiac problems including chest pain and atrial flutter and mild volume overload in the postop course. The patient ruled out for an myocardial infarction. For the first 72 hours on our service he was kept off anticoagulation other then a full dose aspirin. These were as per neurosurgery recommendations for Dr. [**Last Name (STitle) 6910**]. After that period of time the patient was heparinized and went to cardiac catheterization [**2136-11-26**]. The results of the cardiac catheterization from that date are complicated, but can be summarized as follows: All the new grafts as described in the history of present illness are patent and the major territories are supplied, the question of angina from small vessels supplied via retrograde flow from these grafts and no targets for percutaneous intervention were identified. Please see the cardiac catheterization report for full details. In the postop period te patient was maintained on a full dose aspirin in addition to which he was receiving Celecoxib as per neurosurgery. His angina was controlled with a combination of calcium channel blockers, long acting nitrates and aggressive beta blockade. The patient's rate was under variable control during the admission and it was felt that the patient would benefit from electrophysiology consult to evaluate for possible DC cardioversion given his cardiac history and the possibility of rate related ischemia causing angina in him. On [**2136-11-28**] the patient underwent TEE, which showed no mural thrombus and underwent DC cardioversion. The patient was then started on Amiodarone 200 mg t.i.d. for one month and then 200 q.d. to follow. He was discharged from our service on the evening of [**2136-11-28**]. DISCHARGE DIAGNOSES: 1. Status post right craniotomy for trigeminal nerve decompression posterior fossa approach. 2. Coronary artery disease. 3. Atrial flutter. DISCHARGE MEDICATIONS: Lovenox 80 mg subQ q 12 hours, Coumadin 5 mg po q.h.s., Amiodarone 200 mg po t.i.d. times one month, Metoprolol 25 mg po b.i.d., Lisinopril 10 mg po q.d., aspirin 325 mg po q.d., Isordil 40 mg po b.i.d., Amlodipine 5 mg po b.i.d., allopurinol 200 mg po q.o.d. and 300 mg po q.o.d., Celecoxib 200 mg po q.d. DISCHARGE FOLLOW UP: 1. The patient will need to follow up with his physician at [**Name9 (PRE) 41192**] Clinic to check INR for a target range of 2 to 3 at which time the Lovenox can be discontinued. 2. The patient will get cardiology follow up in one months time and sooner if needed, which he wishes to arrange through his primary care physician. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21044**], M.D. [**MD Number(1) 21045**] Dictated By:[**Name8 (MD) 2653**] MEDQUIST36 D: [**2136-12-5**] 09:55 T: [**2136-12-5**] 09:55 JOB#: [**Job Number 41193**]

[ "427.32", "412", "272.0", "V45.81", "401.9", "414.00", "350.1", "V42.2", "413.9" ]

icd9cm

[ [ [] ] ]

[ "04.41" ]

icd9pcs

[ [ [] ] ]

2555, 2670

5628, 5772

5796, 6114

3768, 5607

6126, 6731

2693, 3750

196, 1683

1706, 2305

2322, 2538

46,467

116,534

46525

Discharge summary

report

Admission Date: [**2100-8-6**] Discharge Date: [**2100-8-14**] Date of Birth: [**2018-3-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: worsening shortness of breath, fatigue and dyspnea Major Surgical or Invasive Procedure: [**2100-8-6**] 1. Aortic valve replacement 25-mm Biocor Epic tissue valve. 2. Coronary artery bypass grafting x3: Left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery History of Present Illness: 82 year old male who has been followed for aortic stenosis since [**2098**] after an echo was performed for a murmur prior to his left total hip replacement. Echo revealed moderate aortic stenosis with peak/mean gradient 62/38. Medically managed with serial echocardiograms over the last several years. He noted a marked decrease in exercise tolerance with generalized fatigue. He also complains of dyspnea on exertion. He attributes some of these symptoms to fairly severe arthritis in his knees and hips. His most recent echo showed severe AS (similar to echo in [**2099**]), given his current symptoms he was referred for surgical evaluation. Past Medical History: PMH: Aortic stenosis Insulin dependent Diabetes Mellitus Arthritis Rheumatic heart disiease Coronary artery disease Hypertension Prostate cancer treated with radiation PSH: s/p Left total hip replacement at the [**Hospital3 **] in [**12-15**] s/p Bilateral knee replacements in [**2096**] Right shoulder surgery Prostatectomy [**2075**] Social History: Race: Caucasian Last Dental Exam: [**2-7**] mos. ago Lives with: wife Occupation: retired engineer, published his very moving book on his WWII experiences, keeps very active- builds furniture Tobacco: never ETOH: quit 3 yrs. ago Family History: non-contributory Physical Exam: Preoperative Pulse: 69 Resp: 18 O2 sat: 98%RA B/P Right: 128/89 Left: 123/85 Height: 66" Weight 93 kg (205 lbs) General: NAD, WGWN, appears younger than stated age Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] fixed pupils (cataracts) Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] + BS [x] Extremities: Warm [x], well-perfused [x] Edema: trace pedal edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left:1+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: cath Left:1+ Carotid Bruit -radiated murmur Pertinent Results: Admission [**2100-8-6**] 08:00AM HGB-11.7* calcHCT-35 [**2100-8-6**] 08:00AM GLUCOSE-131* LACTATE-1.0 NA+-141 K+-4.4 [**2100-8-6**] 12:31PM GLUCOSE-178* LACTATE-1.7 NA+-138 K+-4.8 CL--113* [**2100-8-6**] 12:34PM FIBRINOGE-206 [**2100-8-6**] 12:34PM PT-13.9* PTT-30.9 INR(PT)-1.2* [**2100-8-6**] 12:34PM PLT COUNT-154 [**2100-8-6**] 12:34PM WBC-15.3*# RBC-2.54*# HGB-8.0*# HCT-23.2*# MCV-91 MCH-31.5 MCHC-34.5 RDW-13.8 [**2100-8-6**] 02:18PM UREA N-38* CREAT-1.1 SODIUM-143 POTASSIUM-4.6 CHLORIDE-119* TOTAL CO2-22 ANION GAP-7* Discharge [**2100-8-14**] 04:40AM BLOOD WBC-10.8 RBC-2.79* Hgb-8.4* Hct-24.9* MCV-89 MCH-30.2 MCHC-33.8 RDW-13.8 Plt Ct-352 [**2100-8-14**] 04:40AM BLOOD PT-13.5* INR(PT)-1.2* [**2100-8-14**] 04:40AM BLOOD Glucose-99 UreaN-29* Creat-1.4* Na-136 K-4.6 Cl-100 HCO3-28 AnGap-13 [**2100-8-14**] 04:40AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.2 ECHO [**2100-8-6**]: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. 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 descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is borderline functional mitral stenosis due to mitral annular calcification (MVA-2.2 cm2) Mild (1+) mitral regurgitation is seen. POSTBYPASS: There is preserved biventricular systolic function. There is a well seated, well functioning bioprosthesis in the aortic position. There is trace valvular AI. The remaining study is unchange from prebypass. Chest x-ray [**8-11**]: PA and lateral chest submitted for review on [**8-13**] shows a stable postoperative appearance to the enlarged mediastinum. Aside from mild right basal atelectasis, lungs are clear. Pleural effusions are small if any. No pneumothorax or pulmonary edema. Brief Hospital Course: Mr. [**Known lastname 50500**] was admitted on [**2100-8-6**] and taken to the operating room where he underwent Aortic valve replacement and Coronary artery bypass grafting x3. Please see operative note for details, in summary he had: Aortic valve replacement 25-mm Biocor Epic tissue valve and Coronary artery bypass grafting x3 with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and the posterior descending artery. His bypass time was 129 minutes with a crossclamp of 106 minutes. He tolerated the operation and immediately post-operatively was admitted to the ICU intubated and sedated on propofol and on neo for BP support. Propofol was weaned off readily and patient was extubated without difficulty on POD #1. On POD#2 he developed rapid afib which was treated with IV Lopressor and amiodarone and he continued to require neo for blood pressure support. He converted to sinus rhythm and Neo-Synephrine infusion was weaned off. Chest tubes and pacing wires were removed per cardiac surgery protocol. On POD# 3 he was transferred to the step down unit for ongoing post-operative care. He was diuresed postoperatively and developed ATN which improved when Lasix dose was decreased. Once on the stepdown floor he continued to have intermittent episodes of rapid afib and his beta blocker was titrated accordingly, rate control was difficult to achieve. EP was consulted and he was also started on Coumadin for his atrial fibrillation. The remainder of his hospital course was uneventful. He was evaluated by physical therapy for strength and conditioning and a brief rehabilitation stay was recommended prior to returning to home. He was discharged to [**Hospital 24806**] rehab on POD 8. Medications on Admission: Insulin Lispro (Humalog) 30 units daily Insulin Glargine [Lantus]100 unit/mL Solution 30U at 2300 hrs Latanoprost [Xalatan] 0.005 % Drops, 1 drop(s) both eyes bedtime Proscar 5mg daily Ramipril 10mg daily Aspirin 81mg 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. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 1 doses: Titrate for a Goal INR 2.0-2.5. 10. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID () for 3 days. 11. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35) Subcutaneous once a day: at breakfast. 12. Insulin sliding scale Please see attached chart for sliding scale insulin (Humalog) dosing 13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please take 200mg three times a day for 5 days. Then take 200mg twice daily for 7 days. Finally, take 200mg daily until stopped by cardiologist. Discharge Disposition: Extended Care Facility: [**Hospital 24806**] Care Center - [**Hospital1 1562**] Discharge Diagnosis: Aortic Stenosis/Coronary artery disease s/p Aortic Valve Replacement and Coronary artery bypass graft x 3 PMH: Diabetes Mellitus Osteoarthritis Rheumatic heart disease Hypertension Prostate cancer s/p XRT s/p left total hip replcaement s/p Bilateral knee replacements in [**2096**] s/p Right shoulder surgery s/p Prostatectomy [**2075**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tramadol Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 1+ 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** Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw - day after discharge, [**8-15**] Rehab to arrange Coumadin follow-up with PCP Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2100-9-2**] 1:00 in the [**Hospital **] Medical office building [**Hospital Unit Name **] Cardiologist: Dr. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2100-9-21**] 4:00 Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 98813**] to be seen in [**5-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2100-8-14**]

[ "V15.3", "V43.65", "584.5", "997.5", "398.91", "V43.64", "401.9", "716.90", "V10.46", "E937.8", "997.1", "518.5", "V45.77", "E878.2", "285.1", "396.2", "V58.67", "414.01", "348.39", "427.31", "250.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

8288, 8370

4966, 6730

360, 627

8751, 8973

2700, 4943

9970, 10702

1925, 1943

7004, 8265

8391, 8730

6756, 6981

8997, 9947

1958, 2681

270, 322

655, 1302

1324, 1662

1678, 1909

21,424

150,642

24830

Discharge summary

report

Admission Date: [**2179-10-12**] Discharge Date: [**2179-10-19**] Date of Birth: [**2108-11-10**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [**2179-10-12**] Three vessel coronary artery bypass grafting utilizing left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to PLV. History of Present Illness: This is a 70 year old male with known coronary disease. He sustained a myocardial infarction in [**2177**] and underwent stenting to his LAD at that time. He continued to experience angina and exertional shortness of breath. An echocardiogram in [**2179-6-25**] was notable for an LVEF of 30-35% with mild MR. Subsequent cardiac catheterization found an occluded LAD stent with 60% lesion in his circumflex and 70% diagonal stenosis. Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Coronary artery disease - as above, Hypertension, Hypercholesterolemia, Chonic Obstructive Pulmonary Disease, s/p Left Nephrectomy, Right Hip Fracture, s/p Prostatectomey, Artificial Urinary Sphincter, Sleep Apnea, Gastroesophageal Refulx Disease, s/p Parathyroidectomy, s/p Vasectomy, Cataract Surgery Social History: Retired machinist. No significant tobacco or ETOH history. Lives alone. Family History: Parents and sibling had CAD - unknown age Physical Exam: Vitals: BP 104/68, HR 57, SAT 98% room air, WT 87kg General: Well appearing male in NAD HEENT: Oropharynx bengin Neck: supple, no JVD Lungs: clear bilaterally Heart: regular rate, normal s1s2, no murmur or rub Abd: soft, nontender, normoactive bowel sounds Ext: warm, no edema Neuro: nonfocal Pulses: 1+ distally, no carotid bruits Pertinent Results: [**2179-10-19**] 05:20AM BLOOD WBC-11.6* RBC-3.53* Hgb-10.9* Hct-32.3* MCV-92 MCH-30.8 MCHC-33.7 RDW-13.1 Plt Ct-270 [**2179-10-12**] 11:43AM BLOOD PT-15.7* PTT-32.7 INR(PT)-1.7 [**2179-10-12**] 01:05PM BLOOD UreaN-18 Creat-1.2 Cl-109* HCO3-24 [**2179-10-19**] 05:20AM BLOOD Glucose-103 UreaN-20 Creat-1.6* Na-139 K-4.6 Cl-101 HCO3-28 AnGap-15 Brief Hospital Course: Mr. [**Known lastname 62520**] was admitted and underwent coronary artery bypass grafting by Dr. [**Last Name (STitle) 1290**]. Surgery was uneventful and he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Low dose beta blockade was resumed. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. He experienced brief bouts of atrial fibrillation for which beta blockade was advanced as tolerated. He remained mostly in a normal sinus rhythm. His last episode of atrial fibrillation was on postoperative day two. His preoperative medications, including Plavix were eventually resumed. He otherwise responded well to diuretics and by discharge, was close to his preoperative weight. PT followed pt during entire post-operative course and was at level five by discharge. He continued to make clinical improvements, labs were stable, physical exam unremarkable and was cleared for discharge on postoperative day seven. At discharge, his room air saturations were 96%. He went home with VNA services and the appropriate follow-up appointments. Medications on Admission: Lopressor 25 [**Hospital1 **], Plavix 75 [**Last Name (LF) **], [**First Name3 (LF) **] 162 qd, Lipitor 80 qd, Nexium 40 qd, Niacin, Fish Oil, Norvasc 5 qd, Spiriva, Advair prn, Flonase Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 caps* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. 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* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 6011**] Care Discharge Diagnosis: Coronary artery disease - s/p Coronary Artery Bypass Graft x 3, Prior Myocardial Iinfarction with LAD stent, Hypertension, Hypercholesterolemia, Chronic Obstructive Pulmonary Disease, s/p Left Nephrectomy, Right Hip Fracture, s/p Prostate surgery, Artificial Urinary Sphincter, Sleep Apnea Discharge Condition: Good Discharge Instructions: Patient may shower. No baths. No creams or lotions to incisions. No lifting more than 10 lbs for 10 weeks. No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in 4 weeks Dr. [**First Name (STitle) **] in [**1-28**] weeks Dr. [**Last Name (STitle) 22980**] in [**1-28**] weeks Completed by:[**2179-11-2**]

[ "496", "530.81", "V45.82", "414.01", "427.31", "272.0", "V10.52", "413.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5141, 5197

2308, 3467

356, 557

5531, 5537

1940, 2285

5727, 5908

1530, 1573

3703, 5118

5218, 5510

3493, 3680

5561, 5704

1588, 1921

285, 318

585, 1099

1121, 1425

1441, 1514

30,985

128,503

53914+59560

Discharge summary

report+addendum

Admission Date: [**2112-6-15**] Discharge Date: [**2112-6-28**] Date of Birth: [**2029-6-16**] Sex: F Service: MEDICINE Allergies: Lidocaine / Codeine / Iodine; Iodine Containing / Tylenol Attending:[**Last Name (NamePattern1) 1572**] Chief Complaint: chest pain, dyspnea Major Surgical or Invasive Procedure: [**2112-6-17**] Transeophageal echocardiogram History of Present Illness: 82F w/ CAD s/p CABG, CHF (EF 30-40%), PAF, and HTN, with acute onset bilateral squeezing chest pain and dyspnea at 4AM. She had associated left neck and jaw pain, nausea, and lightheadedness. The pain was similar to her prior anginal pain. She missed her dose of Lasix yesterday. She called EMS, received SL NTG x 1 and O2 en route. In the ED, VS were BP 110/64, AF w/ HR 142, RR 28, O2sat 91% RA and 98% 4LNC. She received Lasix 120mg IV and was started on a nitro gtt. She was also given diltiazem 30mg po and 10mg IV. Her SBP subsequently dropped to 90 with RVR still in 130s. The nitro gtt was stopped. She had intermittent recurrent chest pain that responded to SL NTG. She was transiently on CPAP. She was then put on a diltiazem gtt, still with poor rate control. She was 100% on 4L NC and BP 107/60. She was transferred to the CCU for further monitoring. . Currently, she feels well. She denies chest pain, difficulty breathing, lightheadedness, abdominal pain. She reports occasional angina, increasing in frequency over the last couple of months. She also has occasional PND. She has chronic bilateral ankle edema, and L leg edema since saphenous vein graft harvest in [**2098**]. She states this has been unchanged. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Past Medical History: 1. CAD- s/p emergent CABG in [**2098**] after failed PCI, last cath [**2109**] with 3-vessel native CAD, known occluded SVG-PDA, patent SVG-D1-OM2, s/p PCI to RCA 2. HTN 3. Hypercholesterolemia 4. IBS 5. DJD 6. PVD 7. hiatal hernia . Cardiac Risk Factors: Dyslipidemia, Hypertension . Cardiac History: CABG, in [**2108**] anatomy as follows: SVG-D1-OM2, SVG-PDA . Percutaneous coronary intervention, in [**12-23**] anatomy as follows: 3v native CAD, known occluded SVG-PDA Social History: She lives alone and has elder services. She states she performs ADLs independently. She reports she has no family or friends. She has a brother with whom she does not speak. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature CAD. Brief Hospital Course: #Rhythm: PT was found to have new onset atrial fibrillation. Initially was placed on a diltiazem gtt. She underwent cardioversion which restored to NSR. SHe was started on amiodarone for rhythm control as well as coumadin. In addition her Metoprolol was changed to 50mg [**Hospital1 **]. She was set up for outpatient coumadin clinic for follow up. . # CAD: Pt had ongoing chest discomfort on this admission initially thought to be associated with reflux sx, but TWI noted [**6-19**] in precordial leads, concerning for LAD ischemia. Symptoms now more frequent, have been treated with nitro with some success. CEs persistently negative, EKG with TWIs in precordial leads unchanged. She underwent cardiac cath which demonstrated her SVG to PDA was known occluded and unchanged, LAD had 90% ostial lesion but fills via SVG, LCX had 70% lesion at OM2 but fills via SVG and the RCA was widely patent. She was continued on aspirin, metoprolol, statin and isordil (reduced to [**Hospital1 **] dosing). Her plavix was discontinued and aspirin was lowered to 81mg daily. . # Pump: ECHO [**6-16**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated. LV wall thicknesses normal. LV cavity size normal. Overall LV systolic function moderately depressed (LVEF= 30-40 %), somewhat lower than in [**2108**]. RV free wall is hypertrophied. RV cavity is dilated with depressed contractility. Pt was continued on home lasix dose 80mg daily, 120mg on Sundays. Lisinopril was stopped [**2-20**] low BP. . # Valves: 3+ MR, 1+ TR . # HTN: Currently normotensive. Discontinued lisinopril and diltiazem given adequate pressures. . # UTI: U/A consistent with infection, although afebrile, has frequency and burning. Cephalexin 250 Q8 x 3 days and she was to complete the course on discharge. . Medications on Admission: ASA 325mg daily Plavix 75mg daily Diltiazem 30mg TID Isosorbide dinitrate 20mg TID Metoprolol succinate 50mg daily Lisinopril 20mg daily Lasix 80mg po daily, 120mg daily on Sunday Lipitor 80mg daily KCl 10meq daily Magnesium 64mg daily Sucralfate Meclizine 12.5mg prn Diazepam 2mg prn Immodium prn Tums prn Folic acid 1mg daily Vitamin E Multivitamin Discharge Medications: 1. Outpatient Lab Work Blood draw: INR. Standing order for every 7 days starting [**2112-6-29**], Please fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 13780**] 2. Atorvastatin 80 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Isosorbide Dinitrate 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) ML Inhalation Q4H (every 4 hours) as needed for wheezing. 8. Valium 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8) hours as needed for anxiety. 9. Latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS (at bedtime). 10. Miconazole Nitrate 2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Dorzolamide 2 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic TID (3 times a day). 13. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 14. Furosemide 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): Take 120mg daily on Sunday (1.5 tablets). 15. Potassium Chloride 10 mEq Tablet Sustained Release [**Hospital1 **]: One (1) Tablet Sustained Release PO once a day. 16. Magnesium 84 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet Sustained Release PO once a day. 17. Aspirin 81 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Atrial fibrillation s/p TEE/DCCV UTI Discharge Condition: Stable Discharge Instructions: You were admitted with an abnormal heart rhythm called atrial fibrillation. You were then cardioverted into normal sinus rhythm. You were given a medication called Coumadin which you will need to continue to take. You need to take this every single day. You will have your labs followed up and this medication may be adjusted. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 2204**] on Thursday, [**6-30**] at 2:00 PM. 2. An outpatient GI followup appointment has been scheduled with Dr. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] at [**Hospital1 69**], [**Hospital Ward Name 12837**]. Her office is located on [**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] [**Location (un) **]. Wednesday 1:00 PM. MD phone: [**Telephone/Fax (1) 1983**] Date/Time:[**2112-6-29**] 1:00 PM. 3. Ms. [**Known lastname 22741**] should have her INR checked first checked on Monday [**6-27**]. Unless otherwise notified by her doctor, Ms. [**Known lastname 22741**] should have her blood drawn every 7 days starting [**2112-6-24**]. She should go to [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Location (un) **] Laboratory Services to have her blood drawn. [**Hospital1 18**] [**Location (un) **] is located on 1000 [**Last Name (LF) **], [**First Name3 (LF) **], [**State 350**]. Phone: ([**Telephone/Fax (1) 81319**]. Hours of operation Monday thru Friday 8:00AM-5:15PM. Results will be faxed to her PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for followup: Fax: [**Telephone/Fax (1) 13780**]. Name: [**Known lastname 18109**],[**Known firstname **] Unit No: [**Numeric Identifier 18110**] Admission Date: [**2112-6-15**] Discharge Date: [**2112-6-28**] Date of Birth: [**2029-6-16**] Sex: F Service: MEDICINE Allergies: Lidocaine / Codeine / Iodine; Iodine Containing / Tylenol Attending:[**Last Name (NamePattern1) 18111**] Addendum: Pt with documented Chronic Systolic Heart Failure Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 14680**] Completed by:[**2112-8-10**]

[ "414.01", "414.02", "041.4", "V45.82", "412", "553.3", "427.31", "401.9", "272.4", "413.9", "428.22", "276.51", "V58.61", "428.0", "599.0", "530.81", "427.1" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "99.61" ]

icd9pcs

[ [ [] ] ]

9450, 9694

2888, 4694

346, 393

7319, 7328

7705, 9427

2819, 2865

5096, 7157

7259, 7298

4720, 5073

7352, 7682

287, 308

421, 2007

2029, 2504

2520, 2803

13,457

103,720

54438

Discharge summary

report

Admission Date: [**2189-8-26**] Discharge Date: [**2189-9-23**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Nausea Vomitting Major Surgical or Invasive Procedure: None History of Present Illness: This is a 86 year old male w/ MMP, h/o ileocecectomy for Stage I CR CA- subsequently developed high grade dysplasia and ~ 2weeks ago underwent a transverse colectomy (has an ileo-dscending colostomy). He was transfered here from a [**Hospital 760**] Hospital after persistent nausea and vomitting and inability to take a regular diet. Studies: [**8-24**] CT showed some free air in the left hemidiaphram. [**8-24**] Gastograffin enema - no obstruction or leak [**8-25**] UGI - delayed gastric emptying Past Medical History: PMH: Afib, DM2, CAD, PUD, HTN, BPH, depression PSH: B2 (antecolic j-j)~ 25 years ago, ileocecectomy ~ 20 years ago, CABG, pacer, open Chole. Social History: Patient born and raised in [**Month/Year (2) 36978**]. [**Hospital1 **]. WWII survivor. Met wife in [**Name (NI) 36978**]. Patient and wife coauthored book about life in [**Name (NI) 36978**] during WWII. Patient has authored several other publications about the holocaust. Immigrated to U.S. 35 [**Last Name (un) **]. Patient moved here to escape communism, Physical Exam: PE: 97.3 77 167/84 22 99RA GEN: comfortable at rest HEENT: NCAT, anicteric CV: RRR, pacemaker in place Pulm: CTAB Abd: soft, NT, minimally distended, vertical midline incision healing well, no erythema, no induration Ext: no LE edema Pertinent Results: Cardiology Report ECG Study Date of [**2189-8-26**] 10:38:38 AM Atrial sensed ventricular paced No previous tracing available for comparison Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 130 466/466 0 -44 126 CHEST (PA & LAT) [**2189-8-27**] 9:38 AM CHEST (PA & LAT) Reason: 86 year old man with ? of obstrxn / p/op leak [**Hospital 93**] MEDICAL CONDITION: 86 year old man with ? of obstrxn / p/op leak REASON FOR THIS EXAMINATION: 86 year old man with ? of obstrxn / p/op leak CHEST RADIOGRAPH INDICATION: 86-year-old man with history of colorectal carcinoma and colectomy. No prior studies are available for comparison. FINDINGS: Left-sided dual chamber pacemaker is identified. There is a free lead that probably corresponds to prior advise. Bibasilar opacities are seen consistent with pleural effusions. The cardiac silhouette is obscured by these opacities and cannot be evaluated. The aorta appears tortuous. _____ vascular calcifications are identified. The upper lung zones appear clear. IMPRESSION: Bilateral pleural effusions. Surgical clips are seen overlying the right upper quadrant and the mid abdomen Cardiology Report ECG Study Date of [**2189-8-28**] 3:27:52 PM Ventricularly paced rhythm, rate 60. Probable underlying atrial fibrillation. Compared to the previous tracing of [**2189-8-28**] no diagnostic change. Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 59 258 142 492/489.72 28 -38 51 CT ABDOMEN W/CONTRAST [**2189-8-30**] 1:30 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: please eval for collection, obstruction. please give gastro Field of view: 36 [**Hospital 93**] MEDICAL CONDITION: 86 year old man s/p transverse colectomy, now w/ vomiting, fever REASON FOR THIS EXAMINATION: please eval for collection, obstruction. please give gastrograffin (pt had ? of leak on outside hospital scan--we could not see evidence of such on studies). page [**Numeric Identifier **] w/ questions. CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 86-year-old man status post transverse colectomy, now with vomiting and fever. Evaluate for collection or obstruction. Please administer Gastrografin. TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis were performed with IV contrast. CT ABDOMEN WITH IV CONTRAST: There is a large right pleural effusion with associated atelectasis and a small-to-moderate size left effusion. The liver, pancreas, spleen, adrenal glands, kidneys are unremarkable with the exception of a left large simple renal cyst. There are no pathologically enlarged lymph nodes within the retroperitoneum or mesentery. There is a small amount of free air within the abdomen and subcutaneous tissue adjacent to incision site. Surrounding site of anastomosis in the region of the hepatic flexure, there is a moderate amount of fat stranding with no definite fluid collection identified. These findings could represent sequelae of the prior anastomosis from 10 days ago. CT PELVIS WITH IV CONTRAST: The urinary bladder, rectum, and sigmoid colon are unremarkable. The prostate is slightly enlarged. BONE WINDOWS: No suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. Large right and small-to-moderate left pleural effusions. 2. Small amount of free air within the abdomen and subcutaneous tissues adjacent to incision site, likely postoperative sequelae. 3. Small amount of fat stranding surrounding anastomotic site, consistent with postoperative sequelae. No focal fluid collection is identified. Contrast is seen passing this site. 4. No evidence of bowel leak or obstruction. BILAT LOWER EXT VEINS [**2189-8-31**] 12:03 PM BILAT LOWER EXT VEINS Reason: eval for dvt [**Hospital 93**] MEDICAL CONDITION: 86 year old man with fevers, increasing WBC, with bilat pitting edema & [**Last Name (un) **] signs REASON FOR THIS EXAMINATION: eval for dvt INDICATION: An 86-year-old male with fevers and increasing white blood cell count and bilateral pitting edema. Evaluate for DVT. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the right and left common femoral, superficial femoral, and popliteal veins were performed. Normal compressibility, augmentation, flow, and waveforms are demonstrated. There is no evidence of intraluminal thrombus. IMPRESSION: No evidence of DVT bilaterally. PORTABLE ABDOMEN [**2189-9-1**] 4:50 PM PORTABLE ABDOMEN; FOLLOW-UP,REQUEST BY RAD. Reason: CHK FOR GASTRIC EMPTYING POST UGI INDICATION: Check for gastric emptying status post upper GI. Note is made of the GI/small bowel follow through of [**9-1**], [**2188**]. SUPINE ABDOMINAL RADIOGRAPH: Clips are seen in the right upper quadrant. Contrast is seen within the stomach as well as within loops of small and large bowel. Staples are seen over the mid abdomen. There is no evidence of obstruction. IMPRESSION: 1. Contrast remains within the stomach. No evidence of obstruction. BAS/UGI AIR/SBFT [**2189-9-1**] 2:21 PM BAS/UGI AIR/SBFT Reason: eval gastric emptying... directed consult to dr [**Last Name (STitle) **]. pls [**Hospital 93**] MEDICAL CONDITION: 86M s/p distant B2 with gastric bezoar (but no strciture on EGD) & N/V after transverse colectmoy REASON FOR THIS EXAMINATION: eval gastric emptying... directed consult to dr [**Last Name (STitle) **]. pls call with questions INDICATION: A distant history of gastric bezoar with nausea and vomiting after transverse colectomy. Please evaluate gastric emptying. COMPARISON: None. FINDINGS: A focussed fluoroscopic study of the stomach was performed. Patient was orally administered a thin barium, which demonstrated free passage through the esophagus into the stomach. There is no evidence for hiatal hernia. There was significant reflux with a large column of contrast refluxing into the esophagus to the upper mediastinum. This was accompanied by dysfunctional tertiary peristaltic waves. Esophageal lumen is featureless with a small diverticulum noted in the mid portion of the esophagus. The patient was kept in the fluoroscopic suite for 20 minutes without opacification of the stomach antrum. Given a large column of reflux of contrast, a decision was made not to administer fizzies for stomach dilation. Study will be continued on the floor with subsequent portable abdominal radiograph to assess gastric emptying. Three-lead pacemaker is noted with leads coursing their anticipated paths. Surgical clips are present in the right upper quadrant, midline, as well as skin staples present along the midline. Contrast is present within the colon from a previous contrast study. Abdominal supine portable radiograph performed one hour after thin barium administration demonstrates unchanged appearance of contrast in the stomach. Contrast in the colon is from a prior study. Abdominal supine portable radiographs performed two hours after thin barium administration demonstrates contrast opacification of non-distended stomach. Contrast has progressed into the duodenum and proximal jejunum. IMPRESSION: 1. Marked esopphageal reflux with large column of barium persisting in esophagus to the upper mediastinum (exam performed in near upright position). Patient is at risk for aspiration. Small mid-esophageal diverticulum. 2. Contrast passage through non-dilated normal-appearing stomach demonstrated two hours post contrast administration. CHEST (PA & LAT) [**2189-9-2**] 1:29 PM CHEST (PA & LAT) Reason: eval for passage of contrast [**Hospital 93**] MEDICAL CONDITION: 86 year old man with nausea, vomiting, fever. s/p transverse colectomy REASON FOR THIS EXAMINATION: eval for passage of contrast PELVIC ULTRASOUND. INDICATION: Nausea, vomiting, and fever, status post transverse colectomy. COMPARISON: [**2189-8-31**]. Since the prior examination, there has been interval removal of the enteric tube. Stable appearance of the left-sided central venous catheter with its tip projecting over the SVC. Slight increased opacity in the right lung base may represent a possible consolidation. Stable appearance of the left lower lobe opacification. Left-sided dual chamber pacemaker is unchanged with the presence of an abandoned lead from prior device. The upper abdomen demonstrates gas fluid level and barium layering in a slight dilated stomach. Some of the contrast exited the stomach, but cannot be assessed. IMPRESSION: Possible consolidation in both lung bases, particularly in the right. Interval removal of the enteric tube. Large amount of residual contrast layering in the stomach with at least some in the small bowel Cardiology Report ECG Study Date of [**2189-9-8**] 10:19:16 AM Ventricularly paced rhythm at 60 beats per minute with probable underlying atrial fibrillation. Compared to the previous tracing of [**2189-9-3**] the ventricular pacing is new. Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 59 0 128 440/437.72 0 -45 92 ([**-5/4869**]) RADIOLOGY Final Report [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2189-9-16**] 3:43 PM [**Last Name (un) **]-INTESTINAL TUBE PLACEMENT Reason: Please change over a wire and replace NJ tube.*[**Numeric Identifier 111429**] [**Doctor First Name 13291**] [**Hospital 93**] MEDICAL CONDITION: 86 year old man with [**Last Name (un) 1372**]-jejunal tube that is clogged. REASON FOR THIS EXAMINATION: Please change over a wire and replace NJ tube.*[**Numeric Identifier 111429**] [**Doctor First Name 13291**] INDICATIONS: 86-year-old man with clogged nasojejunal tube. TECHNIQUE: Placement of feeding tube under fluoroscopy. FINDINGS: A 14 French [**Doctor First Name 1557**]-[**Location (un) 2174**] nasointestinal feeding tube was passed into the stomach without difficulty, and the existing tube removed. However, attempts to pass the tube beyond the stomach were not successful. A redundant segment was left in the stomach in order to potentially facilitate distal passage. Persistent debris in the fundus of the stomach is noted. IMPRESSION: 1. Placement of feeding tube within the stomach. The tube could not be advanced into the jejunum (the patient is s/p BillrothII) . It could be helpful to acquire an abdominal radiograph in the morning, and if the tube does not spontaneously pass into the jejunum by that time, the patient could be returned to the fluoroscopy suite for repositioning. 2. Persistent debris within the fundus of the stomach. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: [**Doctor First Name **] [**2189-9-17**] 5:06 PM RADIOLOGY Final Report CATHETER, DRAINAGE [**2189-9-17**] 2:32 PM Reason: please place GJ tube tube with G port to vent stomach & J po Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 86M s/p bilroth 2, with delayed gastric emptying & need for feeding tube. REASON FOR THIS EXAMINATION: please place GJ tube tube with G port to vent stomach & J port into efferent jejnual limb for tube feedings... HISTORY: Gastric outlet obstruction in a patient with a Billroth II procedure. Please place GJ tube. TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's anterior abdominal wall was prepped and draped in a sterile fashion. Insufflation of the patient's current NG tube was performed in conjunction with review of a recent CT scan. This demonstrated the gastric remnant to be of decent size and directly below the anterior abdominal wall. Hence, after insufflation, two T-fasteners were placed along the greater curvature of the stomach, after which the Seldinger technique was used to place a 5 French sheath within the gastric remnant lumen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and Kumpe catheter were used to manipulate into the patient's efferent loop. This loop was confirmed both with contrast and passage of a 150-cm wire. The catheter-wire combination were manipulated approximately 100 cm into the efferent limb, after which the wire was exchanged for an Amplatz wire. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12056**]-Coons gastrojejunostomy tube was shortened (regularly 100 cm, shortened to approximately 80 cm) with additional sideholes placed and then advanced into the efferent limb after tract dilatation. The proximal port which is for gastric aspiration, was left within the gastric remnant, the distal port, 80 cm in the efferent limb for tube feeding. The tube was sutured in place with 0-Prolene. As well, it contains a mushroom tip for internal anchoring. IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this patient's gastric remnant, proximal port within the remnant, distal port approximately 80 cm within the efferent limb in this patient who is status post a Billroth II procedure. No complications. DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: TUE [**2189-9-22**] 9:22 AM RADIOLOGY Final Report [**Numeric Identifier 4176**] PERC PLCMT GASTROMY TUBE [**2189-9-17**] 2:32 PM Reason: please place GJ tube tube with G port to vent stomach & J po Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 86M s/p bilroth 2, with delayed gastric emptying & need for feeding tube. REASON FOR THIS EXAMINATION: please place GJ tube tube with G port to vent stomach & J port into efferent jejnual limb for tube feedings... HISTORY: Gastric outlet obstruction in a patient with a Billroth II procedure. Please place GJ tube. TECHNIQUE/FINDINGS: After informed consent was obtained, the patient's anterior abdominal wall was prepped and draped in a sterile fashion. Insufflation of the patient's current NG tube was performed in conjunction with review of a recent CT scan. This demonstrated the gastric remnant to be of decent size and directly below the anterior abdominal wall. Hence, after insufflation, two T-fasteners were placed along the greater curvature of the stomach, after which the Seldinger technique was used to place a 5 French sheath within the gastric remnant lumen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and Kumpe catheter were used to manipulate into the patient's efferent loop. This loop was confirmed both with contrast and passage of a 150-cm wire. The catheter-wire combination were manipulated approximately 100 cm into the efferent limb, after which the wire was exchanged for an Amplatz wire. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12056**]-Coons gastrojejunostomy tube was shortened (regularly 100 cm, shortened to approximately 80 cm) with additional sideholes placed and then advanced into the efferent limb after tract dilatation. The proximal port which is for gastric aspiration, was left within the gastric remnant, the distal port, 80 cm in the efferent limb for tube feeding. The tube was sutured in place with 0-Prolene. As well, it contains a mushroom tip for internal anchoring. IMPRESSION: Placement of a double-lumen gastrojejunostomy tube via this patient's gastric remnant, proximal port within the remnant, distal port approximately 80 cm within the efferent limb in this patient who is status post a Billroth II procedure. No complications. DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: TUE [**2189-9-22**] 9:22 AM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2189-9-22**] 9:26 AM CHEST (PORTABLE AP) Reason: resp distress [**Hospital 93**] MEDICAL CONDITION: 86 year old man with nausea, vomiting, fever. s/p transverse colectomy REASON FOR THIS EXAMINATION: resp distress AP CHEST 9:40 A.M. [**9-22**]. HISTORY: Nausea, vomiting and fever following transverse colectomy. Respiratory distress. IMPRESSION: AP chest compared to [**8-31**] through [**9-21**]: Moderate pulmonary edema best demonstrated in the perihilar left lung has developed since [**9-21**]. There is consolidation in both lower lungs, particularly the right, strongly suggestive of concurrent pneumonia. Accompanying small-to-moderate right pleural effusion could be related to either development. Heart is at least moderately enlarged partially obscured by right-sided consolidation. There is no pneumothorax. Two transvenous right ventricular and one right atrial pacer lead are unchanged in their respective positions originating in the left axillary pacemaker. A right central line probably a PICC can be traced as far as the junction of the brachiocephalic veins. Findings were discussed by telephone with Dr. [**Last Name (STitle) 3446**] at the time of dictation. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2189-9-22**] 9:27 PM Brief Hospital Course: He was admitted to [**Hospital1 18**] on [**2189-8-26**] for nausea and vomitting since recent surgery. He has been unable to take a regular diet since that time. He continued to be nausea. A PICC line was put in and TPN started. He subsequently developed a fever and increased WBC. The PICC was then removed. Blood cultures from [**8-30**] grew Staph form one bottle only. He was started on Vancomycin, but then this was D/C'd on [**9-1**] when other cultures did not reveal any growth. GI: A NGT was placed on [**8-30**]. Very foul smelling output from NG (only 75-100 cc). It was thought that the efferent limb of billroth is twisted due to recent surgery. CT showed oral contrast going down ok. An EGD, down 20-30 cm in efferent limb, showed no stricture or obstruction. A SBFT showed marked esophageal reflux with large column of barium persisting in esophagus to the upper mediastinum (exam performed in near upright position). Regland was started. An EGD on [**2189-9-7**] was performed with dilation, injection, NJ feeding tube placement. He was then started on tube feedings. The tube became clogged and it was then decided to place a GJ tube for nutritional support. His tubefeedings were slowly advanced to goal over the next few days. Geriatrics: [**Female First Name (un) 1634**] was consulted to help manage the care of this 86 year old gentleman. He was depressed and discouraged. He was started back on his home med of Zoloft. Other recommmendations were to D/C Ibuprofen and give Tylenol. Psych: Psych was consulted for his obvious depression and for thought of harming himself. He was switched from Zoloft to Celexa. His mood improved after be able to provide nutrition. Endo: [**Last Name (un) **] was consulted for elevated blood sugars. He needed 15 Units Humalog for a blood sugar on 430 on [**2189-9-4**]. His sliding scale was adjusted and his sugars were in better control. Renal: He was ordered for Lasix 40 mg IV BID for LE edema and pleural effusion. Cardiology: He was noted to have A fib on routine ECG. His pacer was interrogation and shows A fib since early this month. He was on his beta blocker. All cardiac enzymes tested were negative. Musculoskeletal: He complained of joint pain and aches. He was ordered for Tylenol and put back on his Allopurinol and Colchicine. Resp: On [**2189-9-22**], the patient was found by the nurses to be conscious, but not responding. His O2 sats were in the 70's, he was tachypenic, his lungs sounds were wet. It was thought that due to development of pneumonia, his respiratory status was compromised and he most likely aspirated. Secretions were suctioned from his oralpharynx and a NGT was placed to relieve any gastric content. He vommited a small amount of foul smelling brownish gastric contents. He was transfered to the SICU and placed on BIPAP support. He was DNR/DNI and so was not intubated. His family was notified and he was made CMO. He expired on [**2189-9-23**]. Radiology: [**8-27**] Abd Xray - No evidence of obstruction. [**8-27**] Chest Xray - Bilateral pleural effusions [**8-30**] Abd CT - Large right and small-to-moderate left pleural effusions, small amount of free air within the abdomen and subcutaneous tissues adjacent to incision site, likely postoperative sequelae, small amount of fat stranding surrounding anastomotic site, consistent with postoperative sequelae. No focal fluid collection is identified. Contrast is seen passing this site, no evidence of bowel leak or obstruction. [**8-31**] US Lower Ext - No evidence of DVT bilaterally. [**9-1**] Abd X-ray - Contrast remains within the stomach. No evidence of obstruction [**9-2**] Chest Xray - Possible consolidation in both lung bases, particularly in the right. Interval removal of the enteric tube. Large amount of residual contrast layering in the stomach with at least some in the small bowel [**9-6**] CXR - Bilateral loculated effusions, right much larger than left. Medications on Admission: Glipizide 5", Zoloft 100', Atenolol 25', ASA 81mg', Lasix 40', Colchicine 0.6', Doxazosin 4', Glucosamine/chondroitin', [**Last Name (un) **] 400', allopurinol 100' Discharge Disposition: Extended Care Discharge Diagnosis: Delayed Gastric Emptying Discharge Condition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2189-9-24**]

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icd9cm

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198,630

3690

Discharge summary

report

Admission Date: [**2125-2-7**] Discharge Date: [**2125-3-11**] Date of Birth: [**2070-10-2**] Sex: F Service: MEDICINE Allergies: Codeine / Latex Attending:[**First Name3 (LF) 3326**] Chief Complaint: OSH transfer intubated and ventilated Major Surgical or Invasive Procedure: intubation, ventilation History of Present Illness: The pt is a 54 yo female with stage III fibrosis hepatitis C with history of cryoglobulinemia, lymphoma, h/o IVDU including ICU stays for heroin and benzodiazepine overdose, PNA, Candidemia, who was admitted to [**Hospital1 2025**] on [**2-2**] after being found unresponsive in her own vomit. The patient had apparently been using heroin IV along with pills, likely Klonopin and morphine. Her tox screen on admission was positive for opiates, cocaine, benzos, and marijuana. In the field, the patient was hypotensive and hypoglycemic. Her partner found her, but is it unclear how much time had elapsed with her unresponsive before the ambulance was called. . At [**Hospital1 2025**], the patient was intubated secondary to altered mental status. The patient was profoundly hypotensive, requiring norepinephrine to 45 and vasopressin. The likely cause of her hypotension was septic shock; imaging showed a multifocal pneumonia. The patient was started on very broad coverage antibiotics for pneumonia with aspiration, along with micafungin, given a previous history of fungemia. The patient also received stress dose steroids. Within 24 hours, the patient began to turn around, with lower pressor requirements. The patient had been originally placed on ARDSnet protocol. Microbiology was only positive for MSSA on sputum sample. The patient's antibiotics were then tailored to nafcillin/levofloxacin/Flagyl, the course of which will end on [**2125-2-9**]. . The patient has been weaned to Pressure Support with an FiO2 of 40% and a PEEP of 5. Her altered mental status has prevented her extubation. Head CT demonstrated a left tempral gyrus contusion/shear injury of 7mm, representing a likely old concussion. The leading diagnosis for the patient's AMS is a combination of her sepsis and delayed clearance of her sedative drugs. Other contributors may include a recent hypernatremia (to 153), which is thought to be secondary to decreased free water. The patient also has BUN rising to 60s. MRI, EEG, LP have not yet been pursued. . The patient's other issues: a. Daily fevers: The patient has dialy fevers to 101-102, despite resolution of other septic symptoms. CT of chest and abdomen showed multifocal pneumonia, cholelithiasis with stones in CBD and near cystic duct. The patient's total bili is 2.8 and has been trending upward. b. ARF: Creatinine has normalized now. c. Cirrhosis: INR and PTT up. Transaminases have been normal. The patient receives lactulose and puts out good amount of stool to the lactulose. d. Thrombocytopenia, chronic and secondary to liver disease. e. Psychiatric issues: Once AMS recovers, may wish to have Psych see about addiction issues and if patient deliberately overdosed or not. . Past Medical History: history of IVDU depression sialolithiasis fine tremor peripheral neuropathy s/p prolonged ICU stay for heroin and benzodiazepine overdose multi-lobar pneumonia (M. catarrhalis) . Allergies: Codeine Latex . Social History: Social History: Engaged; prior IVDA, per report last use [**2119**], last cocaine [**10-30**]; smoked [**12-24**] ppd x 30 years but trying to quit, on nicotine TD; denies current ETOH use, most recently 2 months ago, when drinks she consumes [**12-24**] glasses of wine. . Family History: Family History: Mother had lymphoma. Otherwise, noncontributory. . Physical Exam: EXAM ON ADMISSION: GEN: intubated, not sedated, not responsive to commands HEENT: PERRL, subconjunctival hemorrhage lateral to [**Doctor First Name 2281**] on left eye, icterus peripherally in both eyes, R IJ in place RESP: Rhonchorous bilaterally CV: S1, S2, systolic murmur heard at left lower sternal border ABD: Distended, +b/s, soft EXT: LE edema 1+, radial/pedal pulses 2+, no stigmata of endocarditis on hands or feet SKIN: no rashes/no splinters, scarring at antecubitum bilaterally NEURO: Grimaces and withdraws to pain. Downgoing plantar reflexes. . EXAM ON DISCHARGE: Patient expired [**3-11**] at 7am Pertinent Results: LABS ON ADMISSION: [**2125-2-7**] 08:46PM BLOOD WBC-6.4# RBC-3.16* Hgb-9.1* Hct-27.9* MCV-89 MCH-28.7 MCHC-32.5 RDW-16.0* Plt Ct-39* [**2125-2-8**] 04:00AM BLOOD PT-23.7* PTT-42.9* INR(PT)-2.3* [**2125-2-7**] 08:46PM BLOOD Glucose-119* UreaN-62* Creat-1.5* Na-153* K-3.0* Cl-117* HCO3-28 AnGap-11 [**2125-2-7**] 08:46PM BLOOD ALT-37 AST-73* LD(LDH)-326* AlkPhos-57 TotBili-2.2* [**2125-2-7**] 08:46PM BLOOD Albumin-2.4* Calcium-8.9 Phos-2.3* Mg-2.7* [**2125-2-7**] 08:46PM BLOOD Ammonia-27 [**2125-2-7**] 09:40PM BLOOD Lactate-1.4 . OTHER RELEVANT LABS: [**2125-2-28**] 04:14AM BLOOD Iron-111 calTIBC-346 Ferritn-522* TRF-266 [**2125-2-10**] 03:29AM BLOOD TSH-0.46 [**2125-2-10**] 03:29AM BLOOD Cortisol-16.5 . MICROBIOLOGY: [**2125-2-11**] 5:04 pm Mini-BAL GRAM STAIN (Final [**2125-2-11**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2125-2-16**]): Commensal Respiratory Flora Absent. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. >100,000 ORGANISMS/ML.. SENSITIVE TO CHLORAMPHENICOL (<=8 MCG/ML), SENSITIVE TO TIMENTIN (16 MCG/ML). CEFTAZIDIME , CHLORAMPHENICOL , AND TIMENTIN sensitivity testing performed by Microscan. SERRATIA MARCESCENS. ~3000/ML. DR.[**First Name (STitle) **], D ([**Numeric Identifier 16672**]) REQUESTED WORK UP ON [**2125-2-14**]. 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. PSEUDOMONAS AERUGINOSA. ~3000/ML. DR. [**First Name (STitle) **], D ([**Numeric Identifier 16672**]) REQUESTED WORK UP ON [**2125-2-14**]. sensitivity testing performed by Microscan. . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | SERRATIA MARCESCENS | | PSEUDOMONAS AERUGINOSA | | | CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- =>16 R <=1 S 4 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S =>2 R GENTAMICIN------------ <=1 S 2 S LEVOFLOXACIN---------- <=1 S MEROPENEM------------- <=0.25 S 4 S PIPERACILLIN/TAZO----- <=4 S <=8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S LEGIONELLA CULTURE (Final [**2125-2-18**]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2125-2-12**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2125-2-27**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2125-2-12**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2125-2-14**]): UNABLE TO RECOVER CYTOMEGALOVIRUS DUE TO THE PRESENCE OF HERPES SIMPLEX VIRUS. HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY. . . IMAGING / STUDIES: From [**Hospital1 2025**]: [**2125-2-6**] CT chest: Multifocal areas of consolidation, including inferior portion of RUL, the RML, and both LLs consistent with massive aspiration or multifocal pneumonia. . [**2125-2-6**] CT abd/pelvis: Cholelithiasis and stones in the cystic duct. Splenomegaly and extensive LAD. . [**2-7**] CT head: Punctate 7-mm hyperdense focus within the left middle temporal gyrus concerning for contusion or shear injury. . . # LIVER AND GALLBLADDER US ([**2125-2-8**] at 1:17 PM): FINDINGS: There are no focal or textural abnormalities in the liver. Ascites and pleural effusion are present as on the prior CT. There is both sludge and stones within the gallbladder which is distended. CBD is seen with max diameter of 9.2 mm, which is not significantly different from the most recent CT. Previously described CBD stones are not seen on the current study. Pancreas is normal in appearance. Imaged portion of the IVC is unremarkable. IMPRESSION: 1. Stable appearance of minimally dilated CBD. 2. Cholelithiasis and sludge with a distended gallbladder. Given the patient's intubated and presumed fasting state this is of uncertain significance and should be correlated with the clinical circumstance. . # CT CHEST W/O CONTRAST ([**2125-2-9**] at 2:30 PM): FINDINGS: The heart is normal in size. There is no mediastinal or hilar lymphadenopathy. A central venous catheter terminates in the lower SVC. An endotracheal tube terminates at the carina. There is no pericardial effusion. Diffuse mild emphysematous changes are noted which are most prominent at the lung apices. There are multifocal areas of ground-glass opacity, peribronchial nodules and a more focal area of consolidation at the right base. Multiple small thin-walled cavities are noted within the right middle lobe and right lower lobes. There is diffuse bronchial wall thickening and secretions are noted within the central airways. There is collapse of the left lower lobe basilar segments with no obstructing endobronchial lesion is identified. A small left pleural effusion is new. The right pleural space is unremarkable. There are no bony lesions suspicious for malignancy. Although the study was not designed for subdiaphragmatic evaluation, images of the upper abdomen demonstrate new intra-abdominal ascites and stable splenomegaly. An NG tube terminates within the stomach. IMPRESSION: 1. Multifocal areas of ground-glass opacification, peribronchial nodules, focal right basilar consolidation and multiple small thin-walled cavities within the right middle and lower lobes. These findings are consistent with multifocal pneumonia. Multiple small, thin-walled cavitary lesions within the right middle and lower lobes could reflect pneumatoceles, thin-walled abscesses or septic emboli. 2. Near-complete collapse of the left lower lobe. No obstructing endobronchial lesion identified. 3. Endotracheal tube terminating at the level of the carina. Recommend pulling the tube back by [**1-25**] centimeters. . # LIVER AND GALLBLADDER US ([**2125-2-12**] at 12:11 PM): FINDINGS: The liver contains no focal mass. Note is made of prominence of the portal triads, creating a 'starry-sky' type of appearance. There is no progressive intrahepatic biliary ductal dilation. The main portal vein is patent with normal hepatopetal flow. The gallbladder is notable for cholelithiasis and sludge layering dependently. Note is made of gallbladder mural thickening, as well as pericholecystic fluid which is of little diagnostic utility in the setting of a small volume of ascites in general. The common bile duct is similar to that seen previously measuring 8 mm. The free portion of the common bile duct measures 11 mm. Previously characterized choledocholithiasis is not definitively seen, though is presumed to still be present. Targeted ultrasound in all four quadrants reveals no large pocket of ascites for blind paracentesis. IMPRESSION: 1. Overall, minimal change with redemonstration of a slightly dilated common bile duct as well as cholelithiasis and sludge within the gallbladder. 2. Hepatic echotexture suggestive of hepatitis 3. Small volume of ascites, insufficient to mark for paracentesis. . . # TTE ([**2125-2-13**] at 10:11:42 AM): The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (but cannot definitively exclude). . . # MRCP ([**2125-2-14**] at 8:49 PM): FINDINGS: There is large ascites, markedly increased from the prior CT and ultrasound studies, which slightly degrades image quality. The liver is normal in size and signal intensity and density with no focal enhancing lesions. The gallbladder is again seen to contain dependently layering sludge and stones. There is no intrahepatic or extrahepatic biliary ductal dilatation. The common bile duct measures up to 7 mm with no focal filling defects to suggest choledocholithiasis. Upper abdominal varices are redemonstrated. The hepatic, portal, superior mesenteric and splenic veins are patent. The hepatic, splenic and superior mesenteric arteries are patent. Upper abdominal lymphadenopathy, including retroperitoneal, is also redemonstrated and unchanged. There is redemonstration of an enlarged spleen, which measures 16 cm in AP dimension. The pancreas, adrenal glands and kidneys are unremarkable. There is no pancreatic ductal dilatation. Visualized loops of bowel are unremarkable. Noted only on the localizer images are a Foley, rectal tube and right hip prosthesis. Trace bilateral pleural effusions and bibasilar atelectasis is noted within the partially imaged lower thorax. The visualized osseous structures are grossly unremarkable. Multiplanar 2D and 3D reformations provided multiple perspectives for this examination (689). IMPRESSION: 1. No evidence of intrahepatic or extrahepatic biliary or pancreatic ductal dilatation. No filling defects within these ducts to suggest choledocholithiasis. 2. Large ascites, markedly increased from recent CT and ultrasound studies. 3. Evidence of portal hypertension, unchanged from prior studies. 4. Gallbladder stones and sludge. . # MR HEAD W & W/O CONTRAST ([**2125-2-15**] at 3:25 PM): FINDINGS: The study is limited due to patient motion-related artifacts. Within these limitations, there is no obvious focus of decreased diffusion to suggest an acute infarct. There is no focus of negative susceptibility. On the axial FLAIR sequence, evaluation for focal lesions is limited due to artifacts. The ventricles and extra-axial CSF spaces are mildly prominent, likely related to mild volume loss. There is diffuse increased signal in the left mastoid air cells from fluid/mucosal thickening/both, and minimal in the right mastoid air cells. Slightly increased signal in the left transverse sinus on the T1 and FLAIR sequences may relate to slow flow. However, this can be better assessed with MRV to exclude thrombosis given the fluid/mucosla thickening in the left mastoid air cells. On the post-contrast images, there is no obvious focus of abnormal enhancement in the brain. IMPRESSION: 1. Study limited due to patient motion-related artifacts. Within these limitations, no obvious acute infarction or mass effect. No focus of abnormal enhancement in the brain parenchyma to suggest a mass lesion. 2. Mucosal thickening, fluid/both, diffusely in the mastoid air cells, left more than right, to correlate with clinical examination. 3. Slightly increased signal in the left transverse sinus on the T1 and FLAIR sequences may relate to slow flow/thrombosis. However, this can be better assessed with MRV without contrast to exclude thrombosis given the fluid/mucosla thickening in the left mastoid air cells and h/o macroglobulinemia per Careweb notes. . # Neurophysiology Report EMG Study ([**2125-2-16**]): FINDINGS: Left median motor nerve conduction study showed moderately prolonged distal latency and severely reduced distal response amplitude. A median motor response from the antecubital fossa was unobtainable, possibly due to edema and insufficient stimulation intensity. F responses were absent. Left ulnar motor nerve conduction study showed normal distal latency, severely reduced response amplitudes, and normal conduction velocities. F responses were absent. Left deep peroneal motor nerve conduction study showed moderately-to-severely prolonged distal latency, severely reduced response amplitudes, and normal conduction velocities. F-response minimum latency was normal. Left tibial motor nerve conduction study showed normal distal latency and mildly reduced response amplitude. A tibial motor response from the popliteal fossa was unobtainable, possibly due to edema. F-response minimum latency was mildly prolonged. Left median sensory nerve response amplitude was mildly-to-moderately reduced and conduction velocity was normal. Left ulnar sensory nerve response amplitude was moderately reduced and conduction velocity was normal. Left radial sensory nerve conduction study was normal. Left sural sensory nerve conduction study was normal. High frequency (50 Hz) repetitive nerve stimulation of the left ulnar nerve recording abductor digiti minimi did not result in an increased motor response amplitude. Concentric needle electromyography (EMG) of the left first dorsal interosseous, deltoid, and extensor digitorum communis showed small amplitude, short duration motor unit potentials, poor activation, and moderate-to-severe active denervation. EMG of the left biceps and abductor pollicis brevis showed no motor unit activity and moderate active denervation. EMG of the left tibialis anterior, gastrocenemius, and vastus lateralis showed no motor unit activity. IMPRESSION: Abnormal, technically difficult study. In this clinical context, the patient's electrophysiologic findings are most consistent with critical illness myopathy; however, other myopathic conditions cannot be definitely excluded. In addition, the poor activation observed on needle electromyography is suggestive of superimposed central dysfunction. . # MR CERVICAL SPINE W/O CONTRAST ([**2125-2-16**] at 10:24 PM): FINDINGS: From C2-3 to T3-4 level, there is no evidence of abnormal signal within the vertebral bodies and discs to indicate discitis or osteomyelitis. No evidence of prevertebral fluid collection or intraspinal fluid collection seen. Mild degenerative disc disease is seen. The T1 and T2 vertebral bodies demonstrate small superior endplate defects anteriorly likely a Schmorl's node with sclerosis. No spinal stenosis or extrinsic spinal cord compression seen. No evidence of intrinsic spinal cord signal abnormalities. IMPRESSION: Cervical spine MRI obtained without contrast demonstrates no evidence of intraspinal or paravertebral fluid collection or abscess. No evidence of spinal cord compression or abnormal signal within the spinal cord. No spinal stenosis. . # MRV HEAD W/O CONTRAST ([**2125-2-16**] at 10:17 PM): FINDINGS: The MRV of the head demonstrates normal flow in the superior sagittal and transverse sinuses best visualized on the source images. The review of the previous MRI of the brain demonstrates no evidence of filling defect on post-gadolinium images. IMPRESSION: Normal MRV of the head. No evidence of dural sinus thrombosis. . # LIVER AND GALLBLADDER US ([**2125-2-27**] at 7:49 AM): Normal liver echotexture without focal liver lesion. No intrahepatic biliary dilatation. Again the common bile duct measures 8 mm, stable and unchanged when compared to prior imaging. No evidence for choledocholithiasis. The main portal vein is patent and demonstrates hepatopetal flow. Trace of perihepatic ascites is noted. The gallbladder is only minimally distended. Some sludge is noted within the gallbladder lumen. There is minimal gallbladder wall thickening with some pericholecystic fluid; however, these findings are expected in the presence of ascites. The pancreas is visualized in the midline; however, the distal body and tail are not seen in their entirety. Spleen measures 17 cm. There is trace of fluid identified in the right and left lower quadrant, which is not large enough for either a diagnostic or therapeutic paracentesis at this time. IMPRESSION: 1. Minimal trace of ascites, not sufficient for diagnostic or therapeutic paracentesis. 2. The main portal vein is patent. 3. No intrahepatic biliary dilatation, stable dilatation of the common bile duct measuring 8 mm with no evidence of choledocholithiasis. 4. Sludge noted within the gallbladder with mild edematous gallbladder wall as expected with ascites. The gallbladder is non-distended. . MCRP [**2125-3-4**]: IMPRESSION: 1. Splenomegaly with multiple peripheral splenic infarcts. These have significantly progressed since previous imaging. 2. No evidence of biliary dilatation. 3. Cirrhosis with established portal hypertension. EEG [**2125-3-6**]: IMPRESSION: This is an abnormal routine EEG due to the presence of a poorly organized mixed theta and delta frequency background which represents a moderate to severe encephalopathy. It is also abnormal due to the presence of occasional left temporal and parietal sharp waves which may represent potentially epileptogenic cortex. There were no clear epileptiform discharges or electrographic seizures noted. Brief Hospital Course: 54-year-old woman with a history of polysubstance abuse, HCV + cirrhosis and lymphoma who was transferred intubated and ventilated from OSH following treatment for septic shock [**1-24**] secondary MSSA pneumonia, passed away on [**3-11**] from liver failure and sepsis. # Sepsis: She was initially admitted to an OSH and had a multifocal MSSA pneumonia. She completed an 8-day course of Nafcillin/Levofloxacin/Metronidazole with reported improvement at the OSH, but presented here with persistent fevers, hypotension, tachycardia, and tachypnea. Her hypotension was secondary to severe sepsis and was intially treated with fluid boluses and pressors which were eventually weaned. She was initially unresponsive to wide spectrum antibiotic coverage with the above regimen of Nafcillin/Levofloxacin/Metronidazole. She was switched to Vancomycin/ Meropenem on [**2125-2-9**]. Mini-BAL respiratory cultures colected on [**2125-2-11**] grew Stenotrophomonas, Serratia marcescens, and Pseudomonas aeruginosa. She was started on Bactrim IV and later switched to an equivalent Bactrim PO dose for coverage of the Stenotrophomonas, which was found to be Bactrim sensitive. Vancomycin and Meropenem were discontinued in favor of Nafcillin, but was later changed to Zosyn and Vancomycin. Her treatment course was planned for 15 days. She had completed her Zosyn, Bactrim and vancomycin courses by [**3-3**]. Her liver function continued to deteriorate (see below) and so liver recommended starting vancomycin and zosyn [**2125-3-7**] in the setting of her continued deterioration from a hepatic stand point, which was done. However, patient did not appear to be infected, was not spiking fevers, but WBC began to trend upwards as pt clinically deteriorated. Patient grew psuedomonas from [**3-6**] sputum Cx, which was reported back with sensitivities on [**3-8**]. Patient had already decompensated severely from a hepatic standpoint, and was therefore made CMO on [**3-9**]. Patient passed away on [**3-11**] from asystole. # Respiratory failure: Initially due to septic shock and multifocal pneumonia with hypoxemia from her pneumonia and some degree of fluid overload from resuscitation. The patient also had persistent tachypnea with respiratory alkalosis. These improved with treatment of her pneumonia and with subsequent diuresis for her fluid overload. She responded well to aggressive diuresis and was extubated on [**2125-2-20**] after passing her SBT. She eventually needed Albumin for intravascular depletion, as is discussed below in ARF section. She had severe weakness that caused her difficulty clearing secretions, but was maintaining her sats in the mid to high 90s on shovel mask. On [**2125-2-23**], she developed bleeding from an unclear location in her nasopharynx or hypopharynx, and required reintubation for airway protection given her difficulty clearing secretions. After discussion with her HCP, a tracheostomy was performed on [**2125-2-26**], which she tolerated well. She was ventilated, but soon passed her SBT and maintained her SpO2 in the high 90s on trach mask. She had speech and swallow come to evaluate her, was tried on a passe-muir valve and did very well, was able to have a full conversation. However, her mental status became significantly worse in the setting of liver failure, and her O2 sats began to drop. She was made CMO on [**3-9**] and passed away on [**3-11**]. # Liver failure: Patient has a history of hepatitis C, and recent abdominal imaging showed ascites, splenomegaly, and varices suggesting significant portal hypertension. On admission, low synthetic function was evidenced by low albumin and elevated INR. Elevated direct bilirubin and AST/ALT were worked up with MRCP, which showed cholecystolithiasis and sludge but no evidence of biliary dilation or inflammation, and thus were attributed to worsening severe end-stage liver disease. Her anemia and thrombocytopenia are likely also due to cirrhosis and hypersplenism. She was followed by the liver team and treated with Lactulose and Rifaximin for possible hepatic encephalopathy. She was given Vitamin K 5 mg PO daily from [**2125-2-23**] to [**2125-2-25**] with some improvement in her INR. She was given another dose of Vitamin K on [**2125-2-28**]. Her platelets continued to trend down, but it was felt that in the setting of her not actively bleeding, it was inappropriate to continue to give her platelet transfusions as her thrombocytopenia stemmed from her liver failure. Her AST and ALT continued to elevate until [**3-2**], when AST reached began to finally trend down after a peak on 665 on [**3-1**], and ALT reached a peak on [**3-3**] of 432. As pt's TBili continued to trend up to a high of 15.2 the day she passed away, and her INR continued to trend up to 7.2 on [**3-7**] (after which she was given FFP and vitamin K), it was felt that her transaminase peak reflected her liver burning out and her synthetic function was continuing to worsen and lag behind. Patient had lactulose increased throughout her liver failure course with no improvement in sx of mental status. She became encephalopathic as her LFTs worsened, and she passed away on [**3-11**] after becoming CMO and going into asystole. # Presumed Pancreatitis: pt??????s lipase and amylase were very elevated on [**2-28**], but lipase trending down, amylase trending up. Dobhoff was in place, and tube feedings started [**2-28**]. Triglycerides were not elevated. When patient was put on Passe-Muir valve, she was able to verbalize only some very mild abdominal pain despite having been on aggressive lasix diuresis and getting tube feedings. Therefore, we controlled her pain with 5mg oxycodone Q4H PRN and continued to monitor her amylase and lipase, which peaked on [**3-7**], and then trended down. # ICU Myopathy: After weaning off her sedation, she was noted to be alert but unable to squeeze her hands or wiggle her feet. There was concern for critical illness myoneuropathy, and EMG was consistent with critical illness myopathy. MRI spine was unconcerning. She slowly began to make progress, with the ability to move her fingers and shake her head while responding to questions after extubation. Her CK was noted to be very elevated on [**2-27**] to 1827, and then trended down afterwards. This was thought to be secondary to muscle damage from ICU myopathy. # AMS: The patient was initially delirious after weaning off sedation. This was thought to be multifactorial with hepatic encephalopathy, sedative drugs, ICU delirium, seizure disorder, and critical illness all contributing. Hepatic encephalopathy was treated as above. MRI head was unrevealing. Seizures were managed as below. # Seizure: Patient had a tonic seizure in early afternoon of [**2125-2-17**], with fixed left gaze and flaccid extremities. She was given Lorazepam 4 mg total, after which the seizure broke. No electrolyte abnormalities were evident. Seen by Neuro and considered to be likely toxic/metabolic (benzodiazepine withdrawal or liver disease) versus new CNS infection (less likely). Of note, her benzos (Midazolam) had been stopped on [**2125-2-14**], and the timing fit with a benzo withdrawal state. Her home Clonazepam 0.5 mg [**Hospital1 **] was restarted. EEG showed "abnormal continuous EEG due to the presence of a disorganized [**5-29**] Hz theta rhythm background with absence of normal sleep architecture. Together these patterns are consistent with a mild to moderate diffuse encephalopathy, commonly seen with medication effect, metabolic disturbance, or infection. There were no electrographic seizures seen." Her Clonazepam was discontinued when sedation was intiated for tracheostomy placement and not restarted afterwards. She then seized again the morning of [**3-6**] with fixed gaze. Broke with ativan 1mg x2. Likely etiologies were benzo withdrawal, meds lowering seizure threshold and electrolyte abnormalities. She did have a CNS contusion on admission. Neuro consulted and determined that the seizure was most likely caused by benzo withdrawal even though patient had not had any benzos since [**2-25**] or by metabolic abnormalities. They put her on keppra 500mg [**Hospital1 **], and she had no further seizures until she passed away on [**3-11**]. # Acute Kidney Injury: Her creatinine was 1.5 on admission with a FENa of 0.44% suggestive of pre-renal failure. Her creatinine improved to 1.0 with hydration and BP support. After resuscitation, she became grossly edematous and tolerated aggressive diuresis initially. She remained edematous and had a bump in her creatinine from 1.0 to 1.3 to 1.7, peaking on [**2125-2-22**]. Given her poor synthetic function and liver failure, she was given Albumin (25%) 50 grams total on [**2125-2-22**] in an attempt to increase oncotic pressure to mobilize edematous fluid. Her creatinine subsequently improved back to 1.0 after several days and remained stable afterwards despite aggressive diuresis with lasix. Medications on Admission: albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler 1-2 puffs by mouth every four (4) to six (6) hours as needed for cough/wheezing alendronate 70 mg Tablet 1 Tablet(s) by mouth q week; take with full glass of water on empty stomach. citalopram 40 mg Tablet 1 Tablet(s) by mouth daily fluticasone 50 mcg Spray, Suspension 2 puffs(s) per nostril once a day x one week, then decrease to one puff per nostril furosemide 20 mg Tablet 2 Tablet(s) by mouth qam and 1 qpm gabapentin 300 mg Capsule 3 Capsule(s) by mouth at bedtime [**2125-1-10**] ibuprofen 600 mg Tablet 1 tablet Tablet(s) by mouth tid to qid as needed for prn pain; take with food omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth once a day spironolactone 25 mg Tablet 1 Tablet(s) by mouth twice a day . Meds on transfer: acetaminophen 650mg PO q6h albuterol MDI 4 puff inh q4h docusate 100mg solution [**Hospital1 **] ipratropium MDI 4 puff inh q4h lactulose 30mL qid levofloxacin 500mg IV q48h metronidazole 500mg IV q8h nafcillin 1500mg IV q4h omeprazole 20mg QD senna 10mL [**Hospital1 **] . . Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: *Patient expired [**3-11**] at 7am* Primary: Sepsis secondary to MSSA + Stenotrophomonas + Serratia Marascens + Psuedomonas pneumonia Liver failure Thrombocytopenia Pancreatitis Acute Kidney Injury ICU Myopathy S/P Seizure Secondary: Hepatitis C Substance Abuse Discharge Condition: *Patient expired at 7am on [**3-11**]* Discharge Instructions: N/A Followup Instructions: N/A

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Discharge summary

report

Admission Date: [**2103-12-9**] Discharge Date: [**2103-12-16**] Date of Birth: [**2057-3-3**] Sex: F Service: SURGERY Allergies: Compazine / Promethazine / Tylox / Demerol Attending:[**First Name3 (LF) 3127**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: Status post livng related kidney transplant History of Present Illness: 46-year-old, Caucasian lady with a long and complicated history. In brief, she has had two prior deceased donor kidney transplants. The first one was in [**2086**] for rapidly progressing glomerulonephritis which was lost due to acute rejection. She had a subsequent transplant in [**2089**] which recently failed and she has been back on hemodialysis for approximately two months via a Perm Cath Past Medical History: -Type A aortic dissection -Colon resection secondary to diverticulitis and colostomy which has been closed -Multiple CVAs with residual right-sided weakness and slurred speech. -She has had numerous skin cancers requiring resection -Bilateral reductive mastectomy, -Osteoporosis, hyperparathyroidism, and hypertension Social History: She has a history of smoking for about 10 years. She smokes approximately one pack per month Physical Exam: General: no acute distress, awake, alert and orient to time person and place HEENT: EOMI, PEERLA, neck supple, clear oropharynx Cardio: RRR LUNGS: CTA b/l Abd: soft, non-tender, positive bowel sounds Pertinent Results: [**2103-12-9**] 09:24PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2103-12-9**] 09:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2103-12-9**] 09:24PM URINE RBC-[**2-24**]* WBC-0 BACTERIA-FEW YEAST-NONE EPI-[**6-1**] [**2103-12-9**] 06:20PM GLUCOSE-102 UREA N-52* CREAT-6.2*# SODIUM-141 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-21* [**2103-12-9**] 06:20PM CALCIUM-9.3 PHOSPHATE-5.6* MAGNESIUM-2.4 [**2103-12-9**] 06:20PM PLT COUNT-261 [**2103-12-9**] 06:20PM WBC-9.6 RBC-5.02 HGB-14.6 HCT-44.6 MCV-89 MCH-29.1 MCHC-32.8 RDW-18.8* [**2103-12-9**] 06:20PM PT-19.0* PTT-30.0 INR(PT)-2.5 Brief Hospital Course: Pt was admitted [**2103-12-9**] for elective living donor kidney tranplant. Procedure was performed by Dr. [**Last Name (STitle) **]. Please see operative note for details. Patient tolerated procedure well and had an uneventful recovery in PACU. Patient was subsequently tranfered to the transplant floor on [**Wardname 13487**]. Her postoperative course went as expect acheiving goals of adequate urine output, good PO intake, out of bed and ambulating with good pain control. On postoperative day 7 discharge plans were discussed with patient after appropiate education for wound care and medication administration was given by nursing staff. After stable postoperative course it was agreed by supervising attending and patient that discharge would take place on the [**2103-12-16**] pending appropiate FK level. Patient was discharged with a Fk level 4.9 up from <1.5 the previuos day. She is d/c with appropiate followup appointment and medication. Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*14 Tablet(s)* Refills:*2* 2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*7 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*7 Tablet(s)* Refills:*2* 8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*14 Tablet(s)* Refills:*0* 9. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO ONCE (once) for 1 doses. 10. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO ONCE (once) for 1 doses. 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. Disp:*25 Capsule(s)* Refills:*0* 13. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) for 2 doses. Discharge Disposition: Home Discharge Diagnosis: ESRD Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 4838**] office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take medication, increased abdominal pain, increased redness, drainage, or bleeding from incision. [**Month (only) 116**] shower No driving while taking pain medication No heavy lifting Followup Instructions: Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-12-20**] 10:10 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-12-26**] 10:00 Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-12-31**] 10:50 Completed by:[**2103-12-17**]

[ "427.1", "401.9", "438.11", "733.00", "V10.83", "V16.3", "V12.79", "585.6", "305.1" ]

icd9cm

[ [ [] ] ]

[ "00.91", "89.60", "55.69" ]

icd9pcs

[ [ [] ] ]

4802, 4808

2190, 3145

307, 353

4857, 4866

1467, 2167

5214, 5687

3168, 4779

4829, 4836

4890, 5191

1246, 1448

263, 269

381, 780

802, 1121

1137, 1231

21,887

185,765

44203+58690

Discharge summary

report+addendum

[**2106-5-14**] Name: [**Known lastname 94830**], [**Known firstname **] Unit No: [**Numeric Identifier 94831**] Admission Date: [**2106-5-9**] Discharge Date: [**2106-5-12**] Date of Birth: [**2032-8-8**] Sex: M Service: OMED CHIEF COMPLAINT: Weakness, nausea, vomiting. HISTORY OF PRESENT ILLNESS: The patient is a 73 year old male with a history of metastatic melanoma admitted with acute renal failure, weakness, encephalopathy and hypotension. The patient originally presented with a left forearm mass and was treated with excision and skin graft status post progression in [**2088**]. He had recurrence in [**2103**], and underwent a left axillary node dissection. After this, he was treated with interferon therapy which was discontinued in [**2105-3-2**] when hepatic and meningeal metastases were discovered. After this, he received [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**First Name4 (NamePattern1) 25368**] [**Last Name (NamePattern1) **]-chemotherapy protocol with two cycles of ...... therapy followed by a cycle of Biotherapy. This was discontinued in [**2105-12-2**], because of progression including involvement of the second portion of the duodenum and spleen. He was subsequently placed on low dose Taxol. Initially, the patient appeared to improve on Taxol gaining weight and strength. However, because of his progression on CT scan, the Taxol was discontinued on [**2106-4-12**]. In addition, the patient's wife states that his health has deteriorated rapidly over the past month. He has lost weight and eats and drinks less than he previously did. He is also no longer able to walk. He has become increasingly somnolent. The patient has not been noticed to be confused and disoriented except occasionally after doses of morphine. The patient was admitted from [**4-29**] until [**2106-5-1**], on the OMED Service with acute renal failure. At that time, a renal ultrasound revealed mild left hydronephrosis. The patient was given intravenous fluids and his creatinine decreased from a peak of 3.4 to a level of 1.8 at discharge. Over the week following discharge, the patient has had continued somnolence and decreased p.o. intake. One day prior to admission, the patient developed nausea, vomiting, and weakness. His family phone in and he was transported to [**Hospital1 69**] Emergency Department where, on arrival, his blood pressure was 68/43. In the Emergency Department, the patient received six liters of normal saline and 4 mg of dexamethasone for resuscitation. His initial labs are significant for a total bicarbonate of 11 with an anion gap of 23, BUN of 52 and creatinine of 2.9. A blood gas at that time revealed a pH of 7.24, pCO2 of 22 and pAO2 of 104. The patient received three ampules of bicarbonate as well as three amps of D5W with a change in his blood gas to 7.28, 29, 80. He also received doses of Ceftriaxone and Levofloxacin. Between the time of arrival to the Emergency Department and transport to the Medical Intensive Care Unit, the patient developed a decreased level of consciousness. He was no longer responding to verbal stimuli. A CT scan of the head was negative for acute intracranial process. PAST MEDICAL HISTORY: 1. Malignant melanoma with metastases to bone, liver, spleen, right kidney, adrenals, duodenum. 2. Chronic renal failure with baseline creatinine of 1.2 to 1.5. 3. Hypertension. 4. Hypercholesterolemia. 5. History of colonic adenomas. 6. Anemia. PAST SURGICAL HISTORY: Status post hernia repair. SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a former engineer and ship designer. He quit smoking in [**2094**]. He reports occasional social alcohol use. MEDICATIONS: 1. Protonix. 2. Promethazine. 3. Colace. 4. MSIR 50 mg q. four to six hours p.r.n. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission to the Medical Intensive Care Unit his temperature was 95.6 F.; heart rate 95; blood pressure 107/56; saturation of 99% on room air. In general, this is an ill appearing white male, somnolent, who opens eyes briefly and responds to verbal or tactile stimuli. HEENT examination: Sclerae anicteric. Pupils round 3 millimeters to 2 millimeters, with light. Oral mucosa was dry. Neck with reduced jugular venous pressure at 20 to 30 degrees. Lungs with decreased breath sounds at the right lung base. Heart is regular rate and rhythm with a normal S1 and S2. III/VI systolic ejection murmur which was diffuse; no rubs. Abdomen soft, nontender, nondistended, with hypoactive bowel sounds. Extremities with no peripheral edema. Neurological: mental status as above. Two plus deep tendon reflexes in triceps, biceps and quadriceps. LABORATORY: On admission, CBC revealed a white count of 12.4 with 75% neutrophils, 0% bands, and 20% lymphocytes. Hematocrit was 36.1 with an MCV of 82. Platelet count was 402. Sodium was 135, potassium 5.3, chloride 102, bicarbonate 12, BUN 48, creatinine 2.3, glucose of 95. The anion gap was 21. Calcium was 10. Magnesium 1.6, phosphorus 6.8. INR was 1.3. Liver function tests were within normal limits except for an elevated alkaline phosphatase at 435, amylase was 76 and lipase was 52. Urinalysis showed a specific gravity of 1.020 with nitrites positive, 3 to 5 white blood cells, moderate bacteria. Renal ultrasound showed a stable left mild hydronephrosis and right lower pole mass. Chest x-ray showed no evidence of heart failure or pneumonia, but was positive for a small right pleural effusion. CT scan of the head showed no hemorrhage, lesions, hydrocephalus. There was a small air fluid level in the left maxillary sinus. HOSPITAL COURSE BY PROBLEMS: 1. HYPOTENSION: The patient's initial hypotension with systolic blood pressure in the 60s on arrival to the Emergency Department, was felt to likely be secondary to hypovolemia given the patient's recent history of decreased p.o. intake, nausea and vomiting. Also, in the differential was sepsis and adrenal insufficiency as well as cardiogenic process including pericardial tamponade. The patient was treated with a aggressive fluid repletion with normal saline, with good response. In addition, a cosyntropin stim test was done which was positive. He was subsequently started on dexamethasone 0.5 mg q. h.s. for adrenal insufficiency which was likely secondary to metastatic disease. Following fluid repletion and improvement in the patient's blood pressure, the patient's renal function improved significantly. His creatinine on the day of discharge is 1.7 which is essentially at his baseline. As previously stated, a repeat renal ultrasound was done which showed stable mild hydronephrosis. A Foley catheter was placed to rule out any contribution of obstruction due to the patient's acute renal failure. 2. METASTATIC MELANOMA: The patient was status post local resection as well as biochemotherapy by the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25368**] protocol. He had most recently been treated with Taxol initially with good response and then with progression of his disease. At this time, per his primary oncologist, there are very limited options for further therapy. A discussion regarding this was held between the attending and the patient on [**2106-5-11**], and the decision was made to move towards comfort care. The patient will therefore be discharged with Hospice home services. 3. ANEMIA: The patient's hematocrit trended down during this admission with a nadir of 23.8. He was transfused with two units of packed red blood cells with an appropriate bump in his hematocrit. 4. URINARY TRACT INFECTION: The patient was started on Levofloxacin for a urinary tract infection and will complete a seven day course as an outpatient. 5. FLUIDS, ELECTROLYTES AND NUTRITION: The patient has very poor p.o. intake during this admission and was continued on intravenous fluids. At this time, given the change in the emphasis of care to comfort measures only, no parenteral or enteral feeding will be initiated. The patient will be discharged with intravenous fluids which he can discontinue at his own discretion. 6. RIGHT PLEURAL EFFUSION: Chest x-ray from [**2106-4-9**], showed bilateral pleural effusions, right greater than left, with associated compressive atelectasis on the right side. The patient maintained good room air saturations throughout this admission and there was no evidence of respiratory compromise. Thoracentesis was not pursued. If the patient becomes hypoxic, the issue of therapeutic thoracentesis will need to be addressed with the family. DISCHARGE DIAGNOSES: 1. Metastatic melanoma. 2. Acute on chronic renal failure. 3. Hypovolemic shock. CONDITION ON DISCHARGE: Fair. DISCHARGE MEDICATIONS: 1. Protonix 40 mg q. day. 2. Tylenol p.r.n. 3. Oxycodone p.r.n. 4. Levofloxacin 250 mg p.o. q. day times three days. 5. Heparin subcutaneously 5000 units three times a day. PLAN: The patient is being discharged to home with Hospice Services. DISCHARGE INSTRUCTIONS: 1. He will follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. 2. He will follow-up with us in Oncology, as needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1736**] Dictated By:[**Name8 (MD) 9130**] MEDQUIST36 D: [**2106-5-12**] 14:57 T: [**2106-5-15**] 20:24 JOB#: [**Job Number 94832**] Name: [**Known lastname 14983**], [**Known firstname 77**] Unit No: [**Numeric Identifier 14984**] Admission Date: [**2106-5-9**] Discharge Date: [**2106-5-12**] Date of Birth: [**2032-8-8**] Sex: M Service: ADDENDUM: Please add to the discharge medications; dexamethasone 0.5 mg p.o. q.h.s. [**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**] Dictated By:[**Name8 (MD) 1451**] MEDQUIST36 D: [**2106-5-12**] 14:58 T: [**2106-5-13**] 07:28 JOB#: [**Job Number 14985**]

[ "198.0", "198.7", "584.9", "197.8", "197.7", "511.9", "276.5", "197.4", "198.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8702, 8787

8843, 9093

9117, 10174

3537, 3565

3913, 8681

276, 305

335, 3237

3259, 3512

3583, 3889

8813, 8820

25,736

137,926

50739

Discharge summary

report

Admission Date: [**2175-7-23**] Discharge Date: [**2175-10-4**] Date of Birth: [**2121-6-11**] Sex: M Service: SURGERY Allergies: Reglan / Heparin Sodium Attending:[**First Name3 (LF) 5547**] Chief Complaint: Transfer from OSH for sepsis, resp failure, and possible ERCP Major Surgical or Invasive Procedure: ERCP - [**2175-7-23**] Exploratory Laparotomy, Low Sigmoid Colectomy, End Colostomy, Feeding Jejunostomy Temporary Dialysis Catheter Tunneled Dialysis Catheter History of Present Illness: Pt is a 55 yo male with PMHx significant ADHD who is being transferred from [**Hospital **] Hospital for emergent ERCP. Pt presented to [**Location (un) **] on [**2175-7-17**] after having one day of lower abdominal pain epigastric pain, mild LUQ pain, nausea, emesis, increased frequency and dysuria. CT scan showed mild sigmoid diverticulitis without perforation or abscess. LFTs were elevated, and he was given IVF. Treated conservatively with unasyn and gentamycin. He also had an echo done which showed an EF of 50-55% but an old septal MI. He left AMA. . Patient returned the 13th with worsening pain, nausea, vomiting, and diarrhea. No hematemesis, hematochezia, melena. Tmax was 105.6 and labs notable for WBC 7.6 (down from 17.6 3 days prior), plt 78, AST 108, ALT 91, alk phos 80, bilirubin 8.8. He was started on zosyn, gentamycin, and cipro initially but the latter was stopped. He was found to be hypotensive and required levophed and neosynephrine. He then developed nonanion gap metabolic acidosis and was intubated for "airway protection". He was started on a fentanyl and xigris gtt d/t APACHE score of 27 (the latter d/c'd early). Repeat CT with mild diverticulitis and gallbladder U/S without GB distension/biliary dilation. Normal HIDA scan with minimal filling of gallbladder after 4mg morphine, but no filling in duodenum. Patient transferred for emergent ERCP d/t suspicion for obstructive process and ?ascending cholangitis. He was also noted to be in DIC. All blood cultures from [**7-17**], [**7-19**], [**7-20**] NGTD, UA negative, CXR without infectious process. Past Medical History: Attention deficit hyperactivity disorder Echo- EF 50-55 % with septal wall hypokinesis Social History: Per family and friends: [**Name (NI) 17923**] Occasional drinker No rec drugs Family History: Unknown Physical Exam: VS: 98.2, 104/73, MAP 80, 70, 96% on 500/22/5/0.5 (7.28/40/47 --> increased to 550/22/10/0.6 Gen: Intubated, sedated HEENT: head symmetric, atraumatic, MMM, icteric slera, Neck: obese, no JVP appreciated CV: RRR, NL s1 and s2, II/VII holosytolic ejection murmur, Lungs: CTAB anteriorly (ventilator course BS) Abd: obese, soft, unable to elicit any response to deep palpation d/t sedation, no HSM, no spiders, no telangiectasias, no palmar erythema Ext: Mild LE edema Neuro: Sedated, unresponsive to commands Pertinent Results: [**2175-7-23**] 06:27PM CORTISOL-96.1* [**2175-7-23**] 07:30PM CORTISOL-102.2* [**2175-7-23**] 08:50PM CORTISOL-101.7* [**2175-7-23**] 06:16PM GLUCOSE-109* UREA N-59* CREAT-4.4* SODIUM-140 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-16* ANION GAP-19 [**2175-7-23**] 06:16PM ALT(SGPT)-354* AST(SGOT)-395* LD(LDH)-387* CK(CPK)-77 ALK PHOS-86 TOT BILI-9.3* [**2175-7-23**] 06:16PM CK-MB-3 cTropnT-0.08* [**2175-7-23**] 06:16PM WBC-18.1* RBC-3.62* HGB-11.0* HCT-32.4* MCV-90 MCH-30.5 MCHC-34.0 RDW-15.3 [**2175-7-23**] 06:16PM PLT COUNT-72* [**2175-7-23**] 06:16PM FIBRINOGE-270 [**2175-7-23**] 03:37PM TYPE-ART TEMP-37.2 RATES-22/3 TIDAL VOL-550 O2-50 PO2-182* PCO2-32* PH-7.32* TOTAL CO2-17* BASE XS--8 -ASSIST/CON INTUBATED-INTUBATED [**2175-7-23**] 03:13PM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.020 [**2175-7-23**] 03:13PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0 LEUK-NEG [**2175-7-23**] 03:13PM URINE RBC-29* WBC-3 BACTERIA-NONE YEAST-NONE EPI-<1 [**2175-7-23**] 03:13PM URINE UNKCAST-3* [**2175-7-23**] 03:13PM URINE AMORPH-MANY . EKG: [**7-20**] - sinus tachy at 103, septal infarct, LAD . Radiology: [**7-20**] Abd CT - Left renal stone without obstruction or hydronephrosis. Probably right renal cyst. Sigmoid colon with marked mucosal thickening and diverticular changes. No evidence of perforation or abscess. . [**7-21**] Abd CT - Small bilateral pleural effusions with associated atelectasis. Minimal free fluid in abdomen. Mild degree of diverticulitis assoicate with the sigmoid colon. Not progressed since prior. No free fluid or air. No abscess. . [**2175-7-22**] RUQ U/S: Small amount of ascites, no gallbladder distension or biliary dilatation. Increase echogenicity of liver, nonspecific. . [**2175-7-22**] CXR: RIJ in SVC. Endotracheal tube above thoracic inlet. No pneumo. Pathy opacification is seen scattered throughout both lungs, more so in medial portion of right lung base. . [**7-21**] CT Head - No hemorrhage. Nml. . [**7-21**] CXR - Prominence of pulmonary vessels. . [**7-27**] CT Head w/o contast: No evidence of hemorrhage, mass effect, or shift of normally midline structures. . [**7-27**] RUQ U/S: FINDINGS: Portal veins are patent and have normal direction of flow. The liver is echogenic consistent with fatty infiltration of the liver. However, other forms of more severe liver disease including cirrhosis/fibrosis cannot be excluded on the basis of this study. . [**7-27**] IMPRESSION: 1. Portal venous air and air within the SMV branches. 2. Bowel wall thickening of right and transverse colon with some pericolic fat stranding in region of cecum. Differential diagnosis includes ischemia and inflammatory/infectious colitis. 3. Sigmoid diverticulosis. Per report, on [**7-21**], the patient had acute diverticulitis. The images are not available for comparison currently but the sigmoid appears normal. 4 Nonobstructing 8-mm left renal stone. 5. Splenomegaly. 6. Patchy bilateral pulmonary opacities consistent with pulmonary edema, but infection should be considered in the proper clinical setting. CT w and w/o contrast of Chest/abd/pelv . [**8-2**] CXR - Even though endotracheal tube has been removed, left lower lobe atelectasis has improved. Overall lung volumes are still small, unchanged. Mild interstitial pulmonary edema persists in the left lower lung, clear elsewhere. Heart size top normal. No pneumothorax. Pleural effusion, if any, is small, in the right chest. Bilateral central venous catheters end in the lower third of the SVC. No pneumothorax. . [**8-3**] RUQ U/S: IMPRESSION: Interval development of left occlusive portal vein thrombosis compared to prior ultrasound on MRI. . [**8-4**] CT abd/pelv w/ contrast: IMPRESSION: 1. Persitent IMV gas and thrombus traced to the sigmoid colon, which is thickened as before. Less thickening in the ascending colon and unchanged in the transverse colon with ascites. This all lis likely from an infectious colitis with breakdown of the sigmoid wall causing a septic IMV and portal vein thrombophlebitis. 2. New nonocclusive portal vein thrombus at the confluence of the splenic vein and superior mesenteric vein with persistent left portal vein thrombus. 3. Unchanged left kidney stone. 4. Subtle approximately 1-cm hyperdensity within the anterior right lobe of the liver that cannot be adequately characterized on this study. Followup MR would provide the best characterization for this lesion if the patient can breath-hold. 5. Right upper pole cystic lesion within the kidney likely representing simple renal cyst. Attention can be focused on this lesion on subsequent evaluation of the liver lesion. Cardiology Report ECHO Study Date of [**2175-8-7**] PATIENT/TEST INFORMATION: Indication: Endocarditis. Height: (in) 71 Weight (lb): 272 BSA (m2): 2.41 m2 BP (mm Hg): 110/520 HR (bpm): 80 Status: Inpatient Date/Time: [**2175-8-7**] at 11:57 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006E044-1:21 Test Location: East Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 4514**] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.5 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: 0.42 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm) Aorta - Ascending: *3.5 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 1.25 Mitral Valve - E Wave Deceleration Time: 242 msec TR Gradient (+ RA = PASP): <= 20 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or vegetation on mitral valve. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. No vegetation/mass on pulmonic valve. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%), without regional wall motion abnormalities. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPESSION: No echocardiographic evidence of endocarditis. Preserved global and regional biventricular systolic function. ABDOMEN (SUPINE ONLY) PORT [**2175-8-10**] 3:32 PM ABDOMEN (SUPINE ONLY) PORT Reason: please eval ngt placement [**Hospital 93**] MEDICAL CONDITION: 54 year old man s/p ngt placement,and advancement REASON FOR THIS EXAMINATION: please eval ngt placement INDICATION: Evaluate NG tube placement. COMPARISONS: No comparisons are available. Partial comparison is made to CT of the abdomen from [**8-4**]. TECHNIQUE: AP single view of the abdomen: Note that the upper portion of the abdomen was not included in this radiograph. There is a rectal tube. The small and large bowel gas patterns are unremarkable. No NG tube could be identified in this examination. Chest x-ray is recommended. Subsequent x-ray performed in the same day earlier demonstrates that the NG tube is in the stomach. IMPRESSION: NG tube is not visualized. Subsequent chest radiograph performed in the same day demonstrates that NG tube is in the stomach. [**Numeric Identifier 23286**] US GUID FOR VAS. ACCESS [**2175-8-10**] 1:53 PM Reason: placed right sided HD IJ cath. [**Hospital 93**] MEDICAL CONDITION: 54 year old man with sepsis, diverticulitis, need HD line placement on right side. PT ON HEPARIN FOR PORTAL CLOT. HEPARIN STOPPED AT 3 PM. Pt needs this access today for HD. REASON FOR THIS EXAMINATION: placed right sided HD IJ cath. PROCEDURE: Emergency right internal jugular approach, temporary hemodialysis catheter placement; ultrasound guided venipuncture. CLINICAL INDICATION: Hemodialysis access required. INFORMED CONSENT: The patient himself was unable to provide informed consent due to his medical condition. No siblings or spouse was available for informed consent. Emergency informed consent was obtained from the patient's primary team. OPERATORS: [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) **], M.D. (fellow). [**First Name8 (NamePattern2) **] [**Name8 (MD) 380**], M.D. (supervising staff). DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the procedure to be performed, the site of the procedure, and appropriate requisition material. Once the above were verified, the patient was positioned in supine fashion on a special procedures table. Low right side of the neck was prepped and draped in usual sterile fashion. Ultrasound was employed to visualize the right internal jugular vein which in turn was noted to be widely patent and freely compressible. The skin overlying the anticipated venipuncture site was then infiltrated with approximately 3 cc of 1% Xylocaine for local anesthesia. Utilizing realtime son[**Name (NI) 493**] imaging and a micropuncture access set, uneventful one wall venipuncture below right internal jugular vein was achieved. Utilizing the 4 French catheter at the micropuncture access set, a 0.035 inch 3 mm GA guidewire was advanced under fluoroscopic visualization to the inferior vena cava. The venipuncture track was then serially dilated. A 16 cm long, [**Name (NI) 105557**] [**Last Name (un) **] dual-lumen hemodialysis catheter was delivered over the guidewire and positioned at the superior vena caval-right atrial junction using fluoroscopic guidance. Once satisfactory position was confirmed, the catheter was secured at its retention hub with two, 0 silk retention sutures. The catheter and the puncture site were then overlaid with a Tegaderm patch. No residual bleeding or hematoma was encountered. No pneumothorax was noted. Postprocedural chest x-ray depicted good positioning of the catheter and no kinks along its course. NOTE: Hard copy son[**Name (NI) 493**] images both prior to and after the venipuncture and placement of the catheter were obtained and are recorded which document vessel patency. MEDICATIONS: No additional medications administered. COMPLICATIONS: None immediately. ESTIMATED BLOOD LOSS: Minimal. IMPRESSION: Status post successful placement of 16 cm long, dual-lumen [**First Name9 (NamePattern2) 105557**] [**Last Name (un) **] catheter by right internal jugular approach. Final tip position is at the superior vena caval-right atrial junction. Catheter is ready to employ. RADIOLOGY Final Report CT ABDOMEN W/CONTRAST [**2175-8-11**] 5:33 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: acute process [**Hospital 93**] MEDICAL CONDITION: 54 year old man ARF and sepsis of unclear etiology, h/o diverticulitis and previous CT here with transverse and right sided colonic thickening, now with GNR sepsis and fever. REASON FOR THIS EXAMINATION: acute process CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Acute renal failure and sepsis of unclear etiology, gram-negative sepsis and fever. COMPARISON: [**2175-8-4**]. TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and pelvis with multiplanar reformats was reviewed. CT ABDOMEN WITH CONTRAST: Small right pleural effusion has enlarged in the interval. The lung bases are otherwise only remarkable for a tiny ill-defined patchy opacity at the bases that are unchanged and could represent small areas of focal atelectasis versus pulmonary edema. NG tube is present in the stomach. The visualized portions of the heart are unremarkable. The liver enhances homogeneously. The gallbladder appears normal. There are tiny foci of gas in the portal vein, but overall, gas has nearly resolved from the IMV and portal vein. There has been, however, marked progression of portal venous clot previously located at the splenoportal confluence. The pancreas is unchanged. The spleen has increased in size, today measuring 20 cm. The adrenal glands and kidneys are unchanged, with note of a nonobstructing 7 mm left lower pole stone and 2 cm right lower pole cyst. Multiple mesenteric and retroperitoneal nodes are present, none pathologic. There is a small amount of ascites, unchanged. CT PELVIS WITH CONTRAST: There is mild thickening of the sigmoid colon, unchanged. Note of a rectal tube. There is a small amount of ascites in the pelvis. Small bowel loops are normal in caliber. Distal ureters and bladder appear normal. BONE WINDOWS: Degenerative disease is present throughout the osseous structures, but there is no evidence for suspicious lesions. IMPRESSION: 1. Progression of main portal vein clot with increase in the size of the spleen. 2. Inferior mesenteric and portal venous gas has nearly completely resolved with only small foci of residual gas. 2. Enlarging small right pleural effusion. 3. Unchanged thickening of the sigmoid colon that could be infectious in nature as previously described. CHEST (PORTABLE AP) [**2175-8-14**] 3:04 AM CHEST (PORTABLE AP) Reason: ?interval change [**Hospital 93**] MEDICAL CONDITION: 54 yo male with complicated diverticulitis now acute tachypnic REASON FOR THIS EXAMINATION: ?interval change SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Evaluate interval changes in 51-year-old male with complicated diverticulitis and early CHF. Comparison is made with multiple prior studies, most recent one dated [**2175-8-12**]. FINDINGS: Mild CHF has improved. Persistent opacity in the right lower lobe is consistent with aspiration/aspiration pneumonia. There is no pneumothorax or pleural effusion. Cardiomediastinal contour is unremarkable. Right internal jugular sheath and left subclavian central venous line tip in standard positions, unchanged. There is no pneumothorax or pleural effusion. NG tube with tip not included on the film passing the stomach. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 105558**],[**Known firstname 275**] [**2121-6-11**] 54 Male [**-6/3093**] [**Numeric Identifier 105559**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. SAMEDI/dif SPECIMEN SUBMITTED: RECTUM, SIGMOID COLON (1). Procedure date Tissue received Report Date Diagnosed by [**2175-8-14**] [**2175-8-14**] [**2175-8-19**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/tk?????? DIAGNOSIS: Segmental resection of colon (sigmoid): Diverticular disease, with rupture of diverticula associated with pericolic and serosal acute inflammation, abscess formation, extravasation of fecal material, granulation tissue, organizing fat necrosis, and fibrosis. The colonic mucosa between and within diverticula shows evidence of healed mucosal injury (crypt architectural distortion; villiform surface change). This finding may represent the chronic colitis of diverticular disease or, by exclusion of other causes, inflammatory bowel disease. Five pericolic lymph nodes: Reactive changes. Resection margins: No diagnostic abnormalities recognized. C1750 CATH,HEMO/PERTI DIALYSIS LONG TERM [**2175-8-24**] 5:15 PM Reason: Needs tunneled cath placement for dialysis. **Please place [**Hospital 93**] MEDICAL CONDITION: 54 year old man on dialysis. REASON FOR THIS EXAMINATION: Needs tunneled cath placement for dialysis. **Please place on Right arm.** INDICATION FOR EXAM: 54-year-old male with acute renal failure that has a temporary dialysis catheter placed, that needs to converted to a tunneled dialysis catheter. CONSENT: Informed consent was obtained from the patient. RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 15785**] and [**Name5 (PTitle) 380**], the attending radiologist who was present and supervising throughout the procedure. PROCEDURE AND FINDINGS: The patient's right neck and chest and indwelling catheter were prepped and draped in standard sterile fashion. After release of the sutures on the indwelling catheter, a tunneled tract was created for placement of the dialysis catheter, with subcutaneous injection of 10 cc of 1% lidocaine. The hemodialysis catheter was then attached to a tunnel device and advanced through the tunnel tract, exiting at the site of the right internal jugular vein puncture. A 0.035 [**Doctor Last Name **] wire was advanced into the inferior vena via the lumen of the indwelling catheter in place under ultrasonographic guidance. The catheter was then removed and a 14.5 French sheath was then advanced over the wire. The wire and the inner dilator were then exchanged for the hemodialysis catheter. A final chest x-ray was obtained demonstrating the tip of the catheter to be at the junction of the right atrium and inferior vena cava. The line was flushed. The catheter was secured with 0 silk sutures. The puncture site to the internal jugular vein was then closed with Dermabond. The dialysis catheter measures 19 cm, tip to cuff. IMPRESSION: Successful exchange of a right IJ temporary dialysis catheter for a tunneled dialysis catheter. PORTABLE ABDOMEN [**2175-8-28**] 8:26 AM PORTABLE ABDOMEN Reason: Ileus vs. Ascites [**Hospital 93**] MEDICAL CONDITION: 54 year old man s/p colostomy with distended abdomen REASON FOR THIS EXAMINATION: Ileus vs. Ascites INDICATION: Colostomy with distended abdomen, ileus versus ascites. COMPARISON: [**2175-8-10**]. FINDINGS: There is a paucity of air within the small bowel loops. Air is present within a normal caliber transverse and left colon. Air fluid levels cannot be determined given supine only projection. Abdominal skin staples are present. Note is again made of a 7mm calcification within the left kidney, unchanged from [**2175-8-10**]. IMPRESSION: Paucity of air within small bowel loops but no dilated loops identified. Cardiology Report ECG Study Date of [**2175-9-1**] 7:21:56 AM Sinus tachycardia with ventricular premature beats. Leftward axis. Anteroseptal myocardial infarction - age undetermined. Compared to the previous tracing of [**2175-8-8**] the rawte is slightly slower. Otherwise, no significant change. Read by: [**Last Name (LF) 474**],[**First Name3 (LF) 475**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 104 172 98 344/404.57 60 -23 56 LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2175-9-6**] 4:13 PM LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC Reason: please eval for clot progression, gallbladder pathology [**Hospital 93**] MEDICAL CONDITION: 54 year old man with known portal vein clot, now w/ RUQ pain REASON FOR THIS EXAMINATION: please eval for clot progression, gallbladder pathology INDICATION: 54-year-old male with known portal vein thrombosis, now with right upper quadrant pain. COMPARISON: CT abdomen and pelvis [**2175-8-11**], and liver ultrasound [**2175-8-3**]. FINDINGS: Again demonstrated is complete occlusion of the left portal vein. Intraluminal echogenic material consistent with thrombus is noted within the main portal vein, as well as anterior and posterior right portal vein branches. These vessels remain patent on Doppler evaluation; however, there is lack of wall-to-wall blood flow consistent with partial thrombosis. Within the main portal vein, intraluminal echogenic material occupies approximately 50% of the diameter. Assessment of the splenic vein was not possible due to the patient's request to prematurely terminate the study. There is no intra- or extra-hepatic biliary ductal dilatation. No focal hepatic lesion is identified. The gallbladder is contracted. The spleen is similar in size to CT of [**2175-8-11**], measuring approximately 19 cm. There is now a moderate amount of ascites in the lower quadrants, which has significantly increased from [**2175-8-11**]. IMPRESSION: 1. Persistent complete occlusion of the left portal vein and interval progression of non-occlusive thrombus within the main portal vein and right portal vein branches. 2. Contracted gallbladder. 3. Interval increase in ascites, which is now moderate. The results of this study were immediately discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of the surgical team taking care of the patient, at 5 p.m. on [**2175-9-6**]. CT ABDOMEN W/O CONTRAST [**2175-9-28**] 1:44 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: Obstruction / ThrombusNO IV Contrast - Renal Failure Field of view: 46 [**Hospital 93**] MEDICAL CONDITION: 54 year old man ARF and sepsis of unclear etiology, h/o diverticulitis and previous CT here with transverse and right sided colonic thickening, now with persistent nausea and vomitting REASON FOR THIS EXAMINATION: Obstruction / ThrombusNO IV Contrast - Renal Failure CONTRAINDICATIONS for IV CONTRAST: Renal Failure INDICATION: 54-year-old man with ARF and sepsis of unclear etiology, history of diverticulitis and previous CT with transverse and right-sided colonic thickening now with persistent nausea and vomiting. Question obstructions. COMPARISON: CT abdomen and pelvis [**2175-8-11**]. TECHNIQUE: Axial images of the abdomen and pelvis were obtained without IV contrast. Coronally and sagittally reformatted images are available. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases reveal bilateral pleural effusions which are increased compared to the previous study most significantly on the left. Compression atelectasis is noted bilaterally as well. The visualized portions of the heart and pericardium are unremarkable. Non-contrast evaluation of the liver reveals no abnormalities. Splenomegaly is again seen with the spleen measuring approximately 18 cm. The gallbladder, pancreas, adrenal glands, are unremarkable. The right kidney demonstrates a stable low attenuation cystic lesion near the lower pole likely representing a simple renal cyst measuring approximately 2.3 cm. The left kidney demonstrates a 7 mm non-obstructing stone near the lower pole. Scattered intra-abdominal lymph nodes are identified which appear stable compared to the previous study and which seemed to meet pathologic criteria for enlargement. Ascites is again noted and appears stable compared to the previous study. Note is made of a persistent fluid collection in the left colic gutter which demonstrates attenuation characteristics most consistent with a simple fluid collection, however, further evaluation is difficult without contrast. No free air is identified. The patient is status post sigmoid colectomy with formation of a diverting colostomy. The remaining large bowel appears unremarkable. Intra-abdominal small bowel also appears unremarkable and no evidence of obstruction is identified. Without contrast it is difficult to make any comment about the previously identified portal vein clot. CT of THE PELVIS WITH IV CONTRAST: The rectal stump is unremarkable. The prostate demonstrates calcifications within. The seminal vesicles and bladder are unremarkable. No pathologically enlarged pelvic lymph nodes are identified. Osseous structures again reveal degenerative changes without any suspicious lesions identified. Coronal and sagittal reformations support the above findings. IMPRESSION: 1) This patient is status post sigmoid colectomy with diverting colostomy. No evidence of obstruction is identified. 2) Bilateral pleural effusions increased since [**Month (only) 216**] most significantly on the left. 3) Ascites approximately stable compared to the previous study. Persistent fluid collection in the left colic gutter with attenuation characteristics most consistent with a simple fluid collection, however, further characterization is difficult without IV contrast. 4) 7 mm left kidney non-obstructing calculus unchanged compared to the previous study C1750 CATH,HEMO/PERTI DIALYSIS LONG TERM [**2175-9-29**] 1:34 PM Reason: Please exchange over wire HD catheter. [**Hospital 93**] MEDICAL CONDITION: 54 year old man with non-functioning HD catheter REASON FOR THIS EXAMINATION: Please exchange over wire HD catheter. DIALYSIS CATHETER CHANGE INDICATION: 54-year-old man with nonfunctioning hemodialysis catheter. Details of the procedure and possible complications were explained to the patient and informed consent was obtained. RADIOLOGIST: Dr. [**Last Name (STitle) 380**] was performing the procedure. TECHNIQUE: Using sterile technique and local anesthesia, two Amplatz wires were advanced through the ports of the catheter and positioned in the IVC under fluoroscopic guidance. The catheter was then removed and a new 14- French tunneled dialysis catheter placed over the wire with its tip positioned in the right atrium under fluoroscopic guidance. Position of the catheter was confirmed by chest x-ray in one view. Guidewires were then removed. The catheter was secured to the skin. A sterile dressing was applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated fluoroscopically guided exchange of a right IJ tunneled dialysis catheter for a new tunneled catheter. Brief Hospital Course: Pt is a 54 year old male with ADHD who presents on transfer from OSH with multiorgan failure and sepsis likely secondary to diverticulitis . # Fever - - Abd CT suggestive of pylephlebitis, probably secondary to h/o sigmoid diverticulitis; no surgical intervention initially until he was stable. - RUQ U/S with L portal vein thrombosis, air seen in previous abd ct. - Cx now with GNR, on Gent/Meropenem for better gram negative/bacteriacidal coverage. - Cx [**8-2**] growing yeast in [**1-11**] bottles; will treat with AmBisome, understanding implications for kidneys which are already in failure. Will change anti-fungal pending CX sensitivities. - long ABX course, c. Diff [**7-2**] negative; repeat c. Diff [**7-4**] negative. - Possible biliary source given increased Bili and alk Phos, repeat Bili and alk Phos trending down. unclear relationship between PVT and increased LFT's. Possible septic emboli to sinusoidal cavities, leading to transient cholestatic picture. He continued to have intermittent fevers and had blood cultures positive for gram-negative rods as well as gram-positive cocci. Several line changes have ensued, however he has continued to remain febrile with shaking chills and rigors. #Surgery Given the fact that the patient is febrile and has reached clinical stability with near-normal liver function tests, he next went to the OR on [**2175-8-14**] for resection of the sigmoid colon and the mesocolic abscess in order to stem the ongoing sepsis from this intraabdominal abscess. #Ostomy He had a creation of a sigmoid colostomy. Pouch is on and intact, stoma is black thru the pouch. Ostomy supplies were ordered and pouch changes were done on a regular schedule. On [**2175-9-28**] a routine change was performed. Nursing staff changed Mr. [**Known lastname 105560**] pouch today, patient has decline to assist in self-ostomy care, and at this time is not receptive to learning. Stoma continues to be retracted and unable to see mucosa. Skin opening for stoma is very small. Effluent is liquid brown. Pouching system ConvaTec Surfit system with 2 [**1-11**] inch flange with [**Last Name (un) **] seal. #ID - He was started on Zosyn, Gentamycin, and Cipro initially but the later was stopped. He was found to by hypotensive and required Levophed and Neo-Synephrine. He then developed nonanion gap metabolic acidosis and was intubated for "airway protection". He was started on a fentanyl and xigris gtt d/t APACHE score of 27 (the later d/c'd early). Repeat CT with mild diverticulitis and gallbladder U/S without GB distension/biliary dilation. Normal HIDA scan with minimal filling of gallbladder after 4mg morphine, but no filling in duodenum. He was also noted to be in DIC. All blood cultures from [**7-17**], [**7-19**], 7/13 [**7-21**] were negative, UA negative, CXR without infectious process. He was able to be weaned off pressors and extubated on [**7-26**]. He still remains febrile. We are doing an exhaustive work up to identify the source of his sepsis. Initially, we considered the rise in his LFT's to be due to shock liver - however - they still remain elevated (ALT of 121, AST 157, Alk Phos 233, T Bili 7.3) - he also had a RUQ U/S on [**8-3**] that showed LPV thrombosis. Surgery was consulted - felt not to be a surgical intervention until he was stable- he was started on IV heparin on [**2175-8-3**]. He also has ongoing anemia and a very elevated WBC (up to 24.1 today) - only new micro data is from BCX drawn from the HD line on [**8-3**] showing 1 bottle (anaerobic) with Gram neg rods. He was covered for a while on Vanco/Zosyn/Doxy. Vanco DC'ed on [**7-28**] secondary to large rash. Babesia seen at OSH (although very low parasite count) - not seen here.We stated empiric TX for babesia - Clinda/quinine - but d/D/C'd after 5 days because we didn't think this is what it was. He came off of all ABX briefly - then in the setting of the LPV thrombus - he went back on Zosyn and Vanco. He had become hypotensive - concern is diverticulitis has seeded a septic thrombus that is now in his PV system. Repeat ABD Ct showed: Persistent IMV gas and thrombus traced to the sigmoid colon, which is thickened as before. Less thickening in the ascending colon and unchanged in the transverse colon with ascites. This all is likely from an infectious colitis with breakdown of the sigmoid wall causing a septic IMV and portal vein thrombophlebitis. New nonocclusive portal vein thrombus at the confluence of the splenic vein and superior mesenteric vein with persistent left portal vein thrombus. He is on broad spectrum ABX and heparin. In terms of culture data: 1 out of 4 BCX grew out yeast on [**8-2**] started on AmBisome then 1 out of 4 Bc from [**8-3**] grew out Enterobacter- [**Last Name (un) 36**] to [**Last Name (un) **] and Gent - which he is now on. Also - swab from wound on right thigh on [**7-30**] was Pos for HSV2 - so now on acyclovir (needs 10 days of TX). He is on multiple antibiotics for polymicrobial sepsis and will likely need to be on them for 4-6 weeks to treat for endovascular infection (infected portal vein clot). He is on Vanc for enterococcus bacteremia and COAG neg staph in blood. On Cipro and Flagyl for anaerobes, gram negatives / bacteroides fragilis bacteremia . On Fluco for HX candidemia. He has recently developed mild maculopapular rash on abdomen/ thighs which may be due to ABX. Also with lowish platelet count. HIT Ab negative. For now we are holding course but may need to alter ABX if rash worsens. After several weeks of antibiotics, these were D/C'd on [**2175-9-25**]. . # ARF - ATN, likely d/t prerenal etiology in setting of sepsis in addition to being dosed with gent and mult IV contrast exposures. Also with evidence of renal stone, but per U/S, no evidence of hydronephrosis or obstruction. TTP/HUS unlikely per heme. On [**2175-8-24**] he received a tunneled catheter for ongoing dialysis. He was being followed closely by the Renal service and getting dialysis 3 days/week (Mon., Wed., Fri.). - renally dosed meds. (his Vancomycin level was monitored and dosed when <20). - Follow serum/urine lytes - Will give liquid form of phosphate binders. Creatinine has actually been improving lately. A 60-h Creatinine est's GFR to be 14 cc/min. He will need continued dialysis for creatinine >3.4 and will need to follow with the Renal Service for placement of an A/V fistula. . # Mental Status - Probably a combination of uremic/hepatic encephalopathy in the setting of sepsis. Given lack of obvious infectious source, some central infection may be a possibility. - Stable. relatively oriented and passed a speech/swallow evaluation. - Neurologic exam improving with dialysis. - No LP for now as MS improving - He is A+O x 3. At times can be rude with nurses. He is not motivated to perform Ostomy care. . # Thrombocytopenia - [**Month (only) 116**] have been due to DIC, although there was clumping so the low platelets may have been spurious. Either way, platelet count is stable now. He was switched from Heparin and anticoagulated with Argatroban and bridged to Coumadin. He is currently therapeutic on his Coumadin. . # Anemia - [**Month (only) 116**] be secondary to sepsis and frequent blood draws. Has fallen to 21.3 over stay. Currently stable. No evidence of acute hemolysis or exsanguination at this time. Based on Heme/Onc review of the smear and lab data, it is possible that the patient had low grade DIC initially with an elevated fibrinogen (Acute phase reaction) and FDP in the setting of sepsis, however, we do not feel this is a persistent process as his platelets are improving and his fibrinogen has remained within normal limits. #Ophthalmology: Given h/o fungemia, ophtho consulted to rule out endophthalmitis. Exam positive for 3 flat white spots on L eye, ? cotton wool vs. ophthalmitis. - Ophtho: no candidal infection at this time. Issue stable . # F/E/N - Passed speech/swallow study. He was on tube feedings of Nepro full strength and was taking minimal PO's. A calorie count revealed inadequate PO nutrition. He continued tubefeedings for several weeks, while encouraging PO's. He was having bouts of nausea and emesis. On [**9-21**], an ABD x-ray did not reveal any obstruction. His tubefeedings were held until the nausea subsided. On [**2175-9-25**], tubefeedings were stopped. Calories counts from [**9-25**] to [**9-29**] showed PO intake to be inadequate. Roughly 1100 to 1200 kcal/day and 40 to 50 grams of protein/day. Tube feedings were restarted and cycled at night. He continued to have a small amount of daily emesis in the AM. There was no clear etiology as to why this was happening and all CT scan were negative for obstruction or blockage. - We follow lytes and repleted them PRN. . # Access: New tunneled HD catheter ([**8-24**]) and PICC. New tunneled line place on [**2175-9-29**]. . # Contact: [**Name (NI) **] HCP. Sister: [**Name (NI) **] [**Name (NI) 105561**] [**Telephone/Fax (1) 105562**] c [**Telephone/Fax (1) 105563**]. [**Name (NI) 1439**] [**Name (NI) **] (friends). Spoke with family [**7-29**] about pt's current status. . # Prophylaxis: PPI, pneumoboots . # Code Status: Full Code Medications on Admission: Ritalin Discharge Medications: 1. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): See sliding scale. 2. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Given at Dialysis! 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 1-2 MLs PO Q3-4H (Every 3 to 4 Hours) as needed. 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO MONDAY AND WEDNESDAY AND FRIDAY (): Monitor INR. 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO TUESDAY, THURSDAY, SATURDAY, SUNDAY (): Monitor INR. 9. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**1-9**] Injection Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital 38**] Hospital Discharge Diagnosis: Sigmoid Diverticulitits with Diverticular Abscess Renal Failure Discharge Condition: Good. Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Other symptoms concerning to you Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**] Date/Time:[**2175-10-17**] 1:45 Please follow-up with the Renal Service in 2 weeks. Call ([**Telephone/Fax (1) 26815**] to schedule an appointment. You will need an A/V Fistula in the future. Completed by:[**2175-10-4**]

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icd9cm

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icd9pcs

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6,612

167,163

8813

Discharge summary

report

Admission Date: [**2117-5-14**] Discharge Date: [**2117-5-17**] Date of Birth: [**2050-4-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfur / Codeine / Vicodin / Oxycodone Attending:[**First Name3 (LF) 5368**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 67 yo F with a h/o asthma who p/w "an asthma attack" to the ER. The patient was feeling in her usual state of health until last night when she felt the sudden onset of wheezing, SOB, and chest tightness. She gave herself a nebulizer treatment and her symptoms resolved and she was able to sleep through the night. This morning, the patient was in the car on the way to see her PCP (Dr. [**Last Name (STitle) **] when she had the sudden onset of chest tightness and wheezing not responsive to MDI's. She called EMS and was transported to the [**Hospital1 18**] ER. . On initial ROS, the patient denied radiating chest pain, abdominal pain, urinary sypmtoms. She had left calf pain (chronic and unchanged). In the ER, the patient was treated with continous albuterol/combivent nebullizer treatments, given a dose of solumedrol 125mg IV x 1. She was started on a heparin drip because of concern for PE, but this was stopped when the CTA was read as negative. Her peak flow was originally 250 in the ER (after neb treatments), and she was admitted to ICU for frequent nebs. Past Medical History: 1) DVT/PE: history of 6 DVTs, first during pregnancy, 1 PE, all were treated in [**Male First Name (un) 1056**] with Coumadin x 2 weeks. Treated with coumadin for ?PE on admission in [**3-22**] (CTA unable to see RLL). Sent home on coumadin 5mg QHS (to complete 6 month course) 2) [**Doctor Last Name 30762**] syndrome: on cortisone 25mg QD for life 3) Asthma: fair control, followed by Dr. [**Last Name (STitle) **] of Pulmonology, PFTs with restrictive defect; optimal peak flow is 350. Did not have asthma as child. 1st symptoms 20+ years ago. 4) Hypothyroidism: on levothyroxine 5) Hiatal hernia 6) Hypertension 7) Diastolic CHF Social History: Lives alone in apartment, daughter lives nearby, denies tobacco, EtOH, and drugs Family History: no DVT/PE, mother with DM2 and breast cancer Physical Exam: Vitals - 137/66 HR 97 O293%2L RR22 Peak Flow 370 (350 baseline) General - hispanic female, sitting up in bed, NAD, breathing comfortably, not using accessory muscles to breath HEENT - sclerae anicteric, moist MM, OP clear Neck - supple, difficult to assess JVP, no carotid bruits Lungs - fair air movement, crackles all the way up the lungs; scattered expiratory wheezes Heart- RRR, 2-3/6 SEM at LUSB, nl S1/S2 Abd- obese, NABS, ND, soft, NT Ext- trace pitting edema b/l, + L calf tenderness, L knee with surgical scars Pertinent Results: Micro: End of [**Month (only) 958**] AFB Smears neg x 3 Imaging: [**2117-5-14**] CXR - No radiographic evidence of acute cardiopulmonary process [**2117-5-14**] CTA - No evidence for pulmonary embolism. [**2117-5-6**] LLE U/S - No evidence of left lower extremity DVT [**2117-4-10**] LLE U/S - Proximal left DVT EKG - NSR@96bmp, normal axis, no ST segment changes Brief Hospital Course: Patient is a 67 year old woman with history of DVT/PE, asthma, who presented with chest tightness and shortness of breath c/w an asthma exacerbation. . SOB: The patient has a significant h/o asthma and pt's SOB was responsive to steroid and neb tx c/w asthma exacerbation. She was admitted overnight in ICU for continuous nebs, and then was c/o to floor. She does have a known h/o mild hemoptysis, with a negative AFB w/u during prior admission. She notes a h/o orthopnea and had some hypoxia and rhales on exam. Given her h/o diastolic CHF, she was given a small amount of diuresis with some improvement in her hypoxia. Her pro-BNP, however, was normal. . Her peak flows improved after several days to the low 300's, and it was decided that she should be placed on a slow taper of Prednisone and continue inhalers. She was thought to benefit from outpatient pulmonary rehab, which was arranged. She will also follow-up with Dr [**Last Name (STitle) **] from Pulmonology as well. A consideration was made of a vasculitic process given her h/o sinusitis, hemoptysis, eosinophilia, and frequent asthma exacerbations. She will have a work-up inclusing and ANCA as an outpatient with Dr [**Last Name (STitle) **]. . DVT: The patient reports that she has been compliant with her coumadin, but her INR was only 1.1 on admission. She was started on lovenox to bridge her to a therapeutic INR with coumadin. Her coumadin was increased to 7.5mg QD. She has a f/u appt with Dr [**Last Name (STitle) **] 3 days after discharge where her INR will be checked, and may d/c Lovenoz at that time. Medications on Admission: - Advair 500, [**Hospital1 **] - Singulair 10 mg, qhs - Flonase 2 inh, e/n, [**Hospital1 **] - [**Doctor First Name **] 180 mg, qam - Losartan 100mg qd - levothyroxine 100mcg qd - Bupropion SR 150mg qd - Cortisone 25mg [**Hospital1 **] - Neurontin 600mg qhs - Fexofenadine 180mg qd - Ambien 10mg qhs prn - Coumadin 5mg QHS Discharge Medications: 1. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*14 Tablet(s)* Refills:*0* 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QD (). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 9. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Flonase 50 mcg/Actuation Aerosol, Spray Sig: Two (2) puffs Nasal twice a day. 11. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). Disp:*28 syringes* Refills:*0* 12. Prednisone 10 mg tabs, 4 tabs QD [**Date range (1) 30765**], 3 tabs QD from [**Date range (1) 30766**], then 2 tabs daily Dispense: # 45 (forty five) Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Asthma Exacerbation History of DVT and PE [**Doctor Last Name 30762**] Syndrome Hypothyroidism Diastolic CHF, EF > 60% Discharge Condition: Improved- breathing comfortably on room air with no chest tightness Discharge Instructions: Please weigh yourself every morning, and call your doctor if weight increases by more than 3 lbs. . Please adhere to 2 gm sodium diet . Fluid Restriction: 1.5 liters a day . Please call your doctor or go to the ER if you have any further wheezing, chest tightness, shortness of breath, or any other symptoms that concern you. Followup Instructions: Primary Care: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2117-5-20**] 2:00. Dr. [**Last Name (STitle) 11715**] should check your INR at this appointment, and may adjust your Coumadin dose depending on the results. . Outpatient Pulmonary Rehab: Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Date/Time:[**2117-5-26**] 8:45 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4851**], M.D. Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2117-5-27**] 11:30 Completed by:[**2117-5-18**]

[ "453.40", "493.92", "429.9", "253.2", "244.9", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6286, 6335

3218, 4802

332, 338

6498, 6568

2827, 3195

6942, 7558

2225, 2271

5176, 6263

6356, 6477

4828, 5153

6592, 6919

2286, 2808

273, 294

366, 1450

1472, 2110

2126, 2209

9,552

105,679

26306

Discharge summary

report

Admission Date: [**2160-3-6**] Discharge Date: [**2160-3-12**] Date of Birth: [**2083-6-5**] Sex: M Service: SURGERY Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 5547**] Chief Complaint: Urosepsis, Respiratory depression Major Surgical or Invasive Procedure: Emergent intubation Percutaneous nephrostomy tube placement. Central line placement Foley catheter placement History of Present Illness: 76 year old gentleman with a complicated and prolonged recent medical course including recent SBO, AVR presented with sepsis, hypotension, respiratory distress, and fever Past Medical History: Colon CA s/p colectomy/5-FU, CLL, Lung nodule s/p resectioin, HTN, cachexia, dementia, GERD, SBO not requiring surgical intervention. Social History: patient lives at home with wife. [**Name (NI) **] gradually become more demented and eating less over the past year. Family History: non-contributory Physical Exam: On admission 104.0 120 82/40 24 98% Appeares in distress Tachycardia CTA bilaterally Abdomen soft, distended, bilateral lower quadrant tenderness, reducable hernia Guiac negative rectal exam Pertinent Results: [**2160-3-12**] 02:45AM BLOOD WBC-14.7* RBC-3.78* Hgb-10.0* Hct-31.1* MCV-82 MCH-26.5* MCHC-32.2 RDW-16.8* Plt Ct-272 [**2160-3-10**] 04:06AM BLOOD WBC-19.3* RBC-3.36* Hgb-8.8* Hct-27.8* MCV-83 MCH-26.3* MCHC-31.8 RDW-16.8* Plt Ct-248 [**2160-3-9**] 12:40AM BLOOD WBC-14.4* RBC-3.22* Hgb-8.6* Hct-26.5* MCV-82 MCH-26.6* MCHC-32.4 RDW-16.7* Plt Ct-217 [**2160-3-8**] 04:08AM BLOOD WBC-27.7* RBC-3.42* Hgb-9.3* Hct-27.9* MCV-82 MCH-27.4 MCHC-33.5 RDW-17.0* Plt Ct-279 [**2160-3-7**] 04:33AM BLOOD WBC-30.1* RBC-3.45* Hgb-9.5* Hct-28.3* MCV-82 MCH-27.6 MCHC-33.6 RDW-16.7* Plt Ct-296 [**2160-3-6**] 11:09PM BLOOD WBC-49.0*# RBC-3.79* Hgb-9.9* Hct-31.2* MCV-82 MCH-26.2* MCHC-31.8 RDW-16.0* Plt Ct-382 [**2160-3-12**] 02:45AM BLOOD Plt Ct-272 [**2160-3-11**] 03:34AM BLOOD Plt Ct-216 [**2160-3-11**] 03:34AM BLOOD PT-15.0* PTT-40.9* INR(PT)-1.3* [**2160-3-10**] 04:06AM BLOOD Plt Ct-248 [**2160-3-7**] 04:33AM BLOOD PT-16.6* PTT-47.2* INR(PT)-1.5* [**2160-3-6**] 11:09PM BLOOD Plt Ct-382 [**2160-3-6**] 05:20PM BLOOD Plt Ct-310 [**2160-3-12**] 02:45AM BLOOD Glucose-51* UreaN-17 Creat-0.6 Na-148* K-3.7 Cl-112* HCO3-29 AnGap-11 [**2160-3-11**] 03:34AM BLOOD Glucose-137* UreaN-19 Creat-0.7 Na-144 K-3.8 Cl-113* HCO3-26 AnGap-9 [**2160-3-6**] 11:09PM BLOOD Glucose-128* UreaN-54* Creat-1.4* Na-145 K-4.1 Cl-115* HCO3-17* AnGap-17 [**2160-3-6**] 01:35PM BLOOD Glucose-137* UreaN-60* Creat-1.5* Na-139 K-5.6* Cl-109* HCO3-15* AnGap-21* [**2160-3-6**] 01:35PM BLOOD ALT-127* AST-58* CK(CPK)-61 AlkPhos-141* Amylase-60 TotBili-0.5 [**2160-3-6**] 01:35PM BLOOD cTropnT-0.02* [**2160-3-12**] 02:45AM BLOOD Calcium-7.2* Phos-2.3* Mg-1.9 [**2160-3-11**] 11:00AM BLOOD Mg-1.9 [**2160-3-6**] 11:09PM BLOOD Calcium-7.4* Phos-4.5 Mg-1.5* [**2160-3-6**] 01:35PM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.6 Mg-2.0 [**2160-3-11**] 08:19AM BLOOD Type-ART Temp-37.5 Rates-/23 Tidal V-600 PEEP-5 FiO2-50 pO2-83* pCO2-45 pH-7.41 calHCO3-30 Base XS-2 Intubat-INTUBATED [**2160-3-11**] 11:12AM BLOOD K-4.5 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2160-3-9**] 12:52 PM CHEST (PORTABLE AP) Reason: Please evaluate for infiltrates [**Hospital 93**] MEDICAL CONDITION: 76 year old man w/ sepsis, s/p intubation, removal of PICC REASON FOR THIS EXAMINATION: Please evaluate for infiltrates PORTABLE CHEST ON [**2160-3-9**] AT 13:25 INDICATION: Sepsis, PICC line removal. COMPARISON: [**2160-3-8**] FINDINGS: The tip of the ETT remains high 8 cm above the carina. Dr. [**Last Name (STitle) 31839**] was informed of this finding at 7:55 p.m. on [**2160-3-9**]. The right CVL remains in place and there is no PTX. No new consolidations are seen and there is continued blunting at the right CP angle. IMPRESSION: Stable appearance versus prior with ETT tip still high, as discussed above. RADIOLOGY Preliminary Report PERC NEPHROSTO [**2160-3-7**] 11:08 AM PERC NEPHROSTO Reason: please place percutaneous nephrostomy tube per urology. Do n Contrast: OMNIPAQUE [**Hospital 93**] MEDICAL CONDITION: 76 year old man with REASON FOR THIS EXAMINATION: please place percutaneous nephrostomy tube per urology. Do not crush or manipulate kidney stone, perc neph only for decompression. HISTORY: 76-year-old man with urosepsis and obstructive left ureteral stone presents for nephrostomy tube placement in the left kidney. Prior CT scan had shown an exophytic ring lesion at the mid third of the left kidney, suspected to possibly represent a cystic/necrotic renal cell carcinoma. RADIOLOGISTS: Dr. [**First Name (STitle) **] [**Name (STitle) **], Dr. [**First Name (STitle) 379**] [**Name (STitle) **], Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 380**], and Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Doctor Last Name **]. Drs. [**Last Name (STitle) 380**] and [**Name5 (PTitle) **] [**Name5 (PTitle) **], the attending radiologists, were present and supervised the entire procedure. FINDINGS/TECHNIQUE: Informed consent was obtained before the procedure. The intubated patient was placed prone on the angiographic table. 1% lidocaine was administered for local anesthesia over the left flank. Ultrasound imaging of the left kidney was performed which demonstrated moderately distended renal pelvis and calyces, several cysts, and a cystic exophytic lesion suggestive of a renal cell carcinoma previously demonstrated by the CT scan. Using ultrasound guidance, a 22-gauge Chiba needle was advanced towards the collecting system of the left kidney. This collecting system was difficult to visualize by ultrasound at the level of the lower pole of the kidney. Attempts to opacify the collecting system through the Chiba needle were unsuccessful. Fluoroscopy and ultrasonography showed that the window available for percutaneous access was relatively [**Name2 (NI) 15015**], between the spine medially, aerated bowel laterally, ribs cranially and the left iliac [**Doctor First Name 362**] caudally. In addition, the cystic exophytic lesion mentioned above was adjacent to the only posterior calyx of the mid third of the kidney. Lastly, the lower pole calyces were not visible by ultrasound. Therefore, it was decided to access the posterolateral calyx of the mid third of the kidney. This was done successfully without much difficulty, again using the Chiba needle and real-time ultrasound guidance. Cloudy urine obtained on aspiration was sent for culture. A percutaneous antegrade nephrostogram was performed. It demonstrated moderately dilated collecting system of the left kidney with no passage of contrast into the mid ureter. An 0.018 nitinol wire was advanced and the needle was exchanged for an Accustick system which was positioned in the left renal pelvis. The inner dilators and the wire were removed, and a 0.035 guidewire was coiled within the left renal pelvis. The sheath was exchanged for an 8-French nephrostomy with the pigtail formed within the left renal pelvis. The catheter was connected to the bag drainage. It was secured to the skin with StatLock and 0 silk stitch. Sterile dressing was applied and the patient was transported to the ICU in good condition. Ultrasound images were obtained before and after obtaining the percutaneous nephrostomy access. COMPLICATIONS: No immediate complications. IMPRESSION: Percutaneous nephrostogram demonstrated moderate hydronephrosis on the left with ureteral obstruction in the mid ureter. An 8 French left nephrostomy tube was placed percutaneously under ultrasound and fluoroscopic guidence and connected to external bag drainage. DR. [**First Name (STitle) 39935**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39936**] DR. [**First Name (STitle) 16722**] [**Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16723**] RADIOLOGY Final Report CT ABDOMEN W/CONTRAST [**2160-3-6**] 6:51 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: eval for PE Field of view: 38 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 76 year old man with h.o SBO now with rigid abd and distention, cough, fever and tachy with hypoxia REASON FOR THIS EXAMINATION: eval for PE CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 76-year-old man with history of small bowel obstruction now with rigid abdomen and distention who presents with cough, fever, and tachycardia. TECHNIQUE: Multidetector axial images of the chest, abdomen and pelvis were obtained with oral and IV contrast. 130 cc Optiray. Coronal and sagittal reformatted images were obtained. CT CHEST: Although not optimized for it, no pulmonary embolism is identified. Aortic and coronary calcifications are identified. The heart size is normal. Mediastinal lymph nodes do not meet CT criteria for pathologic enlargement. There is no axillary or hilar lymphadenopathy. There are patchy bilateral lower lobe opacities as well as bibasilar atelectasis. No pleural or pericardial effusions are identified. Endotracheal and nasogastric tubes are noted. CT ABDOMEN: The liver, gallbladder, pancreas, spleen and adrenal glands are unremarkable. Again identified in the left kidney is a 2.5 x 2 cm solid and cystic lesion highly concerning for renal neoplasm. A very unusual manifestation of infection or wall thickeneing about a renal cyst is in the differential. Additional low- attenuation foci, consistent with cysts are again seen. The previously seen 1.9 x 1.1 cm renal calculus has now descended into the ureteropelvic junction and is causing mild hydronephrosis and perinephric stranding. The corticomeduallary junciton is preserved. The right kidney is stable in appearance with a cyst and multiple additional low- attenuation foci which likely represent cysts but are too small to be fully characterized. There is prominent dilatation of small bowel loops up to 5 cm. The distal most loops are decompressed but fluid filled. The colon contains both air and fluid. There is no free air or free fluid. No mesenteric or retroperitoneal lymphadenopathy is identified. CT PELVIS: Air and Foley catheter are observed in the bladder. The sigmoid colon and rectum are fluid filled. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Right hip prosthesis is noted. IMPRESSION: 1. Large left ureteropelvic junction stone which is causing mild hydronephrosis. 2. Dilated small bowel loops with decompressed but fluid-filled distal small bowel and colon suggestive of an ileus pattern or partial small-bowel obstruction. 3. Bilateral lower lobe patchy opacities concerning for aspiration or developing pneumonia. 4. Redemonstration of 2.5-cm enhancing solid and cystic left renal lesion concerning for renal cell carcinoma. Ddx includes very unusual manifestation of abcess or wall thickening about a cyst. Further evaluation with MRI is strongly recommended. Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] in respiratory distress and with hypotension. He was intubated and fluid resuscitated. Antibiotics were started. CT scan showed . Large left ureteropelvic junction stone which is causing mild hydronephrosis. 2. Dilated small bowel loops with decompressed but fluid-filled distal small bowel and colon suggestive of an ileus pattern or partial small-bowel obstruction. 3. Bilateral lower lobe patchy opacities concerning for aspiration or developing pneumonia. 4. Redemonstration of 2.5-cm enhancing solid and cystic left renal lesion concerning for renal cell carcinoma. Ddx includes very unusual manifestation of abscess or wall thickening about a cyst. Given these findings fevers and hypotension were attributed to urosepsis. Patient was transferred to the intensive care unit. A percutaneous nephrostomy tube was placed to decompress the kidney and antibiotics were continued. Patients improved clinically and remained hemodynamically stable. Patients fever subsided. Ventilatory support was weaned and patient was extubated on [**2160-3-11**]. Given patients long progressive clinical decline, the patient, his wife and family decided that no further heroic measures should be undertaken. He was made DNR/DNI and was discharged home with hospice care on comfort measures only on [**2160-3-12**]. Discharge Medications: 1. Ativan Elixir 2mg/mL. Take 0.5-1 mg every 2 hours as needed for agitation, anxiety 10 ml per vial. Dispense 5 vials. [**Month (only) 116**] refil 5 times. 2. Medication Morphine sulfate (MSO4) 20 mg per 1 cc. 2-20 mg every 1-2 hour SC injection 120cc vial. Dispense 3 vials [**Month (only) 116**] refil 4 times. 3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) Sublingual every four (4) hours for 7 days. Disp:*42 drops* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: Urosepsis, septic shock ARF Discharge Condition: Fair to home with Hospice care. Discharge Instructions: Discharge home with hospice care. Comfort measures only. Followup Instructions: No follow up necessary. Completed by:[**2160-3-12**]

[ "591", "294.8", "486", "401.9", "592.1", "599.0", "518.81", "038.9", "560.9", "584.9", "V10.05", "785.52", "995.92" ]

icd9cm

[ [ [] ] ]

[ "55.03", "96.71", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

12873, 12892

11027, 12382

311, 421

12964, 12998

1181, 3289

13104, 13159

930, 948

12405, 12850

8129, 8229

12913, 12943

13022, 13081

963, 1162

238, 273

8258, 11004

449, 621

643, 779

795, 914

80,882

113,274

33743

Discharge summary

report

Admission Date: [**2103-4-6**] Discharge Date: [**2103-4-7**] Date of Birth: [**2052-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Placement of [**Last Name (un) 10045**] tube for variceal bleeding Cardiopulmonary resuscitation History of Present Illness: Mr. [**Known lastname 51106**] is a 50M with history of hepatitis C s/p aborted IFN treatment and alcohol cirrhosis, who is transferred from OSH with GI bleed and hypotension. On transplant list. Discharged on 20th hepatic encephalopathy. . Presented yesterday morning to [**Hospital 792**]Hospital with massive esophageal bleed with hgb 5, sbp 50s. [**Last Name (un) **] was placed in the ED, had esoph banding x 5. A total 10u rbc, 8u ffp, 15u platelets, 15mg vit K, 7L NS was given in the course. Post banding he arrived to the OSH MICU. He was progressively hypotensive and was started on 20 of levophed + vasopressin. He was placed on protonix and octreotide drip. Decision to transfer to [**Hospital1 18**] yesterday. This now on 2 of levophed, off vasopressin, map 65. Intubated on pressure control 40 fio2, 22/5. This AM prior to transfer hgb 8.8, plt 120--> 71 despite transfusion, wbc 8.7. Was placed on cefotaxime for empiric sbp coverage but climb from 1.2-2.6. Potassium to 6 this am-- got ca gluc, insulin, d50, starting bicarb gtt, no peaked T wave changes on EKG. INR from 5--> 1.8 after vit k, ffp. T bili 16.1, AST 1323, 314. Prior to tranfer map 65, hr 70 (L arm 20mm difference),patient intubated sedated (morphine and ativan). Note of a distended abdomen with report of kub with gas. No further active hematemesis. Yesterday blood coming from mouth and nasopharynx which was thought [**1-15**] trauma. [**Last Name (un) **] has been discontinued. He received 4mg morphine, 4mg ativan over past 24h. Access included R IJ TLC, 2 periph 18, 1 20gg IV. They had planned to order 2u RBC for transport. Discussion with [**Hospital1 18**] hepatology service was done prior to transfer. Last MELD 42. . On arrival to the [**Hospital1 18**] ICU patient hypotensive to 70/40, vasopressin added with good result MAP to 62. Abdomen markedly distended. . Patient is known to the liver service at [**Hospital1 18**]. Hepatitis C genotype 3 s/p IFN, treatment stopped due to thrombocytopenia, participated in Eltrombopag study, last HCV VL 1,540 IU/mL, has been decreasing w/o treatment. Cirrhosis with encephalopathy and ascites with hx of SBP on norfloxacin prophylaxis, diuretics. Esophageal varices s/p banding at [**Hospital 792**]Hospital [**2103-3-8**]. No EGD in [**Hospital1 18**]. Creatinine baseline 0.6-0.9. No hx of hepatorenal. Past Medical History: - hepatitis C genotype 3 s/p IFN, treatment interrupted due to thrombocytopenia, participated in Eltrombopag study, last HCV VL 1,540 IU/mL, has been decreasing w/o treatment - cirrhosis c/b encephalopathy and ascites; workup started for transplant - varices (?type) s/p banding at [**Hospital 792**]Hospital [**2103-3-8**] - bronchitis - asthma - h/o seizure in the setting of alcohol withdrawal - h/o negative PPD Social History: He lives alone in a rooming house. His daughter lives 15 minutes a way, and another daughter lives close by. He has a companion who is supportive but is also a recovering alcoholic. He smokes cigarettes. He has smoked for 35-40 years at 2-3 packs per day, but now has cut down to less than 1 pack per day. He has been drinking alcohol since age 14-15 with 6-12 beers a day with shots of liquor, but has been sober for 21 months. He previously used quite a bit of recreational drugs including marijuana, cocaine, psychedelic drugs. Brief IVDA in the past. Family History: His father, uncle, brother and wife all died of alcoholic cirrhosis. There is no history of heart disease, diabetes or cancer in the family. Physical Exam: VS: 104, 80/40, 98.4, CVP 33, bladder pressure 25. AC PEEP 5, RR 14, TV 550. GEN: ill appearing male with distended abdomen on ventilator, jaundiced HEENT: icteric difficult to assess JVP. Blood suctioned from oropharynx, ET tube present CV: RRR no MRG CHEST: diminished breath sounds bilaterally ABD: distended, tense, dullness to percussion. No bowel sounds heard. Hepatosplenomegaly present. Site of previous para with oozing of peritoneal fluid, echymoses. EXTR: edema, cool LE, palpable distal pulses NEURO: sedated. Pertinent Results: CHEST (PORTABLE AP) [**2103-4-6**]: SINGLE PORTABLE AP UPRIGHT CHEST: Compared to CT of [**2103-4-1**]. The extreme lung apices are excluded on this study as is the left CP angle. There is a NG tube in place with its tip in the fundus of the stomach. The visualized lung parenchyma is clear. There is no evidence of CHF/volume overload. The heart size is within normal limits and the mediastinal and hilar contours are unremarkable. ABDOMEN U.S. (COMPLETE STUDY) PORT [**2103-4-6**]: IMPRESSION: 1. Findings consistent with cirrhosis. 2. Bidirectional Doppler waveform in the main portal vein, indicating mixed hepatopetal and hepatofugal flow. 3. Gallstones with gallbladder wall thickening, stable. 4. Small amount of ascites. CHEST (PORTABLE AP) [**2103-4-7**]: SINGLE SUPINE PORTABLE RADIOGRAPH: Compared to study of one hour prior. The [**Last Name (un) **] tube remains in place with its tip coursing off the inferior aspect of the image. It loops on the superior aspect of the image, perhaps residing outside of the patient, but may be coiled in the hypopharynx. The balloon has been deflated since the prior radiograph. There is no definitive evidence of pneumomediastinum or pneumothorax. There remains moderate volume overload. Right IJ tip is difficult to directly visualize given technique. ABDOMEN (SUPINE ONLY) PORT [**2103-4-7**]: FINDINGS: There is a nasogastric tube and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube identified. There is a large amount of gas seen within the stomach. There are prominent loops of likely colon. There is also increased density throughout the abdomen consistent with known ascites. There is no definite evidence for free intra-abdominal air or pneumatosis. This bowel gas pattern is nonspecific. If there is high clinical concern, a CT scan could be performed. HEMATOLOGY: [**2103-4-6**] 03:18PM BLOOD WBC-10.3# RBC-2.71* Hgb-9.0* Hct-23.7* MCV-87# MCH-33.1* MCHC-37.8* RDW-19.6* Plt Ct-85* [**2103-4-6**] 09:51PM BLOOD WBC-5.8 RBC-1.47*# Hgb-4.9*# Hct-13.2*# MCV-90 MCH-33.0* MCHC-36.6* RDW-21.1* Plt Ct-46* [**2103-4-6**] 11:14PM BLOOD WBC-5.8 RBC-1.54* Hgb-4.9* Hct-14.2* MCV-92 MCH-32.1* MCHC-34.7 RDW-20.2* Plt Ct-41* [**2103-4-7**] 12:06AM BLOOD WBC-4.6 RBC-2.03*# Hgb-6.4*# Hct-18.8*# MCV-93 MCH-31.3 MCHC-33.7 RDW-17.0* Plt Ct-69*# COAGS: [**2103-4-6**] 03:18PM BLOOD PT-34.0* PTT-50.7* INR(PT)-3.6* [**2103-4-6**] 09:51PM BLOOD PT-38.9* PTT-70.7* INR(PT)-4.2* [**2103-4-6**] 11:14PM BLOOD PT-41.9* PTT-80.6* INR(PT)-4.6* [**2103-4-7**] 12:06AM BLOOD PT-22.4* PTT-81.7* INR(PT)-2.1* [**2103-4-6**] 03:18PM BLOOD Fibrino-113* CHEMISTRIES: [**2103-4-6**] 03:18PM BLOOD Glucose-82 UreaN-38* Creat-2.7*# Na-138 K-5.9* Cl-104 HCO3-21* AnGap-19 [**2103-4-6**] 09:51PM BLOOD Glucose-35* UreaN-37* Creat-3.3* Na-140 K-5.8* Cl-106 HCO3-17* AnGap-23* [**2103-4-6**] 11:14PM BLOOD Glucose-94 UreaN-35* Creat-3.0* Na-139 K-6.3* Cl-106 HCO3-15* AnGap-24* [**2103-4-7**] 12:06AM BLOOD Glucose-108* UreaN-31* Creat-2.7* Na-144 K-5.8* Cl-110* HCO3-14* AnGap-26* [**2103-4-6**] 03:18PM BLOOD ALT-2844* AST-8550* AlkPhos-709* TotBili-21.5* [**2103-4-6**] 09:51PM BLOOD ALT-1794* AST-6158* LD(LDH)-4494* AlkPhos-529* TotBili-15.9* [**2103-4-6**] 11:14PM BLOOD ALT-1462* AST-4930* LD(LDH)-3660* CK(CPK)-1274* AlkPhos-437* TotBili-13.6* [**2103-4-6**] 03:18PM BLOOD Albumin-2.4* Calcium-7.7* Phos-8.6*# Mg-1.8 LACTATES: [**2103-4-6**] 03:34PM BLOOD Lactate-5.9* [**2103-4-6**] 06:32PM BLOOD Lactate-7.1* [**2103-4-6**] 10:00PM BLOOD Lactate-9.0* [**2103-4-6**] 11:19PM BLOOD Lactate-10.8* [**2103-4-7**] 12:15AM BLOOD Lactate-10.7* ASCITIC FLUID STUDIES: ASCITES ANALYSIS [**2103-4-6**] 05:00PM WBC 80, RBC 3925, Polys 18, Lymphs 13 ASCITES CHEMISTRY [**2103-4-6**] 05:00PM Glucose 100, LD(LDH) 154 Brief Hospital Course: Following patient's admission he immediately required addition of vasopressin to norepinephrine to support his blood pressure. Hepatology service was aware of patient prior to transfer and was consulted at time of admission. Due to low tidal volumes on ventilator and a tense abdomen at admission, a therapeutic paracentesis was performed with removal of 5 liters of ascitic fluid and noted improvement in both tidal volumes and bladder pressures. The fluid proved to have a high RBC count; however, was not consistent with SBP as there were only 80 total WBCs. 100 grams of albumin were given at time of paracentesis in order to support intravascular volume. Patient was also ordred for 2 units of PRBCs to be transfused at time of admission; however, his HCT was stable upon transfer from outside hospital. Several hours following admission, the patient's blood pressure began to drop with MAPs in the mid-50s despite 1 L NS as well as the previously mentioned 100 g albumin. PRBCs were unable to be obtained for transfusion due to the patient having antibodies making crossmatch exceedingly difficult. At this time 1 L NS was infused and phenylephrine was initiated as a third vasoactive [**Doctor Last Name 360**] to support blood pressure. In recognition of falling blood pressure, NG tube was hooking to suction and appromiately 500 mLs of dark red blood were pulled to suction trap. Then in recognition of likely repeat variceal bleeding, additional NS was infused and blood bank was contact[**Name (NI) **] for emergency release of blood prior to complete crossmatch. Hepatology service was simultaneously contact[**Name (NI) **] and they came into the hosptial with plans to place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube to tamponade the bleeding. Shortly after blakmore was inserted and prior to confirmatory CXR or inflation of [**Last Name (un) **] balloon, the patient became bradycardic and lost a pulse. CPR was initiated as indicated for pulseless electrical activity. During code compressions were done continuously save rhythm checks. Several rounds of atropine and epinephrine were given. A femoral cordis was placed and many units of blood were given via rapid transfuser. In all, patient received 9 units of PRBCs, 8 units of FFP, 2 bags of platelets, and 2 units of cryoprecipitate. He was shocked a single time following identification of an unstable narrow-complex tachycardia. A pulse and stable blood pressure were regained and code was ceased. Despite the massive amount of blood products transfused, the patient's HCT only changed from 13 prior to code to 19 at the end of the code. Patient's two daughters had been present for most of code. They were updated on the patient's poor prognosis following the code and decided to make the patient DNR/DNI as well as "comfort measures only". Prior to being able to carry out cessation of supportive medication and ventilation, the patient became bradycardic and lost his pulse again. He was pronounced dead shortly following this second episode of bradycardia and loss of pulse. Medications on Admission: MEDICATIONS AT HOME (per last D/C summary): Albuterol 90 mcg 2 puffs every day Advair 250/50 1 INH [**Hospital1 **] Furosemide 40 mg once a day Spironolactone 100 mg once a day, Nadolol 20 mg once a day Esomeprazole (Nexium) 40 mg once a day, Lactulose 30cc QID Norfloxacin 400mg daily Trazodone 50 mg qHS Magnesium oxide 400mg daily Citalopram 40mg daily Nicotine 21mg [**12-15**] patch daily MEDICATIONS AT TIME OF TRANSFER: Levophed gtt Octreotide gtt Protonix gtt Morphine prn Ativan prn Discharge Medications: None, patient expired. Discharge Disposition: Expired Discharge Diagnosis: Primary: Gastrointestinal bleeding Secondary: Hepatic cirrhosis Hepatic failure Discharge Condition: None. Patient expired. Discharge Instructions: None. Patient expired. Followup Instructions: None. Patient expired. Completed by:[**2103-4-18**]

[ "560.1", "584.5", "456.20", "789.59", "276.7", "493.90", "784.7", "567.23", "571.2", "303.93", "518.81", "070.44" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.71" ]

icd9pcs

[ [ [] ] ]

11990, 11999

8319, 11400

324, 423

12123, 12148

4528, 8296

12219, 12273

3828, 3971

11943, 11967

12020, 12102

11426, 11920

12172, 12196

3986, 4509

273, 286

451, 2800

2822, 3240

3256, 3812

19,120

139,233

12874

Discharge summary

report

Admission Date: [**2148-8-2**] Discharge Date: [**2148-8-16**] Date of Birth: [**2087-5-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: T3N1 esophogeal adenocarcinoma s/p chemotherapy, radiation therapy Major Surgical or Invasive Procedure: [**8-2**] lap esophagogastrectomy [**8-9**]-- flexible bronchoscopy [**8-12**]-- Bedside and videoswallow History of Present Illness: 61 y/o male w/ T3N1 esophageal cancer s/p chemotherapy and radiation therapy as neoadjuvant treatment. He presents now for definitive therapy. A minimally invasive esophagectomy was offered to the patient and accepted. The patient originally had been scheduled earlier but had a small neurological event from which he is totally recovered, and he presents now for operation. He is somewhat further out than normal due to these extenuating circumstances. Past Medical History: PMH: Gastric esophogeal reflux disease, Barretts esophagitis, Esophogeal Cancer adenocarcinoma T3N1,s/p chemotherapy and radiation therapy , Hypertension, depression, Leg cramps, h/o substance abuse; Cerebral Vascular accident-small subacute right parietal infarct which appears embolic. Hypertension, Chronic obstructive pulmonary disease, renal calculi PSH: lithotripsy x 3, sigmoid colectomy, Jejunostomy tube/portacath [**3-25**] Social History: lives w/ wife. Family History: non-contibutory Physical Exam: General- elderly male, articulate HEENT-no LAD REsp- clear Cor-RRR Abd- soft, J- tube in place Ext-no clubbing, cyanosis, edema Skin/ Incisions- cervical- slight erythema' abdominal Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2148-8-15**] 08:55AM 10.3# 2.86*# 10.2*# 29.3*# 102* 35.6* 34.8 14.3 534* Source: Line-portacath [**2148-8-15**] 06:34AM 6.4# 2.03*# 7.1*# 20.9*# 103* 34.8* 33.8 14.3 375 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2148-8-15**] 08:55AM 534* Source: Line-portacath [**2148-8-15**] 06:34AM 375 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2148-8-13**] 06:02AM 95 18 0.7 135 4.4 102 23 14 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2148-8-3**] 09:07AM 636* [**2148-8-3**] 03:17AM 580* GREEN TUBE CPK ISOENZYMES CK-MB MB Indx cTropnT [**2148-8-3**] 09:07AM 10 1.6 <0.011 1 <0.01 RADIOLOGY Final Report CHEST (PA & LAT) [**2148-8-12**] 11:48 AM Reason: change in infiltrate? [**Hospital 93**] MEDICAL CONDITION: 61M s/p lap esophagogastrectomy REASON FOR THIS EXAMINATION: change in infiltrate? REASON FOR THE STUDY: Assessment for after laparoscopic esophagogastrectomy. TECHNIQUE OF THE STUDY: PA and lateral view of the chest. COMPARISON: Done with the study done on [**8-11**]. FINDINGS: Bilateral midzone densities have resolved. Bibasilar discoid and linear atelectases, new compared to the previous study. Small bilateral pleural effusions. This is stable compared to previous study. No pneumothorax is observed. Heart size is top normal. Reatined contrast in intrathoracic stomach. Repeat video swallow [**2148-8-15**]: IMPRESSION: Both oral and pharyngeal dysphagia. Penetration and aspiration with small amounts of thin liquids that was improved with a chin tuck maneuver. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**] Approved: [**Doctor First Name **] [**2148-8-15**] 5:15 PM CHEST (PA & LAT) [**2148-8-14**] 8:42 AM Reason: please evaluate lung fields [**Hospital 93**] MEDICAL CONDITION: 61M s/p lap esophagogastrectomy REASON FOR STUDY: Evaluation of the lung fields. The patient is status post laparoscopic esophagogastrectomy. TECHNIQUE: PA and lateral view of the chest and the study is compared to the previous one done on [**8-9**]. FINDINGS: There are bilateral parenchymal densities suggesting areas of atelectasis. There is an IJ port-a-cath on the right side with its tip projecting over the SVC. There is left pleural effusion, mild and stable . IMPRESSION: Partial resolution of areas of atelectasis. Left pleural effusion mild and stable. Brief Hospital Course: Patient admitted SDA for esophagectomy [**2148-8-2**] w/ [**Name8 (MD) **], MD [**First Name8 (NamePattern2) **] [**Name8 (MD) 39594**], MD. [**First Name (Titles) **] [**Last Name (Titles) 8337**] procedure fairly well, transferred to ICU in stable condition, intubated on vent, epidural in place, Ct in place to sx, NGT to LCS, J-tube to gravity, cervical JP drain. POD#1-1L IVF bolus for low BP w/ continuous hydration; wean to SIMV in preparation for extubation, meticulouos I/O; pulmonary toilet, iv antibiotics; CT to waterseal;epidural for pain control. POd#2- Extubated but worsening hypoxia on NC/ FM, pulmonary toilet, diuresis; start trophic tube feedings via J-tube. POD#[**3-24**]--Aggressive pulmonary toilet; Ct d/c; antibiotic d/c. REquired BIPAB overnight and intermittently during day. CT angio -R/O'd P. Diuresis w/ improved O2 sat low 90's. CXRY no ptx. low grade fever- 100.6. Epidural changed to PCA. Tubefeedings advanced slowly to goal over 24-36 hours, NPO. POD#[**5-25**]-([**2148-8-7**]) Sputum cx> 4+GNR, 4+GPC. started on Vanco and Zosyn; respiratory status improved; ++ copious secretions mobilized w/ CPT, pulmonary toilet. Lasix gtt started. Bronchoscopy done- cx sent.--moderate amt secretions LLL, LMB, tx aspiration. NGT d/c. POD#7- Sputum + serratia, antibiotic cont. PCA d/c, started on roxicet via j- tube. CXRY- no pts, LLL atlectasis, sm bilat eff, some pul edema. Probable aspiration pna. TF changed to FS Pormote w/ fiber @75h, pt remains NPO. Lasix gtt d/c. POD#[**8-28**] Oxygenation slowly improving, Temp-100, WBC trending down, remains in ICU for pulmonary toilet. POD#10-([**2148-8-12**]) Transfer to floor, iv antibiotics cont, swallow eval done- see results-passed for ground solids, thick liquids. f/u 1 week for ? advancement. TF cont, as po intake [**Month/Day/Year 8337**]. Some diarrhea- Cdiff negative x2. Good pain control on roxicet elixer. Physical Therapy evaluation- OOB, ambulation w/ assist- good potencial to meet goals, now deconditioned w/ anticipation of improved function POD#11- Some diarrhea on FS TF- Cdiff negative x2. Excellent progress w/ PT, amb w/ assist.PO intake excellent- 2000cc, TF turned off for majority of day. Patient given further counseling regarding post esophagectomy diet Incisions slight erythema- staples d/c, cervical drain d/c. weight#82.7kg POD#12 repeat video swallow -passed for thin liqs w/ chin tuck and ground solids. persistant diarrhea w/ increased po intake -? dumping. encouraged sm freq meals. immodium added. this d/c summary was written by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP Medications on Admission: prilosec 40", lasix 25', atenolol 25', compazine 10", quinine sulfate 260', neurontin 300', wellbutrin 150', ASA 81', MgSO4 500', morphine sulfate 30", endocet 7.5/325", endocet 10/325', diazepam 5', 21mg nicotine patch, dilaudid Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution [**Last Name (NamePattern1) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (NamePattern1) **]: 5000 (5000) units Injection [**Hospital1 **] (2 times a day): sq. 3. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 4. Lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day) as needed for via j tube. 5. Bupropion 75 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) as needed for via J-tube. 6. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) cc PO DAILY (Daily) as needed for via j tube. 7. Quinine Sulfate 260 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime) as needed for via j tube. 8. Atenolol 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO DAILY (Daily) as needed for via j tube. 9. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed. 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 11. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN 10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units heparin) each lumen Daily and PRN. Inspect site every shift. 12. cefapime [**Last Name (STitle) **]: One (1) gram Intravenous (only) Q 24hr for 14 days: [**Date range (1) 39595**]. 13. oxygen .5-2L prn 14. Insulin Regular- sliding scale REfer to RISS order sheet 15. Furosemide 20 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily). 16. Loperamide 2 mg Tablet [**Date range (1) **]: 1-2 Tablets PO tid prn. Tablet(s) 17. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN 10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 1495**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Discharge Diagnosis: Hypertension, Chronic obstructive pulmonary disease, renal calculi T3N1 esophogeal adenocarcinoma s/p chemotherapy, radiation therapy. Cerebral Vascular accident-small subacute right parietal infarct which appears embolic. PSH: lithotripsy x 3, sigmoid colectomy, Jejunostomy tube/portacath [**3-25**] Discharge Condition: fair Discharge Instructions: Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office [**Telephone/Fax (1) 170**]) for any post surgical issues. Followup Instructions: Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office [**Telephone/Fax (1) 170**]) for an appointment after your return home from rehabilitation center Completed by:[**2148-8-16**]

[ "997.3", "151.0", "724.02", "401.9", "486", "507.0", "V13.01", "V44.4", "496", "518.0", "723.0", "799.02", "530.81", "E878.8", "V12.59", "530.85" ]

icd9cm

[ [ [] ] ]

[ "38.91", "33.22", "96.05", "43.99", "96.6", "42.23" ]

icd9pcs

[ [ [] ] ]

9306, 9433

4385, 7005

394, 502

9780, 9787

1728, 2607

9949, 10132

1494, 1511

7285, 9283

3793, 4362

9454, 9759

7031, 7262

9811, 9926

1526, 1709

288, 356

2705, 3756

530, 986

1008, 1445

1461, 1478

81,363

127,708

41705

Discharge summary

report

Admission Date: [**2103-1-20**] Discharge Date: [**2103-1-29**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: Fall with head injury Major Surgical or Invasive Procedure: None History of Present Illness: This is a 87 year old man with history of orthostatic hypotension who is status post witnessed fall from standing with 5-7 minutes of unresponsiveness per the report of the family following the event. The patient initially was brought to [**Hospital6 18075**] by EMS at which time he has a CT which was consistent with Subarachnoid/subdural hematoma and skull fracture. The patient was transferred here for further evaluation and care. The patient arrives alone and reports that he is amnestic to the event. Upon arrival, he is actively vomiting coffee ground emesis. He denies headache,weakness, numbness, tingling sensation, hearing or vision deficit. Past Medical History: CABG postural hypotension hypercholesterolemia arteriosclerosis Social History: He is retired from the fire department. He lives alone in an apartment. He is separated from his wife but sees her on a regular basis. He has two sons who are close. No history of tobacco use. Drinks 2.3-3 oz alcohol daily. No illicit drug use. Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: O: T:96.2 BP: 122/69 HR:69 R:18 O2Sats:97% Gen: comfortable HEENT:small amount of red blood in oral pharynx. NO battle sign/NO raccoon sign/No otorrhea/No rhinorrhea/No head laceration Pupils: 3-2mm bilaterally EOMs:intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam BUT SLOW to follow commands, amnestic to the event Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. Naming intact. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power 5-/5 throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally . Discharge exam: Expired Pertinent Results: Admission labs: [**2103-1-20**] 07:05PM BLOOD WBC-19.6*# RBC-4.23* Hgb-13.3* Hct-38.9* MCV-92 MCH-31.3 MCHC-34.1 RDW-12.9 Plt Ct-173 [**2103-1-20**] 07:05PM BLOOD Neuts-86* Bands-1 Lymphs-3* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2103-1-20**] 07:05PM BLOOD PT-10.9 PTT-24.9* INR(PT)-1.0 [**2103-1-20**] 07:05PM BLOOD Glucose-165* UreaN-23* Creat-2.1* Na-140 K-3.4 Cl-100 HCO3-25 AnGap-18 [**2103-1-20**] 10:35PM BLOOD CK(CPK)-102 [**2103-1-20**] 10:35PM BLOOD CK-MB-3 cTropnT-<0.01 [**2103-1-21**] 04:17AM BLOOD CK-MB-2 cTropnT-0.01 [**2103-1-25**] 09:40PM BLOOD CK-MB-4 cTropnT-0.02* [**2103-1-20**] 07:05PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.5 [**2103-1-20**] 10:35PM BLOOD Phenyto-11.1 . Imaging: Head CT: FINDINGS: There are bilateral acute subdural and subarachnoid hematoma primarily along the frontoparietal lobes, which is unchanged in extent compared to the previous examination from [**Hospital3 **]. Given the pattern of hyperdense blood along the anterior cranial fossa, a component of parenchymal henmorrhagic contusion cannot be excluded. The ventricles and sulci are mildly prominent, likely representative of age-related atrophy. There is mild bihemispheric white matter hypoattenuation consistent with sequelae of small vessel ischemic disease. The visible paranasal sinuses show high-density fluid in the left frontal sinus. Leading into the left frontal sinus is a midline fracture of the frontal bone extending to the vertex. IMPRESSION: 1. Stable bilateral frontoparietal subarachnoid and subdural hemorrhage with possible bifrontal contusions. 2. Fracture of the frontal bone in the midline may extend into the frontal sinus and places the patient at risk for a CSF leak. Brief Hospital Course: 87yo male with past medical history significant for orthostatic hypotension s/p fall with bilateral frontal contusions SAD/SDH and skull fracture being transferred to the MICU with seizure-like activity, minimally responsive, profuse diarrhea, febrile, hyponatremia and hyperkalemia. . # Altered Mental Status: Felt to be multifactorial due to worsening hypernatremia, underlying seizure disorder, head bleeds, and possible viral infection (suspected norovirus given profuse diarrhea). Serial head CTs showed the subdural bleeds were stable. Though there was concern for ongoing status epilepticus, he was monitored on continuous EEG without evidence of seizures, just generalized slowing. Patient was continued on dilantin and keppra. Per neurology, patient was felt to loss of brainstem reflexes felt to be related to trauma. Given the small chance of neurologic recovery, goals of care were discussed with family and he was transitioned to CMO. The patient passed away during the admission while on CMO. . # Code Staus: Transitioned from Full code to CMO given poor neurologic prognosis. Addendum: Patient passed away on the medical floor overnight, prior to initial evaluation by Dr. [**Last Name (STitle) **] (medicine attending). Medications on Admission: 1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 2. fludrocortisone 0.1 mg Tablet Sig: one-half Tablet PO DAILY 3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY 4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. . Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "E888.8", "244.9", "995.91", "585.9", "780.39", "272.0", "E849.8", "276.51", "800.21", "038.9", "403.90", "787.91" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6327, 6336

4353, 4649

273, 279

6387, 6396

2626, 2626

6452, 6462

1337, 1346

6295, 6304

6357, 6366

5618, 6272

6420, 6429

1386, 1676

2598, 2607

212, 235

307, 965

1926, 2582

3343, 4330

2642, 3334

4664, 5592

987, 1052

1068, 1321

15,407

190,594

10334

Discharge summary

report

Admission Date: [**2186-9-27**] Discharge Date: [**2186-10-19**] Date of Birth: [**2113-5-5**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 9240**] Chief Complaint: Hematochezia, Diarrhea Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: 73 y/o m with h/o CAD s/p CABG, afib, h/o VT, PVD, ESRD p/w C. Diff and hematochezia. He was initially admitted on [**2186-9-27**] for treatment of c diff colitis. He was started on Flagyl 9 days ago by his nephrologist, Dr. [**First Name (STitle) 805**]. Due to hypotension, he was transfered to the [**Hospital Unit Name 153**]. He was fluid resuscitated with improvement in blood pressure and was started on Vancomycin 500mg po q 6 hours. He was tranferred out of the [**Hospital Unit Name 153**] [**9-28**], but readmitted when he developed BRBPR with hct drop from 32 to 28 over 24h. GI was consulted; colonscopy revealed a cecal clot which was not disturbed, and no intervention was done. A tagged rbc scan was negative for a source. ASA and plavix were held. A total of 3u prbc (2u initial [**Hospital Unit Name 153**] admission, then 1u when LGIB the latter [**Hospital Unit Name 153**] admission) were tranfsued this hospitalization. A repeat c-scope in the next 2-3 days for possible intervention is planned. He completed the course of vancomycin yesterday, [**10-13**]. Past Medical History: 1. CAD: s/p CABG x 3 (LIMA-LAD, SVG-OM, SVG-Diag in [**9-4**] at [**Location (un) 7349**] [**Hospital1 **] after presenting with loss of consciousness). Followed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. 2. s/p MV repair: [**9-4**] (#28 Physio ring) 3. s/p AICD implant: [**9-4**] for VT 4. AFib 5. ESRD: [**2-2**] IgA nephropathy. on peritoneal dialysis since [**2-5**], s/p L AV fistula [**7-6**]. followed by Dr. [**First Name (STitle) 805**] 6. HTN 7. s/p Left-sided CVA 8. dyslipidemia 9. Gout 10. Elevated PSA, sclerotic lesions on CT scan, but bone scan [**9-6**] negative Social History: He lives alone, has family in [**Location (un) **]. He emigrated from [**Location (un) 30926**] in [**2172**]. He denies cigarette, alcohol or drug use. He does occasionally take Chinese herbal medicines. Family History: His parents are both deceased of unclear cause. He has two siblings, both deceased of unclear cause. He has three children ranging in age from 40-47. He is not able to specify what medical problems they have but says they do have medical problems. Physical Exam: Vitals: T 98.8; BP 142/78; HR 70s: RR 18: 96% RA General: Cantonese speaking man, awake, alert, NAD. HEENT: EOMI, sclera anicteric, MM dry, OP without lesions Neck: supple, no JVD Chest: R sided HD tunneled line without erythema/ TTP Pulm: CTA Cardiac: RRR nl S1/S2, 2/6 systolic murmur LSB Abdomen: + BS, firm but not tense or rigid, NT. Multiple healed PD catheter scars. Ext: 2+ edema b/t. LUE with fistula with palpable thrill, non-tender. R groin with CVL, minimal erythema, no exudate or TTP Neurologic: AAO x 3, appropriate, conversant in Chinese. Moving all 4 extremities equally Pertinent Results: [**2186-9-27**] 05:43AM GLUCOSE-59* UREA N-63* CREAT-6.7* SODIUM-138 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-18 [**2186-9-27**] 05:43AM ALT(SGPT)-12 AST(SGOT)-19 ALK PHOS-67 AMYLASE-48 TOT BILI-0.8 [**2186-9-27**] 05:43AM LIPASE-9 [**2186-9-27**] 05:43AM CALCIUM-7.9* PHOSPHATE-6.9*# MAGNESIUM-2.0 [**2186-9-27**] 05:43AM TSH-2.6 [**2186-9-27**] 05:43AM WBC-7.7 RBC-2.83* HGB-8.5* HCT-27.5* MCV-97 MCH-29.9 MCHC-30.8* RDW-17.8* [**2186-9-27**] 05:43AM PLT COUNT-221 [**2186-9-27**] 05:43AM PT-12.8 PTT-29.5 INR(PT)-1.1 [**2186-9-26**] 10:00PM URINE HOURS-RANDOM [**2186-9-26**] 10:00PM URINE UHOLD-HOLD [**2186-9-26**] 10:00PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.023 [**2186-9-26**] 10:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [**2186-9-26**] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2186-9-26**] 10:00PM URINE AMORPH-MANY [**2186-9-26**] 07:13PM LACTATE-1.7 [**2186-9-26**] 05:47PM GLUCOSE-75 UREA N-55* CREAT-6.5*# SODIUM-143 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-28 ANION GAP-24* [**2186-9-26**] 05:47PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-78 AMYLASE-52 TOT BILI-0.8 [**2186-9-26**] 05:47PM LIPASE-11 [**2186-9-26**] 05:47PM ALBUMIN-2.2* [**2186-9-26**] 05:47PM WBC-10.8# RBC-2.96* HGB-9.2* HCT-28.1* MCV-95 MCH-31.2 MCHC-32.9 RDW-17.7* [**2186-9-26**] 05:47PM NEUTS-93.9* BANDS-0 LYMPHS-3.6* MONOS-2.3 EOS-0.2 BASOS-0.1 [**2186-9-26**] 05:47PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2186-9-26**] 05:47PM PLT SMR-NORMAL PLT COUNT-208 . Abd XR [**9-26**]: ABDOMEN, TWO VIEWS: The inferior most median sternotomy wires, and the right ventricular pacemaker lead are identified. Mobile gallstones are again seen overlying the right upper quadrant. There has been interval removal of a peritoneal dialysis catheter. Multiple small radiopaque fragments overlie the right pelvis, which were not present on the prior study, consistent with residual contrast from the recent CT scan. Air fills the descending and transverse colons, and there are few colonic air-fluid levels. In addition, in the descending colon, there appears to be some thickening of the haustral concerning for infection, inflammation, or ischemia. A CT scan may be helpful. No free intraperitoneal air is identified. . CXR [**9-26**]: CHEST, TWO VIEWS: The patient is status post median sternotomy, a left-sided pacemaker is in unchanged position. The patient has had a mitral valve replacement. There is a large-bore central venous catheter with its tip overlying the right atrium. A vascular stent is in unchanged position. The cardiac and mediastinal contours are stable with a tortuous aorta. The lungs demonstrate bibasilar atelectasis and blunting of the left costophrenic angle, a chronic finding. No free air is identified under the hemidiaphragms. IMPRESSION: No change from the prior study. No free intraperitoneal air seen. . CT Abd/Pelvis [**9-27**]: 1. Features consistent with pancolitis, also with some involvement of the terminal ileum. 2. New abnormal small fluid collections in the left upper quadrant, which may communicate with each other. These do not appear to communicate with bowel. These are non-specific new fluid collections, but infection cannot be excluded. Metastases are felt unlikely. 3. Atrophic native kidneys. 4. Cholelithiasis. . AbdXR [**9-29**]: Non-specific, but no definite evidence for colonic distention . Bleeding study [**10-2**]: No scintigraphic evidence of gastrointestinal hemorrhage, though sensitivity is limited by extremely poor tracer labeling of RBC's, likely due to ESRD. . Abd XR [**10-8**]: No overt features of toxic megacolon, no free air or pneumatosis. A partial or early small-bowel obstruction is possible and clinical correlation and followup film should be considered. . GI Bleeding study [**10-11**]: Source of GI bleeding not identified. . RUE U/S: Large intraluminal thrombus within the right internal jugular vein, which is otherwise patent. Imaging of the left internal jugular was not performed. . Colonoscopy [**2186-10-11**]: A large organized blood clot was seen extending from proximal ascending colon to cecum. The clot could not be lavaged off so underlying mucosa or source of bleeding could not be seen. Red blood was seen in the whole colon. Normal mucosa was noted. There was no evidence of c diff colitis. Multiple diverticula were seen in the sigmoid colon. Diverticulosis appeared to be of mild severity. . Blood in the proximal ascending colon and cecum Blood in the whole colon Diverticulosis of the sigmoid colon Normal mucosa in the colon Otherwise normal colonoscopy to cecum . Colonoscopy [**10-19**] (prelim): multiple diverticula seen but with no clear bleeding source identified, evidence of diffuse colitis, the diffrential includes infectious colitis and ischemic colitis Brief Hospital Course: # GI bleeding. DDX AVM, ischemic colitis, microscopic colitis, diverticular bleed, repeat colonoscopy done when pt's hematochezia resolved did not show clear bleeding source, showed multiple non-bleeding diverticula, and an area of colitis likely corresponding to healing C. Diff. Will need follow up colonoscopy in 3 months and f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (GI) in 3 months for biopsy results and repeat colonoscopy. . # C. diff colitis. Treated with a complete 14 day course of po vancomycin. Will need follow up stool sent for C. Diff, as well as follow up colonoscopy in 3 months. Continued to have likely postinfectious diarrhea while in house but improved somewhat upon discharge. No abdominal pain while in house. . # LUQ lesions on admission CT. Per discussion with radiology likely small abscesses from micro perforations. Too small for drainage. Should have follow up abd CT in [**4-6**] months to document resolution. Pt. had no abdominal pain, and normal WBC and afebrile on d/c. . # ESRD, secondary to IgA nephropathy. Patient on HD M, W, Friday. Will continue HD in [**Location (un) **] as usual. . # CV: s/p CABG, MV repair, AICD, h/o AFib. AAA seen on CT scan. Aspirin and Plavix were held due to GI bleeding, which had been discussed with his cardiologist. Pt. will need to follow up with Dr. [**Last Name (STitle) **] in [**1-2**] weeks after discharge to decide when to restart these medications. His BP medications were also decreased due to recurrent episodes of hypotension in house. His lopressor dose was decreased as well as his norvasc. Continued on amiodarone and is not a coumadin candidate due to bleeding risk. . # Anemia, chronic, secondary to ESRD. Fe studies from [**4-6**] c/w ACD. B12 and folate WNL. . # High PSA. Per patient he was seen by a urologist and was started on Tamsulosin. Recent bone scan did not confirm sclerotic bone lesions on CT. - outpatient follow up . # Prophylaxis: PPI. Pneumoboots. . # FEN: Treated with a brief course of TPN while in house due to profuse diarrhea, then transitioned to renal, cardiac diet. . # Access: Patient with right dialysis catheter, also had PICC placed for TPN while in house, which was removed upon d/c. . # Code Status: FULL CODE . Medications on Admission: Lisinopril 20 mg, Acetaminophen 325-650 mg PO Q4-6H:PRN, pantoprazole 40 qd, Paroxetine HCl 10 mg PO DAILY, Amiodarone HCl 200 mg PO DAILY, Atorvastatin 40 mg PO DAILY, Calcitriol 0.25 mcg PO DAILY, Flagyl 500 mg tid, Metoprolol 50 mg [**Hospital1 **], Norvasc 5 mg daily, Tamsulosin 0.4 mg hs Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*qs 2 weeks* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-2**] Sprays Nasal QID (4 times a day) as needed. 10. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*qs 1 month* Refills:*0* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Clostridium Difficile Colitis Lower GI Bleeding ESRD Discharge Condition: stable Discharge Instructions: Please continue your regular medications except please do not take your aspirin, plavix, or hydrochlorothiazide until you follow up with your PCP or cardiologist, and also your metoprolol dose and your norvasc dose was decreased. You will need a follow up colonoscopy in 3 months. You will also need to follow up with your gastroenterologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**2-3**] months. Please follow up with your PCP, [**Name10 (NameIs) 2085**], and nephrologist in [**2-4**] weeks. You can have your dialysis tomorrow in [**Location (un) **] as usual. Please call your doctor if you experience worsening diarrhea, abdominal pain, fever, or other concerning symptoms. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) **], your gastroenterologist in 3 months. Please call [**Telephone/Fax (1) 11048**] to schedule an appointment. You will need to follow up on your biopsy results and have another colonoscopy at that time. 2. Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-10-26**] 11:20 3. Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2186-11-2**] 9:40 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2186-11-20**] 3:40 4. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 30384**] Call to schedule appointment

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26705

Discharge summary

report

Admission Date: [**2112-3-2**] Discharge Date: [**2112-3-14**] Date of Birth: [**2056-11-5**] Sex: F Service: MEDICINE Allergies: Wellbutrin Attending:[**First Name3 (LF) 2297**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Placement of arterial line Placement of central venous catheter Endotracheal intubation History of Present Illness: 55 year old female with recent admission for osteomyelitis and epidural abscess of L3,L4 presenting with change in mental status, hypotension, and fever. She was discharged to Rehab 6 days prior to this admission. On her last admission she underwent IR drainage of abscess on [**2112-2-12**], went to OR for debridement and fixation on [**2-16**]. She was treated with Linezolid for her MRSA epidural abscess and VRE bacteremia with an end date to be determined by ID in clinic. . [**Name (NI) 1094**] husband states that she has had increased fatigue and malaise over the last few weeks. No fevers until yesterday. Appeared "stoned" at rehab - thought to be due to overmedication (narcotics for back pain). She had increased back pain not as responsive as previous to narcotics. . On admission to OSH, pt was febrile to 103.5F, tachycardic to 130, RR 30, with BP down to 77/58, satting 88-90% on RA, 94% on 100% NRB. She experienced increasing respiratory distress and was intubated in the ED. Subsequent ABG: 7.27/49/56/22 on AC 14/550/5/100%. She was placed on dopamine for hypotension, and placed on empiric levofloxacin, vancomycin, gentamicin, and linezolid. D-dimer was positive, but rising creatinine (2.7) prevented CTA from being done, and pt was thought to be too unstable for V/Q scan. Was placed empirically on heparin gtt. Dopamine was d/c'ed as pt tachycardic, changed to neosynephrine. Was transferred to [**Hospital1 18**] for further workup. Past Medical History: 1) Epidural abscess evacuated on [**12-8**] was MRSA+. Treated with vancomycin. Surgery for L3 osteomyelitis and associated abscess [**2111-12-9**]: Multiple thoracic laminectomies extending from T4-T12; Total laminectomies from L1-L5 with evacuation of epidural abscess, repeat surgery [**2-16**] - debridement and fixation. 2) VRE bacteremia diagnosed [**1-14**] 3) Small cell lung carcinoma on the right- Pt was diagnosed in [**2109**]. s/p chemotherapy and radiation. No metastasis found. Oncologist is Dr [**Last Name (STitle) 21628**] at [**Telephone/Fax (1) **] 4) CAD- NSTEMI in [**2110**], stress test in [**2110**] LVEF of 38% and a moderate sized fixed inferior lateral defect. Echo [**2112-2-23**] with EF >55%, nl wall motion 3. Hypertension 4. GERD 5. S/P excision of lipoma 6. S/P eye surgery 7. S/P knee surgery 8. S/P tonsillectomy 9. COPD 10. Anxiety 11. MRSA bacteremia during her chemotherapy. Social History: Current smoker, used to smoke 3ppd, has cut down in last few months. No ETOH. Lives with husband. Sister also very involved in care. No children. Family History: non-contrib Physical Exam: Vital signs: 100.1 99.2 124/58 109 18 98% Gen: intubated, opens eyes to command; obese HEENT: PERRL, intubated Lungs: wheezy, no crackles anteriorly, symmetric bilaterally CV: tachycardic, regular, nl S1/S2, no murmurs, distant heart sounds Abd: midline incision with dried blood, no surrounding erythema; soft, mildly distended, hypoactive bowel sounds Ext: cool extremities, trace pretibial edema; 2 superficial ulcerations on R shin Neuro: intubated, waxes and wanes in responsiveness Pertinent Results: labs from OSH ABG 7.27/49/57 on A/C FIO2 1, 14X550 133 98 22 146 4.4 28 2.7 Ca: 8.5 AST: 54 ALT: 16 Alk phos: 354 GGT: 295 Amylase: 75 Lipase: 30 LDH: 184 CK 410 (2.0) . Imaging: ECHO [**2112-2-23**] - EF > 55%; no evidence of vegetations . Initial CXR: 1. Asymmetric alveolar opacities, which may represent asymmetric pulmonary edema, pneumonia or ARDS. 2. Somewhat low lying position of endotracheal tube, 1.5 cm above the carina. T- and L-Spine MRI: Severely limited study secondary to motion artifacts in particular the axial post-gadolinium images. Signal changes indicating discitis and osteomyelitis are again seen at L3-4 level. New signal changes are seen at the superior endplate of L5 and L4-L5 disc which could be secondary to discitis at this level. No intraspinal abscess is seen. Further followup is suggested. [**2112-3-3**] TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60-70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The 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. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2112-2-23**], no major change is evident. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. [**2112-3-7**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the entire septum and anterior wall and mild dyskinesis of the distal inferior and apex. Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypetension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2112-3-3**], there has been a marked regional deterioration in left ventricular systolic function c/w interim ischemia (proximal LAD lesion). [**2112-3-9**] TTE: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (ejection fraction 20 percent) secondary to severe hypokinesis/akinesis of the entire interventricular septum and anterior free wall, severe hypokinesis of the lateral wall, and extensive apical akinesis. No definite masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. There is focal hypokinesis of the apical free wall of the right ventricle. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2112-3-7**], no major change is evident. [**2112-3-2**] 07:09PM BLOOD WBC-18.2*# RBC-3.64* Hgb-10.0* Hct-31.9* MCV-88 MCH-27.5 MCHC-31.4 RDW-19.1* Plt Ct-454* [**2112-3-4**] 03:50AM BLOOD WBC-8.4 RBC-2.38*# Hgb-7.0* Hct-20.2*# MCV-85 MCH-29.2 MCHC-34.4 RDW-19.9* Plt Ct-226 [**2112-3-14**] 06:52AM BLOOD WBC-18.5* RBC-4.30 Hgb-11.9* Hct-35.1* MCV-82 MCH-27.5 MCHC-33.7 RDW-18.0* Plt Ct-330 [**2112-3-2**] 07:09PM BLOOD Neuts-39* Bands-52* Lymphs-6* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* [**2112-3-5**] 03:51AM BLOOD Neuts-94.3* Bands-0 Lymphs-4.4* Monos-1.0* Eos-0.1 Baso-0.1 [**2112-3-14**] 06:52AM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2112-3-2**] 07:09PM BLOOD PT-20.0* PTT-150* INR(PT)-1.9* [**2112-3-4**] 03:50AM BLOOD PT-16.8* PTT-35.0 INR(PT)-1.5* [**2112-3-12**] 05:34AM BLOOD PT-15.4* PTT-65.7* INR(PT)-1.4* [**2112-3-13**] 05:29AM BLOOD PT-21.8* PTT-81.0* INR(PT)-2.1* [**2112-3-14**] 06:52AM BLOOD PT-33.6* PTT-100.1* INR(PT)-3.6* [**2112-3-2**] 07:09PM BLOOD Glucose-99 UreaN-30* Creat-2.4*# Na-138 K-4.1 Cl-105 HCO3-16* AnGap-21* [**2112-3-4**] 03:50AM BLOOD Glucose-115* UreaN-35* Creat-1.2* Na-141 K-3.7 Cl-106 HCO3-27 AnGap-12 [**2112-3-14**] 06:52AM BLOOD Glucose-177* UreaN-15 Creat-1.1 Na-138 K-3.8 Cl-96 HCO3-24 AnGap-22* [**2112-3-2**] 07:09PM BLOOD ALT-34 AST-185* LD(LDH)-505* CK(CPK)-289* AlkPhos-303* TotBili-0.2 [**2112-3-4**] 03:50AM BLOOD LD(LDH)-428* AlkPhos-198* TotBili-0.3 [**2112-3-3**] 02:56AM BLOOD CK(CPK)-343* [**2112-3-3**] 05:18PM BLOOD CK(CPK)-246* [**2112-3-14**] 06:52AM BLOOD ALT-14 AST-34 LD(LDH)-442* CK(CPK)-40 AlkPhos-192* Amylase-70 TotBili-0.7 [**2112-3-2**] 07:09PM BLOOD CK-MB-18* MB Indx-6.2* cTropnT-1.24* [**2112-3-3**] 02:56AM BLOOD CK-MB-26* MB Indx-7.6* cTropnT-0.85* [**2112-3-3**] 05:18PM BLOOD CK-MB-15* MB Indx-6.1* cTropnT-0.51* [**2112-3-4**] 01:21AM BLOOD CK-MB-12* MB Indx-5.2 cTropnT-0.49* [**2112-3-8**] 06:15PM BLOOD CK-MB-4 cTropnT-0.48* proBNP-[**Numeric Identifier 65803**]* [**2112-3-14**] 06:52AM BLOOD CK-MB-5 cTropnT-0.35* [**2112-3-2**] 07:09PM BLOOD Albumin-2.7* Calcium-7.0* Phos-6.2*# Mg-1.3* [**2112-3-4**] 03:50AM BLOOD Calcium-8.0* Phos-2.5*# Mg-2.1 [**2112-3-14**] 06:52AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.5* [**2112-3-2**] 07:59PM BLOOD Type-ART pO2-303* pCO2-54* pH-7.15* calHCO3-20* Base XS--10 [**2112-3-4**] 07:08AM BLOOD Type-ART Temp-36.3 pO2-155* pCO2-45 pH-7.39 calHCO3-28 Base XS-2 [**2112-3-14**] 05:52AM BLOOD Type-ART pO2-83* pCO2-38 pH-7.45 calHCO3-27 Base XS-2 [**2112-3-2**] 07:59PM BLOOD Lactate-4.3* [**2112-3-2**] 10:59PM BLOOD Glucose-117* Lactate-5.1* [**2112-3-14**] 05:52AM BLOOD Lactate-2.3* [**2112-3-2**] 07:32PM URINE Color-LtAmb Appear-SlCldy Sp [**Last Name (un) **]-1.020 [**2112-3-2**] 07:32PM URINE Blood-LGE Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2112-3-2**] 07:32PM URINE RBC-8* WBC-99* Bacteri-MANY Yeast-OCC Epi-1 [**3-3**] SCx: Pseudomonas aeruginosa - intermediate FQ sensitivity, otherwise pansensitive All BCx and UCx negative Brief Hospital Course: # Sepsis - Multiple possible sources of sepsis were initially considered, including urosepsis (dirty UA at OSH), pneumonia, worsening of epidural abscess, and possible periumbilical wound infection from laminectomy incision. Elevated alkaline phoshatase on admission also raised the possibility of biliary source or acalculous cholecystitis. A random cortisol was done which was 40.8. From the outside records, however, Mrs. [**Known lastname 18741**] may have received solumedrol on the recommendation of the pulmonology consult, and the decision was made to complete a 7 day course of hydrocortisone nad fludrocortisone. Her pressors were switched to levophed and vasopressin, and were weaned off over the next 36 hours. A RUQ U/S was done, which showed small amount of sludge, but no gallbladder wall thickening or edema, or pericholecystic fluid. Her LFTs trended back towards baseline. There was also significant concern of recurrent epidural abscess or progressive osteomyelitis, considering Mrs. [**Known lastname 21287**] recent admissions for these problems. [**Name (NI) **] the recommendations of her orthopedic surgeon, Dr. [**Last Name (STitle) 363**], a T- and L-spine MRI was done which, per Dr.[**Name (NI) 12040**] read, was consistent with normal post-operative changes and did not suggest a new focus of infection. She was continued on linezolid, with plans to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic to decide on ultimate length of therapy. Out of concerns about endocarditis, given recent VRE bacteremia, a TTE was done, which showed mildly thickened AV, but no vegetations. A TEE was considered, but pt considered too unstable. After her initial period of hypotension and fever, she remained hemodynamically stable. It was ultimately thought that the source of her sepsis was attributable to pneumonia or UTI. # Acute Coronary Syndrome - On arrival, Mrs.[**Known lastname 18771**] CK and troponin were elevated to 289 with MB of 18, and troponin-t 1.24. This peaked the next morning at CK 343 with MB 26, and troponin-t 0.85. She had no ST-T wave changes on her initial EKG, and these laboratory findings were thought to represent a troponin leak in the context of sepsis and hypotension. Cardiac enzymes were monitored and continued to trend down over the next 36 hours. A TTE was done on [**3-3**], which was read as normal EF (60-70%), no visualized WMAs. On the evening of [**2117-3-4**], it was noted that Mrs. [**Known lastname 18741**] became more tachycardic and hypertensive. A repeat TTE was ordered, which was done on [**3-7**], and demonstrated severe regional WMA with anterior and apical hypokinesis and preserved EF 20%. Cardiac enzymes were again cycled, and found to be 162 with MB 4, and troponin-T 0.54. EKG demonstrated TWI in all leads, but no ST elevations or depressions. She was placed on a heparin gtt, and medically optimized with high dose statin, captopril and metoprolol, which were titrated as BP allowed, and ASA. Cardiology was consulted. The continually down-trending cardiac enzymes from the time of admission were felt to be inconsistent with the profound change in TTE seen between [**3-3**] and [**3-7**]. A third TTE was done on [**3-9**], which also demonstrated EF 20% with anterior and apical HK. The best hypothesis was that Mrs. [**Known lastname 18741**] may have had an MI at the OSH, leading to the elevations in cardiac enzymes on admission, with a poor quality [**3-3**] TTE. It was felt that since the likely timing of her ischemic event was over a week prior, that catheterization was not indicated. She was placed on coumadin for apical akinesis, and heparin gtt was continued until therapeutic. She was transferred to the floor still on heparin gtt. # Hypoxic and Hypercarbic respiratory failure - [**2-25**] left sided infiltrates seen on CXR. Sputum cultures were positive for pseudomonas with intermediate FQ sensitivity, but otherwise pan-sensitive. She was placed on a 14-day course of Zosyn. She was gradually weaned from the ventilator with periods on pressure support. Her initial attempt at SBT failed, and she was thought to be significantly volume overloaded, with evidence of pulmonary edema on CXR and physical exam. Her BNP was 119,000. This volume overload was thought to reflect both increased administration of IVF, and decreased EF. She was aggressively diuresed (-6L over 36 hours), with expectation of extubation on [**3-10**]. On the morning of [**3-10**], Mrs. [**Known lastname 18741**] [**Name (STitle) 65804**]. Immediately afterwards, she was noted to be stridorous and laboring for breath. Through previous discussions with her family, and in discussions with Mrs. [**Known lastname 18741**] immediately after extubation, it was made clear that she did not wish to be reintubated, even if this was thought to be the only possible way to manage her respiratory condition. Racemic epinephrine was given x 2, and she was placed on NRB. Her SaO2 remained good, and with aggressive albuterol and atrovent nebs, she did well on O2 by NC over the next 24 hours. # MRSA osteomyelitis - As above, Dr. [**Last Name (STitle) 363**] consulted for input regarding her osteomyelitis and recent epidural abscess, as well as possible wound healing issues. Per Dr. [**Last Name (STitle) 363**], new findings on T- and L-spine MRI c/w normal post-op changes, no indication for urgent surgical management at this point, continued linezolid, with plan to speak with ID prior to d/c about duration of course. . # Anxiety/Depression - Post-extubation, Mrs. [**Known lastname 18741**] appeared significantly anxious and in poor spirits. Psychiatry saw pt, and recommended against starting SSRI [**2-25**] concurrent use of linezolid. Psychiatry also addressed code status further with Mrs. [**Known lastname 18741**] and her husband. After discussions, Mrs. [**Known lastname 18741**] remained DNR/DNI, but admitted that she would like to have further discussions about this issue with her husband, and may revisit the issue. Post-[**Hospital Unit Name 153**] course and death: Mrs. [**Known lastname 18741**] was called out to the floor on [**3-13**], and did well for the first 24-48 hours. Early on the morning of [**3-14**], around 4AM, however, she was noted to have increasing respiratory distress and mental status changes. An ABG done at 5AM was 7.43/38/56 and lactate 2.7, with repeat at 5:50AM 7.45/38/83, lactate 2.3. The [**Hospital Unit Name 153**] team saw Mrs. [**Known lastname 18741**] on the floor at 6AM, at which time she was noted to be confused and minimally responsive, but with no localizing neurological signs, and reactive pupils. A stat head CT was ordered at 6AM, and was transferred to the [**Hospital Unit Name 153**], arriving by 6:50AM. Immediately after arrival to the [**Hospital Unit Name 153**], she was noted to have extensor posturing on the right, and her right pupil was fixed and dilated. She was immediately sent for her head CT, which revealed substantial SAH and a moderate-sized right frontal lobe parenchymal hematoma and hemorrhage, with intraventricular involvement. A mild subfalcine herniation from right to left was noted. While getting her CT, Mrs.[**Name (NI) 18771**] husband was [**Name (NI) 653**] and, after an additional conversastion about code status, agreed that she would want to be intubated if necessary. After the results were known, by7:30AM, she was intubated for airway protection. Her last PTT was noted to be 81 on that morning's AM labs with INR 2.1, with PTT 100 and INR 3.6 on repeat. She was reversed with protamine and given 4U FFP. Neurosurgery was quickly consulted, who advised administration of mannitol, which was done. Given the extensive intraparenchymal and subarachnoid hemmorrhage, however, the neurosurgical team did not feel that surgical intervention or invasive ICP monitoring would contribute to a better outcome. Mrs.[**Known lastname 18771**] husband was [**Name2 (NI) 65805**], the situation explained, and he was asked to come in to the hospital. Once Mr. [**Known lastname 18741**] arrived, and the poor prognosis communicated, a decision was made to change the goal of care to comfort. Her ETT was d/c'ed, and her respirations quickly ceased. She was declared dead, and the proper post-mortem procedures were followed. Medications on Admission: On transfer: heparin gtt linezolid 600mg iv q12h levofloxacin 250mg ? vancomycin 1g iv q48h (last dose 2/8 at 4AM) gentamicin 180mg IV q48h (last dose 2/8 at 10AM) ativan 2-4mg q2-4h prn morphine 2-4mg q2-4hr prn fentanyl patch 125mcg albuterol nebs q4h atrovent nebs q4h esomeprazole 40mg daily colace 100mg [**Hospital1 **] asa 81mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Sepsis Hypoxic respiratory failure Pseudomonas pneumonia Myocardial infarction Subarachnoid hemorrhage Intraparenchymal and intraventricular hemorrhage Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

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icd9pcs

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2813, 2960

17,610

161,643

29032

Discharge summary

report

Admission Date: [**2158-3-21**] Discharge Date: [**2158-6-1**] Date of Birth: [**2092-3-5**] Sex: F Service: NEUROLOGY Allergies: Heparin Agents / Motrin / Phenobarbital / Vancomycin Attending:[**First Name3 (LF) 8850**] Chief Complaint: (1) Planned admission for autologous SCT on BEAM regimen (2) left intraparenchyma bleed Major Surgical or Invasive Procedure: Autologous stem cell transplant Left craniotomy and evacuation of hematoma x 2 History of Present Illness: This is a 65-year-old woman with Stage III high grade B cell lymphoma admitted for autologous stem cell transplant on the BEAM regimen. Upon admission, the patient reports she is feel well with the exception of a pulled muscle in her back which occurred this morning after slipping in the shower. Her pain is a [**2161-4-13**] and she was able to walk after this occurred. Additionally, she reports that is having a recurrence of diarrhea. She recently completed a course of PO Flagyl for C dificile. She was doing fine without recurrence of diarrhea until approximately 2-3 days ago when she started having multiple episodes of diarrhea every day, worse in the morning after eating breakfast and has [**5-14**] episodes of diarrhea in a short period of time. She reports that her current diarrhea appears to be the same as when she had C. difficile. On review of systems, she complains of a dry cough for over week but reports this has improved steadily and only has this intermittently. She denies fevers, chills, night sweats, sore throat, nausea, vomiting, diarrhea or shortness of breath. The patient is currently off her anticoagulation (has a history of HIT) and admits to persistent bilateral lower extremity edema (L>R) which has improved slightly which has remained. She is off anticoagulation given her thrombocytopenia and h/o HIT. She continues to have significant neuropathies in her feet with numbness, and loss of proprioception of the feet while ambulating. Past Medical History: Past Medical History: - Non-Hodgkin's lymphoma as outlined above. - Bilateral pulmonary emboli and left leg DVT. - Heparin-induced thrombocytopenia - Hypertension - Osteoarthritis - s/p Tonsillectomy - s/p Cholecystectomy - s/p Removal of a benign tumor from her right lower abdomen - s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic) involving the infrarenal IVC as well as a thrombosis of the left common iliac vein and left femoral veins. Past Oncologic History: (Per OMR note, [**2158-3-18**]) Onc history begins in [**10/2157**] when patient began to experience two week history of diarrhea, abdominal distention and discomfort. She was seen by her primary care provider and started on ciprofloxacin. Then on [**2157-10-18**], the patient presented to the [**Hospital3 **] emergency room with acute episode of shortness of breath. She was found to have bilateral pulmonary emboli on CTA and was started on heparin. Additional symptoms at that time included night sweats and fever but no weight loss. Evaluation during Mrs.[**Known lastname 69951**] initial admission with CTA showed bilateral proximal large PE's. CT of the chest, abdomen, and pelvis revealed a moderate-size right pleural effusion with enlarged axillary lymph nodes measuring 2.5 cm on the left and 1.5 cm on the right. There was noted a pericardial mass measuring 2.2 cm x 2.5 cm. There was also abnormal enhancement and thickening of the omentum of the lower abdomen and pelvis as well as large right inguinal lymph nodes measuring 2.6 cm. Note was also made of filling defect within the left common femoral artery consistent with DVT of the left lower extremity. Mrs. [**Known lastname **] was initiated on heparin therapy and underwent a left inguinal lymph node biopsy on [**2157-10-25**], which revealed high-grade large B-cell lymphoma with immunohistochemistry study strongly positive for BCL-2 and CD20. Cells were also positive for CD19, CD10, and lambda light chain. The C-MYC analysis was found to be 57%. Bone marrow aspirate and biopsy on [**2157-10-25**] revealed no evidence for lymphoma. Her LDH at diagnosis was 586. Mrs. [**Known lastname **] was then discharged on Lovenox and Coumadin. She underwent a PET scan on [**2157-10-28**], which revealed intense uptake within bilateral axillary node, presternal node, pericardial node, bulky mesenteric mass consistent with matted lymphadenopathy along with some right iliac and bilateral inguinal nodes and some uptake within the subcutaneous region around the umbilicus. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7117**] at [**Hospital6 2561**] on [**2157-11-1**] for initiation of treatment. Mrs. [**Known lastname **] was started on R-CHOP chemotherapy which was planned on a dose-dense schedule with her first cycle on [**2157-11-2**]. She was able to keep on schedule despite admissions for fever and neutropenia. Her sixth cycle was delayed by one week due to an admission for fever and neutropenia with completion of chemotherapy on [**2158-1-17**]. Her treatment was otherwise supported with Neulasta along with Aranesp. In [**11-14**], patient was found to have worsening swelling in her left lower extremity and was found to have heparin induced thrombocytopenia. She was started initially on lepirudin and then transitioned to Coumadin. Additionally, she also was found to have staph infection of her finger requiring surgical drainage and antibiotics and a subsequent staph infection of her right toe. These have both resolved. She had a POC placed for venous access but this became clotted and did not function. She then had a double lumen PICC line placed for the remainder of her treatment. This has since been removed. Mrs. [**Known lastname **] underwent a PET scan after four cycles of her chemotherapy on [**2158-12-9**]. This showed significant improvement within the chest with essentially complete resolution of FDG avid lymphadenopathy within the axilla and pericardial region. There was also significant improvement noted in the size of mesenteric mass with marked decrease degree of FDG uptake, although still with mild-to-moderate uptake noted. A PET scan at the completion of treatment showed no FDG-avid disease. Because Mrs. [**Known lastname **] presented with stage III high-grade lymphoma with significant adenopathy and aggressive disease, it was felt that autologous stem cell transplant offered the best potential for cure. This, however, presented with some difficulties due to her history of HIT and the fact that there would be periods of thrombocytopenia during her treatment course. The stem cells could be collected without the use of heparin and her [**Known lastname **] catheter could be maintained using sodium citrate instead of heparin flushes. Mrs. [**Known lastname **] also had a Port-A-Cath in place which was not functioning. In preparation for her chemotherapy for mobilization and stem cell collections and subsequent autologous transplant, Mrs. [**Known lastname **] was seen in interventional radiology on [**2158-2-10**] for Port-A-Cath removal and IVC filter placement. At the time of the IVC filter placement, there was demonstration of a large thrombus which was chronic in nature involving the infrarenal IVC as well as a thrombosis of the left common iliac vein and left femoral veins. Therefore, the IVC filter was placed in the suprarenal area. Her Port-A-Cath was also removed due to its nonfunctioning nature. The decision was made to proceed with a temporary [**Year (4 digits) **] catheter placement at the time of her stem cell collection as well as a temporary central line at the time of her autologous transplant. Because she would require periods of being off her Coumadin, Mrs. [**Known lastname **] would continue anticoagulation with fondaparinux 7.5 mg subcutaneous daily. Mrs. [**Known lastname **] was admitted for high dose Cytoxan for stem cell mobilization on [**2158-2-16**]. She tolerated this relatively well with some diarrhea, but developed profound pancytopenia as is expected requiring platelet and red cell transfusions. Her fondaparinux has been on hold since [**2158-2-24**] due to low platelets. She also required an admission on [**2158-3-1**] due to fever and chills. No infection source was found and the fevers were felt related to her Neupogen and recovering counts. Her stem cell collections were completed in eight days with over 5 million CD34 cells/kg collected. Social History: She was working fulltime at [**Company 378**] in customer support services prior to her diagnosis and treatment; she is currently on disability. She is also caring for her grandchild. She has been married for 41 years. She has two children, one son and one daughter, and four grandchildren. She is a nonsmoker and does not drink alcohol. Family History: - Mother: [**Name (NI) **] cancer. - Father: Prostate [**Name (NI) 3730**] - Patient has had two negative colonoscopies Physical Exam: Vital Signs: Temperature 97.7 F, blood pressure 134/81, heart rate 83, respiratory rate 20, O2 sat 100% in room air. GENERAL: NAD, Alert and oriented x 3 HEENT: PERRLA, Anicteric, MMM, No JVP CARDIOVASCULAR: RRR, Normal S1 + S2, No murmurs, rubs or gallops RESPIRATORY: Clear to auscultation bilaterally, No wheezes or crackles ABDOMEN: Soft, Nontender, NABS, No hepatosplenomegaly. Large scar in the RLQ from prior surgery. BACK: Tender upon active range of motion, but no pain upon palpation EXTREMITIES: No cyanosis, clubbing or edema; Lower extremities with 1+ edema in RLE and 2+ in LLE (which appears chronic) skin/nails: no rashes/no jaundice NEUROLOGICAL EXAMINATION: She was awake, alert, and oriented x 3. She was able to moves all 4 extremities spontaneously. Pertinent Results: [**2158-4-12**] 12:00AM BLOOD WBC-9.7 RBC-3.31* Hgb-10.2* Hct-28.9* MCV-88 MCH-30.8 MCHC-35.2* RDW-17.8* Plt Ct-20* [**2158-4-8**] 12:00AM BLOOD WBC-0.2* RBC-2.78* Hgb-8.7* Hct-23.5* MCV-85# MCH-31.2 MCHC-36.8* RDW-17.8* Plt Ct-10*# [**2158-3-30**] 12:00AM BLOOD WBC-4.0 RBC-2.84* Hgb-9.0* Hct-25.9* MCV-91 MCH-31.6 MCHC-34.7 RDW-20.9* Plt Ct-37* [**2158-3-21**] 12:28PM BLOOD WBC-6.4 RBC-3.04* Hgb-9.8* Hct-28.2* MCV-93 MCH-32.3* MCHC-34.9 RDW-22.0* Plt Ct-86* [**2158-3-28**] 12:00AM BLOOD Neuts-98.8* Bands-0 Lymphs-0.3* Monos-0.6* Eos-0.1 Baso-0.1 [**2158-3-26**] 12:01AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3* Monos-1.4* Eos-0.2 Baso-0.2 [**2158-3-21**] 12:28PM BLOOD Neuts-81.7* Lymphs-13.8* Monos-3.6 Eos-0.7 Baso-0.2 [**2158-3-28**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Stipple-OCCASIONAL [**2158-4-12**] 12:00AM BLOOD Plt Ct-20* [**2158-4-7**] 12:00AM BLOOD Plt Ct-36* [**2158-3-27**] 01:30AM BLOOD Plt Ct-62* [**2158-3-21**] 12:28PM BLOOD Plt Ct-86* [**2158-3-21**] 12:28PM BLOOD PT-14.0* PTT-25.4 INR(PT)-1.2* [**2158-3-22**] 12:00AM BLOOD Fibrino-430* [**2158-4-12**] 12:00AM BLOOD Gran Ct-7310 [**2158-4-11**] 12:00AM BLOOD Gran Ct-5350 [**2158-4-10**] 12:10AM BLOOD Gran Ct-940* [**2158-4-9**] 12:00AM BLOOD Gran Ct-110* [**2158-4-8**] 12:00AM BLOOD Gran Ct-0* [**2158-4-7**] 12:00AM BLOOD Gran Ct-10* [**2158-4-6**] 12:00AM BLOOD Gran Ct-20* [**2158-4-5**] 12:00AM BLOOD Gran Ct-10* [**2158-4-4**] 12:00AM BLOOD Gran Ct-0* [**2158-4-3**] 12:00AM BLOOD Gran Ct-10* [**2158-4-1**] 12:00AM BLOOD Gran Ct-80* [**2158-3-31**] 12:00AM BLOOD Gran Ct-1440* [**2158-3-30**] 12:00AM BLOOD Gran Ct-3910 [**2158-3-29**] 12:00AM BLOOD Gran Ct-4490 [**2158-4-12**] 12:00AM BLOOD Glucose-97 UreaN-14 Creat-0.6 Na-135 K-3.7 Cl-100 HCO3-25 AnGap-14 [**2158-4-8**] 12:00AM BLOOD Glucose-141* UreaN-24* Creat-0.6 Na-135 K-3.6 Cl-105 HCO3-24 AnGap-10 [**2158-3-29**] 12:00AM BLOOD Glucose-171* UreaN-20 Creat-0.6 Na-140 K-3.8 Cl-107 HCO3-23 AnGap-14 [**2158-3-21**] 12:28PM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-144 K-3.8 Cl-109* HCO3-27 AnGap-12 [**2158-4-12**] 12:00AM BLOOD ALT-16 AST-25 LD(LDH)-373* AlkPhos-90 TotBili-0.5 [**2158-4-5**] 12:00AM BLOOD ALT-16 AST-12 LD(LDH)-240 AlkPhos-47 TotBili-0.5 [**2158-3-29**] 12:00AM BLOOD ALT-41* AST-26 LD(LDH)-184 AlkPhos-45 TotBili-0.5 [**2158-3-21**] 12:28PM BLOOD ALT-25 AST-21 LD(LDH)-195 AlkPhos-63 Amylase-30 TotBili-0.3 [**2158-3-22**] 12:00AM BLOOD Lipase-34 [**2158-3-21**] 12:28PM BLOOD Lipase-40 [**2158-4-12**] 12:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9 UricAcd-2.0* [**2158-4-9**] 12:00AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.3 Mg-2.1 UricAcd-1.6* [**2158-4-4**] 12:00AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.7 UricAcd-2.8 [**2158-3-29**] 12:00AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7 UricAcd-4.3 [**2158-3-24**] 12:00AM BLOOD Albumin-3.6 Calcium-8.2* Phos-2.7 Mg-1.8 UricAcd-5.2 [**2158-3-21**] 12:28PM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.3 Mg-2.0 UricAcd-5.9* [**2158-3-27**] 01:30AM BLOOD Hapto-168 [**2158-4-5**] 12:00AM BLOOD Triglyc-94 [**2158-3-27**] 08:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2158-3-21**] 11:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2158-3-27**] 08:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2158-3-21**] 11:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG CMV Viral Load (Final [**2158-3-29**]): CMV DNA not detected. Performed by PCR. Detection Range: 600 - 100,000 copies/ml. FOR RESEARCH USE ONLY.. NOT FOR USE IN DIAGNOSTIC PROCEDURES. This test has been validated by the Microbiology laboratory at [**Hospital1 18**]. All other culture data (-), CDiff [**3-22**] +, CDiff [**4-5**] (-), CDiff [**4-6**] (-) CXR [**3-21**] - FINDINGS: AP single view of the chest obtained with patient in sitting upright position is analyzed in direct comparison with a similar chest examination of [**2158-3-1**]. Heart size is unchanged and within normal limits. Mildly elongated thoracic aorta with some calcium deposits in the wall at the level of the arch, also unchanged. No pulmonary vascular congestion and no evidence of acute infiltrates. IMPRESSION: Stable chest findings. No evidence of acute cardiovascular pulmonary processes. LSpine xray - The vertebral bodies are intact and normally aligned with no evidence of compression fracture. Pedicles and posterior elements appear normal. There is no paravertebral soft tissue swelling. Slight scoliosis, convex right is visualized. There are some surgical clips in the right upper quadrant and an IVC filter noted. IMPRESSION: L-spine shows only subtle degenerative changes and slight scoliosis but no evidence for metastasis, compression fracture or definite explanation for back pain. [**3-26**] - MRI spine - FINDINGS: No vertebral or paraspinal pathology is seen. There is no spinal stenosis or spondylolisthesis. The visualized distal spinal cord, conus medullaris, and cauda equina are unremarkable. There are moderate-sized anterior osteophytes extending off of the T12 and L1 vertebral bodies. At L2/3, there is a minimal disc bulge with no neural compression. At L3/4, there is a mild disc bulge indenting the thecal sac with no neural compression. IMPRESSION: 1. L2/3 and L3/4 disc bulges with no neural compression. KUB [**3-31**] - No evidence of free intraabdominal air is noted. No evidence of small bowel dilatation is noted. Air is noted within the ascending [**Month/Year (2) 499**] and sigmoid [**Month/Year (2) 499**] excluding a small bowel obstruction. Small-sized air-fluid levels are noted within the small bowel. Incidental note is made of IVC filter. The visualized portions of lung bases are unremarkable. IMPRESSION: No evidence of bowel obstruction or free intraabdominal air is noted. [**4-8**] - CXR portable - FINDINGS: There is no significant change in the right subclavian line with tip in the SVC/RA junction. There is some patchy increased opacity at the left base similar to the film from two weeks ago. There is no new infiltrate. There is no pneumothorax. The cardiac and mediastinal silhouettes are unchanged. Brief Hospital Course: Mrs. [**Known lastname **] is a 65-year-old woman with Stage III high grade B cell lymphoma admitted for autologous stem cell transplant on the BEAM regimen. (1) Stage III High-Grade Non-Hodgkin's Lymphoma: The patient was admitted for autologous stem cell transplant with BEAM therapy. She tolerated her chemotherapy well. She was continued on Ciprofloxacin for prophylaxis. Her counts were supported with PRBCs and platelets as needed. Her course was complicated by recurrent diarrhea for which she was found to be positive C dificle. She has a history of C. difficile and recently finished a 2 week course of PO Flagyl. In this setting, she was started on PO Vancomycin for possible treatment failure C dificile. The patient received 9 total bags of stem cells and was found to be approximately 15 pounds up from her admission weight after getting IVFs during chemotherapy and her stem cells. She was gently diuresed on a daily basis back to near her admission weight. Additionally, while he patient was neutropenic, she began to experience increased abdominal pain described as crampy in nature and worse in the RLQ for which Cefepime/Flagyl were added for possible infectious process. Her abdominal pain seemed to improve after starting antibiotics, and days prior to her discharge, was significantly improved. She was started on Neupogen on Day +4 and continued for a total of 9 days. (2) Abdominal Pain: As the patient's counts trended down, she complained of right sided abdominal pain and was started on Cefepime/Flagyl for concern of an infectious process in the setting of treatment failure C dif. An xray was performed which showed no obstruction or free air, only occasional air fluid levels. The patients abdominal pain improved significantly after having bowel movements. The abdominal pain recurred after her fourth evacuation of her SDH. The etiology was unclear. Abd/pelvic CT was negative for a concerning abdominal process. The patient was given suppositories with some relief. (3) C. Difficile Diarrhea: The patient has a history of C. difficile diarrhea for which she completed a two week course of PO Flagyl about 10 days prior to admission. She had a recurrence of loose stools and was found to be positive again for C. difficile during this hospitalization. She was started initially on PO Vancomycin for possible Flagyl treatment failure. During her autologous transplant, she experienced worsening of her diarrhea for which IV Flagyl was added, in addition to PO vancomycin - with which she was not fully compliant as she did not like the taste. The patient's flagyl course was completed. The diarrhea resolved over a 5 day period with antibiotics and assistance of loperamide. (4) h/o Pulmonary Embolus and HIT: The patient was diagnosed with heparin induced thrombocytopenia during her inital workup and presentation at [**Hospital6 2561**]. A filter was placed and she was put on Fondoparinux for a period of time. On admission, her fondaparinox had been stopped because of low platelets. All heparin products were avoided given history of HIT. Patient was not treated with any anticoagulation throughout her stay. Her platelets had a small drop after the initiation of famotidine treatment and this medication was discontinued the day prior to her discharge. (5) Lower Extremity Edema, L>R: The patient has a history of chronic lower extremity edema thought to be secondary to the lower extremity DVTs found when she was initially diagnosed with lymphoma. She has a left common femoral DVT which explains her left > right lower extremity edema. The patient's lower extremity edema was stable. (6) Back Pain: History and physical exam were most consistent with a muscle strain. A xray of the lumbar spine was negative for compression fractures or other obvious etiology to explain her disease. An MRI did show slight disc protrusions at L2/3 and L3/4 but no evidence of neural impingement. The patient was treated with warm compresses and PRN Oxycodone. (7) Neuropathy: Per patient, this is chemotherapy related peripheral neuropathy. Patient reports difficulty with proprioception and occasional falls at home when ambulating. She takes a Vitamin B complex as per outpatient regimen which was discontinued temporarily during her autologous transplant. She was seen by physical therapy upon admission and used a walker to ambulate for most of her stay. She was put on fall precautions. She did have one fall (see SDH/IPH). (8) Left ICH/SDH: Patient fell and hit her head just prior to d/c home (with plt count of 18), suffered left parieto-occipital IPH and SDH. Patient was confused and mildly disoriented post-fall (on [**4-12**]), but on [**4-13**] on way to CT scanner pt acutely decompensated and became non-responsive/only withdrawing to pain, and her CT showed increased size of bleed. Patient was taken emergently to Or for L craniotomy and evacuation of hematoma; her post-op CT was not significantly changed, so she returned to the OR later that same day ([**4-13**]) for repeat evacuation. The follow-up CT at this time showed decreased mass effect and midline shift. On the morning of [**2158-4-18**], patient developed acute change in mental status, with progression from disorientation to unresponsiveness in the setting of hypertension fever, and hypoxia; Repeat head CT x 2 was done on [**2158-4-18**], and showed no acute changes post her neurosurgery. She was started on Ceftaz, vancomycin, and Acyclovir. She was put on a nitro drip for her HTN. An LP was done which showed [**5-17**] WBC w/ lymphocyte predominance. We checked her daily dilantin level corrected for albumin for goal 15-20. She had an EEG done on [**2158-4-18**] which showed spike waves in left frontal and temporal region c/w her prior bleeding. MRI on [**2158-4-19**] showed left hemisphere swelling, but no acute ischemic changes. Her mental status gradually improved from brainstem reflex only on the early morning of [**2158-4-18**] to withdraw to pain stimulus on mid morning of [**2158-4-18**], to opening eyes spontaenously, following commands, moving all extremities, said "hi" on morning of [**2158-4-19**], to able to speak a couple words, but continued expressive, Wernicke's type, aphasia on morning of [**2158-4-20**]. She was weaned of her nitro drip and started on metoprolol 25 mg PO TID to keep SBP<160. Her respitory status improved as her mental status improved back to her baseline prior to [**Hospital Unit Name 153**] transfer. Neurology and neurosurgery continued to followed the patient during her course. She was called out on to the BMT service on [**2158-4-21**]. While on the BMT service the patient's neurological status improved. PT was working with her and her Wernicke's aphasia was also improving. On [**2158-4-26**], the patient's neuro exam changed. She had worsening RLE and RUE hemiparesis and was much less verbally interactive. A repeat heat CT and MRI showed increasing size of the SDH compared to her scan on [**2158-4-18**]. She was given platelets to increase her platelet count from 70 to > 100. Neurosurgery was notified and took the patient to the OR for evacuation of the blood. She was transferred back to BMT service on [**4-29**] but a repeat CT scan on [**2158-5-1**] showed increasing size of the SDH and shift. Her clinical exam was slightly improved to stable. Her SBP was kept below 160 and her platelets were kept >80 at all times. She was again transferred to the NS service and underwent surgical evacuation of her SDH (fourth time). She was transferred back to the BMT service on [**2158-5-3**]. Her exam was improved. She was able to lift her RUE against gravity and had 5/5 strength in her LUE. She would wiggle both toes to command and would move both legs intermittantly, but not to command. She was kept on dilantin for seizure prophylaxis. Her course was further complicated by ongoing agitation and fever of unkown origin. She have fever spikes daily to 101-103, with no source of infection identified. She was broadly covered with Vanc/Cefepime/Voriconazole/Flagyl. Thought to be possible aspiration event, but her respiratory status was not compromised and she continued to spike fevers despite treatment. As of [**2158-5-20**] - she continued to have fevers. Agitation: she would have parocysms of extreme dysphoria, with loud moaning and crying. Due to her aphasia, she was unable to communicate any specific discomfort. Initially this was attempted to be controlled with Dilaudid and Ativan. We obtained both neurology and psychiatry input. With there help, we changed the aggitation managment to Haldol. She was uptitrated on Keppra and downtitrated on Dilantin for seizure prophylaxys. However, her WBC began to drop and keppra was supected as a possible [**Doctor Last Name 360**]. [**5-20**] neurology was asked about an alterantive seizure medicine. this also would help ally psychiatry's fears of keppra causing some of her aggitation. Agitations finally improved on standing low dose haldol (1mg every 8 hours) and keppra. All narcotics were held to prevent further mental status depression. (9) Transaminitis: The patient developed transaminitis in the setting of abdominal pain, delirium, and expressive aphasia. It was difficult to ascertain the cause of this transaminitis and if it was related to her abdominal pain. Both an abdominal USN and abd/pelvic CT were done which did not reveal any pathology. Her fluconazole and acyclovir were held as these were possible sources of her transaminitis. (10) Thrush: The patient developed thrush and was started on fluconazole. The fluc was discontinued once her LFTs became elevated. . (11) Yeast UTI: urine cultures positive for 10K-100K yeast. Treated with 5 days of fluconazole. (12) Nutrition: Status post J-tube placement and tubefeeds (concentrated TFs to keep rate less than 40ml/hour; higher rates caused emesis.). TF changed to nutren 2.0 + beneprotein, which caused some diarrhea. (13) Respiratory Distress: Desatted to mid-80s on room air and became tachypneic to 40/min. Chest Xray was consistent with volume overload and basilar atelectasis vs aspiration. Repeat CXR with new infiltrate. Improved with antibiotics and diuresis. (14) Zoster: Rash on back that was confirmed by DFA to be VZV. It was treated with 7 days of Acyclovir. (15) Cytopenia: This is from unclear etiology, was thought to be related to drugs. All antibiotics were held and GCSF restarted. WBC finally recovered, and GCSF could be held again. Of note, during the course of cytopenia antibiotics had to be restarted again without negative effect on cell counts. Medications on Admission: - B-Complex with Vitamin C 1 tab PO daily - Atenolol 100 mg PO daily - Oxycodone 5 mg PO Q6H PRN pain - Potassium chloride 20mEq PO daily - Tylenol PRN back pain - Ativan PRN insomnia Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 2. Blistex Lip Ointment Ointment Sig: One (1) Topical QID (4 times a day). 3. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q8H (every 8 hours) as needed for fever. 4. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QDAILY (). 6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Sodium Chloride 0.9% Flush 10 ml IV EVERY SHIFT & PRN CVL with HX HIT 10 ml NS to each lumen every shift and PRN. Inspect site every shift. 11. MethylPREDNISolone Sodium Succ 10 mg IV Q24H 12. Levetiracetam 500 mg IV Q 8H 13. FoLIC Acid 1 mg IV DAILY [**Month (only) **] PUT THRU PEG TUBE! 14. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO every Mo We Fr. 15. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. 16. Acyclovir Sodium 500 mg Recon Soln Sig: Eight Hundred (800) mg Intravenous three times a day for 4 days: Last dose Sunday, [**2158-6-4**] in PM. 17. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day: start on Monday, [**2158-6-5**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Non-Hodgkin's lymphoma Secondary: 1. Bilateral pulmonary emboli and left leg DVT. 2. Heparin-induced thrombocytopenia 3. Hypertension 4. Osteoarthritis 5. s/p Tonsillectomy 6. s/p Cholecystectomy 7. s/p Removal of a benign tumor from her right lower abdomen 8. s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic) involving the infrarenal IVC as well as a thrombosis of the left common iliac vein and left femoral veins. Discharge Condition: Patient discharged to home in stable condition, afebrile, ambulating on her own, tolerating PO feeds and fluids. Discharge Instructions: Patient was admitted for chemotherapy and stem cell transplant. Patient is advised to do the following: 1. Keep all follow-up appointments. 2. Take all medications as prescribed. 3. To seek medical attention if she acquires chest pain, shortness of breath, nausea, vomiting, or any other concern that is out of the ordinary for her. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**7-18**] days Completed by:[**2158-6-1**]

[ "112.0", "E934.2", "853.01", "112.2", "293.0", "356.9", "052.9", "008.45", "780.6", "E885.9", "428.0", "V15.88", "782.3", "202.80", "287.4", "784.3", "401.9", "847.9", "284.8", "E888.1", "V12.51", "790.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "41.04", "01.39", "96.6", "99.25", "03.31", "99.05", "99.14", "01.23", "99.04", "44.32", "99.15" ]

icd9pcs

[ [ [] ] ]

28511, 28590

16108, 26760

400, 481

29082, 29196

9777, 16085

29580, 29699

8848, 8969

26994, 28488

28611, 29061

26786, 26971

29220, 29557

8984, 9758

273, 362

509, 1987

2031, 8477

8493, 8832

7,614

101,341

47434

Discharge summary

report

Admission Date: [**2174-10-15**] Discharge Date: [**2174-10-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Chills and cough Major Surgical or Invasive Procedure: none History of Present Illness: 80y/o M with CAD, EF 55%, COPD, HTN, DM who presented with 1-2 days of increasing cough that became productive, sudden acute weakness and chills. He was sent to the ED because wife was afraid of patient falling. In the ED patient initially normotensive, then suddenly had blood pressure drop to 70/40. Patient given 3L of NS bolus with improvement in blood pressure to 140's. However, increase in blood pressure not sustained and patients blood pressure decreased to 90/50 and started on MUST protocol [**1-3**] increased lactate. Patient was then transferred to the MICU. In MICU given CTX/Azithro, was pan cultured, obtained [**Last Name (un) 104**] stim test. Observed o/n and stabilized. Also noted to have elevated trops which have begun to decrease and no ecg changes. Transferred to floor. Past Medical History: 1. CAD with evidence of 3vessel disease on cardiac cath [**9-4**]. 2. CHF with EF of 55% 3. CRI (b/l 1.7) 4. OSA 5. HTN 6. Diabetes Social History: Retired meat packer, lives with wife, has a nurse that helps him at home up until 4pm. She helps with most of the activities and treatments that the patient needs. She also does some rehab. no tob, no etoh, no ivdu Family History: NC Physical Exam: On admission to floor. T: 97.3, P: 64, BP: 140/79, R: 23 96% on 3L NC GEN: Alert and oriented x 3, NAD, wife at bedside [**Name (NI) 4459**]: NC/AT, wears glasses, EOMI, PERRL, o/p clear, mmm NECK: no LAD, unable to appreciate JVD [**1-3**] neck girth CV: distant, RRR, no m/r/g Pulm: right lung base with crackles, expiratory wheezes. Left lung field without crackles/rhonchi/wheezes. Abd: soft, NABS, protuberant, NT, mild distension. Ext: no c/c/e, DP/PT 1+ b/l Neuro: NC II-XII grossly intact, sensation intact to light touch, strenght: lower ext hip flexors [**2-4**] b/l rest wnl. Pertinent Results: [**2174-10-15**] 06:28PM LACTATE-2.6* [**2174-10-15**] 04:38PM URINE HOURS-RANDOM [**2174-10-15**] 04:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2174-10-15**] 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2174-10-15**] 03:04PM LACTATE-3.1* [**2174-10-15**] 02:45PM GLUCOSE-211* UREA N-37* CREAT-2.0* SODIUM-139 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-19 [**2174-10-15**] 02:45PM CK-MB-8 cTropnT-0.58* [**2174-10-15**] 02:45PM ALBUMIN-4.2 CALCIUM-9.7 MAGNESIUM-1.7 [**2174-10-15**] 02:45PM CORTISOL-39.0* [**2174-10-15**] 02:45PM WBC-14.0* RBC-4.95 HGB-14.4 HCT-40.9 MCV-83 MCH-29.2 MCHC-35.3*# RDW-15.5 [**2174-10-15**] 02:45PM NEUTS-69 BANDS-23* LYMPHS-2* MONOS-4 EOS-0 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [**2174-10-15**] 02:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2174-10-15**] 02:45PM PLT COUNT-186 CHEST (PORTABLE AP) [**2174-10-15**] 8:04 PM No subclavian line is present. There is no evidence of a pneumothorax. The heart remains enlarged, right effusion is present. Compared to the prior film of 5 hours earlier the vasculature appears slightly more prominent and the degree of failure may be now occurring. IMPRESSION: No pneumothorax, cardiomegaly with some evidence of failure. CHEST (PORTABLE AP) [**2174-10-15**] 3:05 PM AP CHEST: This study is limited by low lung volumes and respiratory motion. The heart, mediastinal and hilar contours are unchanged in the interval allow- ing for differences in technique. The aorta is tortuous. There is some elevation of the right hemidiaphragm with possible atelectasis at the right base. IMPRESSION: Limited study due to Low lung volumes and motion. ECG: Sinus rhythm. Conduction defect of right bundle-branch block type. Low QRS voltages in precordial leads. Since the previous tracing of [**2173-9-30**] ventricular ectopy is resolved Brief Hospital Course: 1. PNA: Patient was admitted to the MICU and was aggressively hydrated with fluids and treated with abx: azithromycin and Ceftriaxone. He was pancultured with blood culture and urine culture both negative. His sputum grew many diferent types of oral flora. [**Last Name (un) **] stim test was done but was no longer needed as patient quickly stabilized, no steroides were instituted. He was stabilized and transferred to floor. Abx were continued, Physical therapy and pulmonary toilet were both requested and performed while on the floor. He was continued on his alb/atrovent nebs for the wheezes. He was discharged stable on room air without supplemental oxygen and on azithromycin and cefpodoxime. 2. CAD: asa, lipitor were both continued while in the hospital. He was noted to have elevated troponins but in review of his records he has elevated troponins at baseline due to his CRI. Thus, the small rise in his troponins on this admission was [**1-3**] demand ischemia in setting of stress/hypotension. No further workup was done. CHF: stable, no evidence of heart failure. His Accupril was restarted on day of discharge as his blood pressure had been stable while on the floor for more than 24hours. 3. COPD: stable continued on fluticasone/salmeterol, alb/atrovent, tiotropium 4. OSA: stable, continued on his outpatient doses of ritalin sr and ritalin 5. HTN: restarted on Accupril 5mg once a day. 6. DM: stable, continued on his outpatient NPH doses, and RISS 7. Glaucoma: stable continued on his outpatient latanoprost and timolol 8. Psych: stable continued on his outpatient meds 9. FEN: cardiac healthy diet, [**Doctor First Name **], 2gm sodium 10. Full code. Medications on Admission: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Methylphenidate HCl 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 15. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-3**] Puffs Inhalation Q6H (every 6 hours). 17. medication NPH 20U before breakfast and 20U before dinner 18. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Methylphenidate HCl 20 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 15. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-3**] Puffs Inhalation Q6H (every 6 hours). 17. medication NPH 20U before breakfast and 20U before dinner 18. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* 19. Cefpodoxime Proxetil 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 8 days. Disp:*32 Tablet(s)* Refills:*0* 20. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day. 21. equipment Home Nebulizer Dispense: one Refills: zero Discharge Disposition: Home Discharge Diagnosis: 1. Pneumonia 2. Hypotension Secondary 3. CAD 4. CHF 5. COPD 6. OSA 7. HTN 8. Diabetes 9. Cervical Spondylosis 10. Myopathy Discharge Condition: Stable, ambulatory sats stable. Discharge Instructions: Please take all your medications as prescribed and follow up with all your recommended appointments. Please call your primary care physician if you develop: fevers, chills, chest pain, shortness of breath or other concerning symptoms. You can restart your accupril. Followup Instructions: 1. Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week. Please call to schedule an appointment at [**Telephone/Fax (1) 904**].

[ "721.1", "038.9", "428.30", "414.01", "593.9", "486", "428.0", "995.91", "401.9", "496", "780.57", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9258, 9264

4167, 5842

280, 287

9431, 9464

2145, 4144

9780, 9944

1518, 1522

7421, 9235

9285, 9410

5868, 7398

9488, 9757

1537, 2126

224, 242

315, 1113

1135, 1269

1285, 1502

49,683

185,917

53990

Discharge summary

report

Admission Date: [**2106-8-26**] Discharge Date: [**2106-8-31**] Date of Birth: [**2066-11-7**] Sex: M Service: MEDICINE Allergies: lisinopril Attending:[**First Name3 (LF) 594**] Chief Complaint: Chief Complaint: Hypotension Reason for MICU transfer: Hypotension Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: Mr. [**Known lastname **] is a 39 y.o. man with history of ESRD on HD due to FSGS, RCC with known brain, pulmonary, and hepatic metastases s/p chemo and XRT, who presented to the MICU for hypotension. Notably, he was discharged from [**Hospital1 18**] yesterday to [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. On his last admission, he was sent to the [**Hospital Unit Name 153**] for hypotension which he developed during an MRI. There was concern that it was a contrast reaction, although this was considered unlikely. He also was found to have new ascites and progression of his metastatic disease. His ascites was tapped, and given the 1600 neutrophils he was treated for SBP w/ ceftriaxone. This morning, he was brought for dialysis. When he sat up for dialysis, he became dizzy and hypotensive to the 80s. He was unable to receive dialysis in this setting. He mother notes that he may not have received all of his medications yesterday given the gap between discharge from [**Hospital1 18**] and admission to [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **]. He noted a new raspy voice since this morning, diaphoresis, and a non-productive cough. He also reports that he hasn't had a bowel movement in a week and a half and has had intermittent abdominal pain. He also has had intermittent groin, leg, feet, back, and collarbone pain. He denied fevers/chills, chest pain, SOB, nausea/vomiting, and abdominal pain. Due to his hypotension, he was brought to [**Hospital 47**] Hospital, where they performed a CXR showing an infiltrate. He was started on levaquin and vancomycin, given 1L NS, and he had a R IJ placed. He became hypotensive to the 80s and hypoxic. However, he was 100% on a non-rebreather mask. He was started on a phenylephrine drip (2.5 mcg). He was then transferred to the [**Hospital1 18**] ED. In the [**Hospital1 18**] ED, VS: T 97.1, HR 96, BP 96/54, RR 26, O2sat 97% 2L NC. Labs in the ED were remarkable for K 4.6, BUN 25, Cre 5.4, WBC 7.1, and Hct 28.7. CXR was concerning for a pneumonia. He was continued on phenylephrine and received 2g cefepime. Renal was made aware and will see in the morning. On arrival to the MICU, VS: T 97.7, HR 91, BP 120/84, RR 18, 100% on 4LNC. He had b/l crackles on pulmonary exam, and he had a markedly distended abdomen and absent bowel sounds. Past Medical History: Past Medical History: # ESRD DUE TO: FSGS # ON RENAL REPLACEMENT SINCE: [**2090**] # ACCESS HISTORY AND COMPLICATIONS: R forearm AVF # Renal cell carcinoma, diagnosed on lymph node dissection and wedge resection of RUL, [**2106-4-8**]; brain mets seen on MRI same month; s/p cyberknife radiosurgery, [**2106-6-8**] Hypotension/Hypertension Past Surgical History: -multiple AV fistula placements/repairs -2 breast reduction procedures -2 operations for undescented testes -right orchiectomy -kidney biopsy -repair of a ruptured quadriceps tendon Social History: Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD x 20yrs and quit approximately one month ago. Prior history of alcohol dependence, but quit approximately four years ago. Family History: His mother is healthy at age 60. His father died at age 48 from throat cancer (he consumed cigarettes and alcohol) and colon cancer. His sister and brother are healthy but another brother has the "gene" for colon cancer and gets yearly check ups Physical Exam: Vitals: T 97.7, HR 91, BP 120/84, RR 18, 100% on 4LNC General: Alert and oriented x 3, NAD HEENT: oropharnyx clear, MMM Neck: no LAD CV: RRR, nl S1/S2, no murmurs, rubs, gallops Lungs: diffuse crackles b/l Abdomen: soft, NT, markedly distended, BS absent, no organomegaly Ext: WWP Neuro: alert and oriented x 3, asterixis present Pertinent Results: [**2106-8-26**] 10:42PM LACTATE-1.6 [**2106-8-26**] 10:18PM GLUCOSE-91 UREA N-27* CREAT-5.6* SODIUM-141 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-19 [**2106-8-26**] 10:18PM ALT(SGPT)-7 AST(SGOT)-11 LD(LDH)-195 ALK PHOS-128 TOT BILI-0.2 [**2106-8-26**] 10:18PM cTropnT-0.06* proBNP-4374* [**2106-8-26**] 10:18PM ALBUMIN-3.3* CALCIUM-9.8 PHOSPHATE-4.9* MAGNESIUM-2.0 [**2106-8-26**] 10:18PM TSH-15* [**2106-8-26**] 10:18PM CORTISOL-19.8 [**2106-8-26**] 10:18PM WBC-10.8# RBC-3.29* HGB-9.5* HCT-31.5* MCV-96 MCH-28.9 MCHC-30.1* RDW-19.2* [**2106-8-26**] 10:18PM PLT COUNT-401 [**2106-8-26**] 05:38PM COMMENTS-GREEN [**2106-8-26**] 05:38PM LACTATE-1.2 [**2106-8-26**] 05:35PM GLUCOSE-83 UREA N-25* CREAT-5.4*# SODIUM-141 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-19 [**2106-8-26**] 05:35PM estGFR-Using this [**2106-8-26**] 05:35PM WBC-7.1# RBC-2.98* HGB-8.7* HCT-28.7* MCV-96 MCH-29.1 MCHC-30.3* RDW-18.9* [**2106-8-26**] 05:35PM NEUTS-88.5* LYMPHS-7.2* MONOS-3.3 EOS-0.5 BASOS-0.4 [**2106-8-26**] 05:35PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ STIPPLED-1+ [**2106-8-26**] 05:35PM PLT SMR-NORMAL PLT COUNT-299 [**2106-8-25**] 11:20AM CREAT-4.1*# [**2106-8-25**] 11:20AM HCT-29.6* . CXR [**8-26**] The multifocal airspace opacities have overall slightly improved in the background of metastatic disease and mild pulmonary edema; however, the right upper lobe opacity remains. There is also unchanged mild pulmonary edema. The right IJ line ends in the right cavoatrial junction. No pneumothorax. . KUB [**8-27**] NGS: Three supine images of the abdomen show some stacking of the small bowel. This could represent ileus, but would also be consistent with patient's history of ascites. The loops of bowel do not appear to be distended and there is no obvious evidence of obstruction. Given the supine nature of these films, we are unable to assess for fluid levels or free air in the abdomen. Visualized osseous structures are unremarkable, though these images are limited somewhat because of underpenetration. IMPRESSION: Slight stacking of the small bowel which likely represents ileus but may also be secondary to ascites. Brief Hospital Course: 39 y.o. man w/ a history of ESRD on HD due to FSGS, RCC with known brain, pulmonary, and hepatic metastases s/p chemo and XRT, admitted to the MICU for hypotension which was likely a manifestation of his chronic hypotension from loss of tone from his metastatic disease burden, hypothyroidism, and hypovolemia. The patient's condition deteriorated in the MICU, and after discussion with the patient's family, we transitioned care to comfort measures only. Hypotension: He had several potential etiologies for his hypotension. He does have known baseline hypotension which may have worsened in the setting of not receiving all of his doses of midodrine the day prior to admission. He may also have been volume depleted in the setting of not having air conditioning and becoming diaphoretic, increasing his insensible losses. Hypothyroidism is a possibility given TSH of 15. Obstructive shock due to metastatic disease/ascites is another possibility. Much less likely was the development of septic shock from his possible pneumonia found on CXR. Given his known pulmonary metastases, he is at high risk for a post-obstructive pneumonia. Arguing against sepsis was his lack of elevated WBC, lack of fever, and lack of elevated RR. Also, CXR is generally improved since last performed 1 week prior. A cardiac cause was considered unlikely given the lack of history and unremarkable EKG, but still possible, especially given long history of dialysis and BNP of 4374. His ECHO revealed pulmonary HTN and biatrial enlargement. Adrenal insufficiency was essentially ruled out w/ a cortisol of 22.6 [**2106-8-22**]. Overall, his presentation seemed to be most consistent with rapid progression of his underlying metastatic renal cell cancer with progressive distributive pathophysiology and refractory shock due to the burden and extent of his disease. The patient's condition and mental status continued to deteriorate despite the above treatments. On [**8-28**], in concert with the patient's pre-specified wishes, the patient's family decided that they would like the medical team to perform comfort-focused care. The patient was transferred to the medicine floor on [**8-30**] where he shortly thereafter died. He was comfortable throughout his hospital course. His family declined autopsy. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Midodrine 5 mg PO TID 4. Naproxen 500 mg PO Q12H 5. Nephrocaps 1 CAP PO DAILY 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain hold for sedation 7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H hold for sedation or RR<10, 8. Polyethylene Glycol 17 g PO DAILY Hold if patient having daily BMs. 9. Senna 1 TAB PO BID constipation 10. TraMADOL (Ultram) 50 mg PO TID 11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety 12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis ***Clarify whether pt taking sunitinib*** Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2106-9-7**]

[ "486", "197.0", "585.6", "244.9", "564.00", "198.3", "276.52", "285.21", "403.91", "189.0", "V15.82", "V66.7", "789.51", "785.59", "197.7", "V87.41", "V49.86" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9454, 9463

6443, 8735

338, 362

9514, 9523

4177, 6420

9579, 9616

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3145, 3328

3826, 4158

248, 300

390, 2756

2800, 3122

3344, 3548

81,807

139,492

45117

Discharge summary

report

Admission Date: [**2187-12-24**] Discharge Date: [**2187-12-27**] Date of Birth: [**2104-1-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Ditropan XL / Norvasc Attending:[**First Name3 (LF) 4095**] Chief Complaint: Hypotension, PE Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Pt is a 83 year old female with PMHx sig HTN, HLD, CAD, stage IV CKD (HD MWF), COPD, dCHF (EF >55%) with multiple admissions for CHF exacerbations, and a with recent thrombosis of her left upper extremity AV [**First Name3 (LF) **] treated with thrombectomy on [**2187-12-21**]. Notably, during her last admission, she had been seen by cardiology due to hypotension during dialysis, and was started on midodrine for use during dialysis. Today, she presents from dialysis with acute onset chest pain with dyspnea, tachycardia, and hypotension. She was given a 1100mL bolus and dialysis stopped prematurely, with a total yield of 2000mL off. She was given ASA 325mg at dialysis. From the field, she was noted to have a systolic BP in the 90s and an oxygen saturation in the 80s. . On arrival to the ED, her initial vitals were BP 98/62 HR 118, Sao2: 82% on 4L NC, RR 33. The patient's O2 saturation increased to 100% on NRB. She was initially tachycardic with systolic BP in the 90s, but improvemed after 250cc fluids were given. Her JVP was noted to be elevated. Her examination was otherwise notable for moderate TTP throughout her abdomen. A CXR demonstrated vascular congestion worsened from prior. Bedside ultrasound did not show signs of RV strain. A CTPA showed a subsegmental PE. She was started on a heparin drip, but since she had a reduction of tachycardia and her SBP returned to the 100s, thrombolytics were subsequently deferred. Cardiology was consulted who suggested that the patient is likely preload dependent with AS, as she improved with IVF. Blood cultures were taken. . On arrival to the MICU, the patient's vitals were p101 bp 111/57 r 20, Sao2 99% on 4LNC. She states that she feels much more comfortable than she had been previously, but that she continues to feel pain in her left shoulder. Reports some continued dyspnea. No nausea or vomiting. Past Medical History: PAST MEDICAL HISTORY: 1.) Stage 4-5 CKD c/b anemia and secondary hyperparathyroidism; on HD since [**2187-5-9**], does make some urine 2.) Hypertension 3.) Hyperlipidemia 4.) CAD: per patient, no records at [**Hospital1 18**] 5.) dCHF 6.) R carotid stenosis 7.) Depression 8.) Asthma 9.) Osteoporosis 10.) Osteoarthritis 11.) Thyroid disease- h/o both hypo and hyperthyroidism 12.) Vitamin D deficiency - 25 OH 19 in [**2-/2186**] 13.) Benign adnexal cyst: followed [**8-/2186**] and planned again for imaging [**8-/2187**] 14.) Chronic Aspiration: based on video swallow eval [**8-/2186**] 15.) Chronic labyrinthitis 16.) h/o L pneumothorax . PAST SURGICAL HISTORY: 1.) [**4-/2187**] LUE AV [**Year (4 digits) **] (Dr. [**First Name (STitle) **] 2.) hx bilat cataract surgery 3.) R hip fx s/p ORIF 4.) [**10/2187**] LUE AV [**Year (4 digits) **] thrombectomy and stent placement Social History: Patient is widowed, and she lives with her son, [**Name (NI) **] [**Name (NI) 96427**], and his fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**], with [**Last Name (NamePattern1) 269**] assistance and private home care services. Denies any current or past smoking, current or past alcohol, or current or past drug use. Has care at the [**Location (un) 3137**] Center. Dialysis in [**Location (un) 1468**]. Family History: Son with heart surgery for unknown reason in [**2187**]. No family history of kidney disease. Physical Exam: ADMISSION EXAM: Vitals: T 36.7 p101 bp 111/57 r 20, Sao2 99% on 4LNC General: Alert, oriented, no acute distress, hard of hearing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, III/IV SEM loudest at RUSB, no rubs or gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: soft, with moderate RLQ tenderness to palpation and involuntary guarding, no rigidity, or rebound. bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema - congested veins overlying left shoulder, with some diffuse ttp Neuro: CNII-XII intact, 5/5 strength upper extremities, pt refuses to move lower extremities grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS: [**2187-12-24**] 12:07PM BLOOD WBC-13.4*# RBC-2.90* Hgb-9.5* Hct-28.5* MCV-99* MCH-32.7* MCHC-33.2 RDW-15.0 Plt Ct-313 [**2187-12-24**] 12:07PM BLOOD Neuts-89.7* Lymphs-6.1* Monos-2.9 Eos-1.1 Baso-0.2 [**2187-12-24**] 12:07PM BLOOD PT-24.8* PTT-33.2 INR(PT)-2.4* [**2187-12-24**] 12:07PM BLOOD Glucose-126* UreaN-19 Creat-2.2* Na-136 K-3.5 Cl-100 HCO3-25 AnGap-15 [**2187-12-24**] 12:07PM BLOOD CK(CPK)-18* [**2187-12-24**] 05:12PM BLOOD ALT-16 AST-35 LD(LDH)-322* AlkPhos-91 TotBili-0.2 [**2187-12-24**] 05:12PM BLOOD CK-MB-3 cTropnT-0.07* proBNP-[**Numeric Identifier 96431**]* [**2187-12-24**] 12:07PM BLOOD Calcium-8.5 Phos-2.4* Mg-1.9 [**2187-12-24**] 10:45PM BLOOD %HbA1c-4.8 eAG-91 [**2187-12-24**] 12:05PM BLOOD Lactate-1.3 IMAGING: [**12-24**] CXR: IMPRESSION: Pulmonary edema. Small bilateral pleural effusions CT torso: Pulmonary embolus involving subsegmental branches of the left upper lobe. No evidence of right-sided heart strain or peripheral opacity to suggest pulmonary infarction. 2. Moderate bilateral nonhemorrhagic pleural effusions with adjacent areas of Preliminary Reportcompressive atelectasis. 3. Appendix is dilated up to 9 mm and demonstrates hyperemic wall and is Preliminary Reportfluid filled. The above findings are concerning for early acute or chronic Preliminary Reportappendicitis. Correlate with clinical findings. 4. Extensive coronary and aortic valve calcifications. 5. Small hiatal hernia. 6. Atrophic kidneys, in keeping with patient's known history of hemodialysis. 7. Left adnexal cyst, stable in appearance from MR exam of [**2186-8-17**] MICROBIOLOGY: URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. 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 NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 83 year old female with PMHx sig for HTN, HLD, CAD, stage IV CKD (HD MWF), COPD, dCHF (EF >55%) with multiple admissions for CHF exacerbations, and recent thrombosis of her left upper extremity AV [**Year (4 digits) **], presents with brief episode of hypotension and dyspnea, and with evidence of appendicitis on CT. . # Hypotension: The patient has previously been noted to be hypotensive during episodes of dialysis. She now takes midodrine prior to her dialysis sessions to help guard against this. Her episode of hypotension after HD was likely related to a relative hypovolemia and not due to the PE, as there was no evidence of R heart strain on bedside echo. Her hypotension resolved with IVFs. She did not show signs of infection and her hypotension was not felt to be secondary to sepsis. Patient underwent another round of dialysis without event. . # URINARY TRACT INFECTION: A UA was sent as part of the patient's hypotension work up and came back with a large number of epithelial cells, Urine Cx grew a pan-sensitive Klebsiella and unspeciated proteus. Patient was given cefpodoxime 200 mg to be dosed with HD for a total of 3 sessions or 7 days for a complicated UTI. . # PE: The small size of the patient's PE is unlikely to have caused her to have significant hypotension, given no R heart strain, mild troponin leak, and no EKG changes. The patient was started on a heparin gtt, but this was discontinued and the patient was started back on her warfarin, on which she was already therapeutic. The likely source of the clot was from showering of emboli after [**Year (4 digits) **] thrombectomy and likely does not represent failure of coumadin or a hypercoaguable state. . # Dilation of Appendix: Abdominal CT demonstrates fat stranding and dilation of the appendix. Surgery was consulted and they did not think that the patient had acute appendicitis. We followed the patient with serial abdominal exams, which were stable. . # CKD: Continued her dialysis on its MWF schedule, with administration of midodrine beforehand. We continued sevelamer, nephrocaps. Patient should be dialized to dry weight which should be considered 50.5 kg. . # Systloic CHF: No evidence of acute exacerbation . # Afib: In sinus rhythms continued amiodarone . # Depression: stable, continued venlafaxine . TRANSITIONAL ISSUES: -Final blood cultures were pending but no growth to date at the time of discharge -Goals of care discussion should be had with patient and family -Patient is a full code during this admission, this should be readdressed -Cefpodoxime 200 mg should be administered with HD for the next 3 sessions -Patient's Dry weight should be considered to be 50.5 kg Medications on Admission: 1. sevelamer carbonate 800 mg TID 2. lorazepam 0.5-1.0mg once a day as needed for anxiety. 3. B complex-vitamin C-folic acid 1 mg Daily 4. polyethylene glycol 3350 17 gram/dose Daily 5. Lipitor 40 mg Daily 6. venlafaxine 75 mg QAM 8. docusate sodium 100 mg [**Hospital1 **] 9. amiodarone 200 mg Daily 10. folic acid 1 mg Daily 11. Aranesp 100mcg every wed 12. bisacodyl 5 mg Daily PRN constipation 13. acetaminophen 650 mg Q6H PRN 14. ipratropium bromide 0.02 % nebs Q6H PRN wheezing/sob. 15. warfarin 4 mg Daily 16. midodrine 7.5 mg 3x weekly(MO,WE,FR) please give 30 min prior to HD. 17. Aspirin 81mg Daily 18. Lactulose 30ml Every Tues Thurs Sat 19. Trypsin/balsam [**Location (un) 15555**]/castor oil topical [**Hospital1 **] Discharge Medications: 1. lidocaine HCl 10 mg/mL (1 %) Solution Sig: One (1) mL Injection every other day as needed: for needle insertions with dialysis. 2. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 7. midodrine 5 mg Tablet Sig: 1.5 Tablets PO 3X/WEEK (MO,WE,FR): with dialysis. 8. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO HS (at bedtime). 9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for cough/dyspnea. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 14. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO once a day as needed for anxiety. 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) PO once a day. 16. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 17. Aranesp (polysorbate) 100 mcg/mL Solution Sig: One (1) Injection once a week: every wednesday. 18. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 19. lactulose 20 gram/30 mL Solution Sig: One (1) PO three times a week: every tues, thursday, saturday. 20. trypsin-balsam-castor oil 90-87-788 unit-mg-mg/gram Ointment Sig: One (1) Topical twice a day. 21. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO with dialysis for 3 doses: to be given with the next 3 dialysis sessions for a total course of 7 days of antibiotics. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - Discharge Diagnosis: PRIMARY: -Hypotension -Hypoxia -Pulmonary Embolism -End Stage Renal Disease on Dialysis -Chronic Appendicitis SECONDARY: - Hypertension - Hyperlipidemia - Coronary Artery Disease - Diastolic heart failure - R carotid stenosis - Depression - Asthma - Osteoporosis - Osteoarthritis - Thyroid disease - Vitamin D deficiency - 25 OH 19 in [**2-/2186**] - Chronic Aspiration: based on video swallow eval [**8-/2186**] - Chronic labyrinthitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted from dialysis after your blood pressure dropped during a dialysis session. This was felt to be due to having too much fluid removed during dialysis. You were found to have difficulty breathing as well and were observed in the intensive care unit. Your breathing improved without intervention. A CT scan was performed which showed a small blood clot in your lungs, this was felt to have occurred during your thrombectomy of your fistula the week prior, but not contributing to your low blood pressure or difficulty breathing. You continued to recieve dialysis without problem and were discharged back to rehab. The following changes were made to your medications: -START Cefpodoxime 200 mg with dialysis for a total of 3 sessions. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: ADVANCED VASC. CARE CNT When: THURSDAY [**2188-1-3**] at 11:00 AM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: TUESDAY [**2188-3-11**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12635, 12682

7153, 9465

315, 330

13164, 13164

4605, 4605

14283, 14888

3609, 3704

10620, 12612

12703, 13143

9865, 10597

13344, 14260

2923, 3137

3719, 4586

9486, 9839

259, 277

6258, 7130

358, 2234

4621, 6223

13179, 13320

2278, 2900

3153, 3593

62,186

105,042

47875

Discharge summary

report

Admission Date: [**2158-11-5**] Discharge Date: [**2158-11-16**] Date of Birth: [**2097-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 922**] Chief Complaint: Congestive heart failure Major Surgical or Invasive Procedure: [**2158-11-7**] Aortic valve replacement(21 mm ON-X, Mitral valve replacement 25/33 On-X Conform-X mechanical valve). History of Present Illness: Mr.[**Known lastname **] is a 59-year-old gentleman who is well known to Dr.[**Last Name (STitle) 914**] for previous consultations for surgical correction of his aortic valve and mitral valve. In [**2156-11-10**] he had a septic left wrist. He subsequently became bacteremic and developed endocarditis and hip osteomyelitis. He had a very complex series of events which includes end-stage renal disease secondary to glomerulonephritis for which he underwent kidney transplant in [**2137**], which had failed subsequently and was removed in [**2143**]. He is currently receiving hemodialysis every Monday, Wednesday, and Friday. Dr.[**Last Name (STitle) 914**] had initially seen Mr.[**Known lastname **] in [**2157-2-10**] for MSSA endocarditis, however, he was not a surgical candidate at that time. On [**2158-10-3**] he presented complaining of 5 days of abdominal pain and 3 months of abdominal distention. He has received clearance from GI and general surgery and now presents for surgery. Past Medical History: h/o mitral endocarditis h/o aortic endocarditis h/o septic wrist endstage renal failure on hemodialysis s/p Renal transplant in [**2137**] s/p transplant nephrectomy in [**2143**]. Hypertension Atrial fibrillation Coronary artery disease Diastolic CHF with remote history of systolic CHF h/o MSSA Endocarditis h/o VRE septic arthritis. h/o Left wrist MSSA arthritis s/p Right femoral neck fracture s/p right hip hemiarthroplasty [**2157-1-11**] s/p Right Prosthetic hip infection with explantation [**2-18**] h/o Ischemic colitis/ileitis s/p subtotal colectomy and terminal ileal resection with diverting loop ileostomy and gastrostomy tube placement. s/p Revision left radiocephalic arteriovenous fistula,endarterectomy radial artery s/p Removal right hip hemiarthroplasty. s/p Right ring finger closed reduction percutaneous pinning for mallet finger.Left index and long ring finger PIP joint manipulation Social History: Owner of a clothing store in [**Location (un) 4398**]. Patient has been hospitalized/in rehab since [**2156-12-10**]. Prior to this, he lived in [**Location **] with his mother and brother. [**Name (NI) **] current tobacco and alcohol use but notes intermittent tobacco use in the past (~3 pack-years). Denies illicit drug use. HIV negative [**2156-12-27**] Family History: Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother). Father deceased. Brother has fibromyalgia. Daughter in good health. Physical Exam: admission Pulse: 81 AF Resp: 16 O2 sat:99% RA B/P Right: 94/41 General:A&O x3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur: HSM IV/VI, II/VI at RSB Abdomen: Soft [x] non-distended [] non-tender [] bowel sounds[-]+ ascites, RLQ colostomy bag. +Gastric- external fistula C/D/I Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit-none Right: 2+ Left:2+ Pertinent Results: [**11-10**] Echo: The left atrium is markedly dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2158-10-3**], the aortic and mitral valves have been replaced. The left ventricular ejection fraction is increased. The right ventricle remains dilated and hypocontractile. A small-to-moderate pericardial effusion is now present. [**2158-11-14**] 06:15AM BLOOD WBC-4.3 RBC-2.90* Hgb-8.5* Hct-26.6* MCV-92 MCH-29.2 MCHC-31.9 RDW-19.0* Plt Ct-101* [**2158-11-5**] 04:44PM BLOOD WBC-4.1 RBC-4.00* Hgb-11.8* Hct-36.8* MCV-92 MCH-29.5 MCHC-32.0 RDW-20.3* Plt Ct-114* [**2158-11-14**] 06:15AM BLOOD PT-24.8* PTT-45.1* INR(PT)-2.4* [**2158-11-13**] 12:12PM BLOOD PT-22.8* PTT-37.1* INR(PT)-2.2* [**2158-11-13**] 01:39AM BLOOD PT-22.6* PTT-84.1* INR(PT)-2.1* [**2158-11-12**] 03:00AM BLOOD PT-19.4* INR(PT)-1.8* [**2158-11-14**] 06:15AM BLOOD Glucose-87 UreaN-18 Creat-4.2*# Na-132* K-3.7 Cl-95* HCO3-30 AnGap-11 [**2158-11-5**] 04:44PM BLOOD Glucose-87 UreaN-35* Creat-6.6*# Na-136 K-5.3* Cl-99 HCO3-25 AnGap-17 [**2158-11-15**] 08:30AM BLOOD WBC-5.0 RBC-2.91* Hgb-8.6* Hct-26.6* MCV-91 MCH-29.6 MCHC-32.4 RDW-19.0* Plt Ct-115* [**2158-11-16**] 04:29AM BLOOD Hct-31.0* [**2158-11-15**] 08:30AM BLOOD Plt Ct-115* [**2158-11-16**] 04:29AM BLOOD PT-35.6* INR(PT)-3.6* [**2158-11-15**] 08:30AM BLOOD Glucose-82 UreaN-28* Creat-5.5*# Na-132* K-4.4 Cl-94* HCO3-27 AnGap-15 [**2158-11-16**] 04:29AM BLOOD Na-133 K-3.8 Cl-96 Brief Hospital Course: Mr. [**Known lastname **] was admitted prior to surgery for surgical work-up, IV Heparin bridge and [**Known lastname 2286**]. On [**11-7**] he was brought to the Operating Room where he underwent aortic and mitral valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He did require pressors for hemodynamic support for several days post-op while in the CVICU. [**Month/Year (2) **] was continued post-op while being followed by renal until discharge. Chest tubes and epicardial pacing wires were removed per protocol. Cardiology was consulted to evaluate the patient's second degree AV block (not felt to be a candidate for pacemaker). Heparin was initiated as a bridge until the INR was therapeutic on Coumadin. He was finally weaned off pressors on post-op day six and was transferred to the telemetry floor for further care. Physical Therapy worked with patient during post-op period for strength and mobility. He was ambulatory and has a good home support system and was, therfor, discharged to home. Coumadin was titrated for target INR 3-3.5. This will be managed by [**Hospital6 733**] [**Hospital 197**] Clinic ([**Telephone/Fax (1) 2173**]). On post-op day 10 he was discharged to home with the appropriate medications and follow-up appointments.INR today 3.4 . First blood draw by VNA is tomorrow [**11-17**].He will resume HD schedule of M-W-F. Medications on Admission: Medications at home: - LISINOPRIL 2.5mg(1),- WARFARIN - 2 mg Tablet - up to 3 (three) Tablet(s) by mouth daily (AFib)- B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg (1),- CINACALCET [SENSIPAR] - 60(1) - CIPROFLOXACIN - 500 (1),- EPOETIN ALFA [EPOGEN] - at HD TIW; dosage uncertain - PROTONIX 40mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for cad. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily) as needed for CRF. 5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for cholesterol. 6. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS) as needed for CRF. 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 9. Outpatient Lab Work 10. Outpatient Lab Work Please draw PT/INR on [**11-17**] , [**11-18**] and then [**11-20**] and phone result to [**Hospital 18**] [**Hospital6 733**] [**Hospital 197**] Clinic at 617=[**Telephone/Fax (1) **]. Target INR 3.0-3.5 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 12. Coumadin 2 mg Tablet Sig: one-half Tablet PO once today for 1 days: dose today 1 mg ( half tab)[**11-16**], then all further daily dosing per coumadin clinic [**Telephone/Fax (1) 2173**]. Disp:*50 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: h/o Aortic endocarditis h/o mitral endocarditis h/o septic arthritis wrist mitral regurgitation aortic stenosis aortic regurgitation s/p Aortic and Mitral Valve Replacement end stage renal failure on hemodialysis h/o right hip abscess,hemiarthroplasty and removal of hardware, debridements s/p subtotal colectomy for ischemic gut s/p carpal tunnel releases s/p right hand finger surgeries s/p multiple revisions of AV fistulae Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: sternum clean and healing well, no drainage Edema: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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) 914**] on [**2158-12-12**] at 1:45 PM ([**Telephone/Fax (1) 170**]) Cardiologist: Dr.[**Last Name (STitle) 171**] on [**2158-11-27**] at 8:40 AM ([**Telephone/Fax (1) 62**]) Please call to schedule appointments with: Primary Care: Dr. [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] in [**5-15**] weeks ([**Telephone/Fax (1) 250**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: mechanical valves Goal INR 3 - 3.5 First blood draw on [**2158-11-17**] Call results to [**Hospital 18**] [**Hospital 197**] Clinic at [**Telephone/Fax (1) 2173**] Completed by:[**2158-11-16**]

[ "428.0", "285.9", "V45.72", "V58.61", "427.32", "414.01", "427.31", "403.91", "305.1", "276.1", "588.81", "396.8", "428.30", "V44.2", "V45.11", "585.6", "426.13", "416.8", "423.8" ]

icd9cm

[ [ [] ] ]

[ "39.61", "39.95", "35.24", "35.22" ]

icd9pcs

[ [ [] ] ]

9716, 9774

6223, 7787

345, 465

10245, 10414

3662, 6200

11254, 12100

2818, 2957

8145, 9693

9795, 10224

7813, 7813

10438, 11231

7834, 8122

2972, 3643

281, 307

493, 1495

1517, 2427

2443, 2802

18,633

192,041

9667

Discharge summary

report

Admission Date: [**2156-9-30**] Discharge Date: [**2156-10-5**] Date of Birth: [**2094-11-18**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old woman with a past medical history notable for type 2 diabetes mellitus and end-stage renal disease requiring hemodialysis, as well as a history of methicillin-resistant Staphylococcus aureus bacteremia, who presented to the [**Hospital1 190**] Emergency Department with mild confusion, nausea, and vomiting times one, as well as fever to 102.8 on the day of admission. The patient denied any chills or sweats, although she did admit to headache without photophobia. She also admitted some weakness and fatigue, but no arthralgias or myalgias. The patient further denied abdominal pain, chest pain, and shortness of breath. Further review of systems revealed a complaint of erythema and tenderness over the patient's hemodialysis line site. Otherwise, the patient denied a history of dyspnea on exertion, orthopnea, hematochezia or melena and rashes. In the Emergency Room, the patient received vancomycin, ceftriaxone, Flagyl, and gentamicin times one. She was found to be hyperkalemic with a potassium of 6.6, and an electrocardiogram revealed peaked T waves. The patient subsequently received Kayexalate, insulin, calcium chloride, and glucose. The patient was also found to be hypoxic with variable oxygen requirements in the Emergency Department. On 100% nonrebreather mask her arterial blood gas was 7.44/44/135; although it was unclear to the admitting medical team what the true oxygen amount at that time was. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus, insulin-dependent for approximately seven years. 2. End-stage renal disease, on hemodialysis on Monday, Wednesday and Friday. The patient's nephrologist is Dr. [**Last Name (STitle) 32690**] (phone number [**Telephone/Fax (1) 32691**]). 3. Peripheral vascular disease, status post right below-knee amputation in [**2155-9-26**]. 4. Fungal urinary tract infection. 5. Methicillin-resistant Staphylococcus aureus bacteremia in [**2155-11-26**]. 6. Congestive heart failure with an ejection fraction reported as "low normal" on an exercise treadmill test and thallium study in [**2156-4-25**]. 7. Pulmonary hypertension. 8. Left foot ulcer with a history of Staphylococcus aureus gram-negative rods and diphtheroids for cultures obtained in [**2156-7-25**]. 9. Peripheral neuropathy. ALLERGIES: PENICILLIN (causes rash), SULFA (causes rash), CLINDAMYCIN (causes hives), possible CODEINE allergy, possible ERYTHROMYCIN allergy. MEDICATIONS ON ADMISSION: (Outpatient medications included) 1. Niferex 150 mg p.o. b.i.d. 2. Nephrocaps 1 tablet p.o. q.d. 3. NPH insulin 13 units subcutaneous q.a.m.; 10 units subcutaneous q.p.m. 4. Sinemet 25 mg to 100 mg q.h.s. 5. Zantac 150 mg p.o. q.d. 6. Regular insulin sliding-scale. 7. Senokot. 8. Lasix 40 mg p.o. q.d. 9. Neurontin 100 mg p.o. b.i.d. 10. Levaquin 250 mg p.o. times one year; reasons unclear. PHYSICAL EXAMINATION ON PRESENTATION: (Performed by admitting Renal and Medical Intensive Care Unit teams) Emergency Department vital signs were temperature of 101.7, blood pressure 114/64, heart rate 102, respirations 20, satting 85% on room air. HEENT revealed pupils were constricted to approximately 1 mm, reactive. Extraocular movements were intact. Mucous membranes were moist. No jugular venous distention or lymphadenopathy. Chest had crackles at the bases bilaterally, approximately one-third of the way up the posterior fields. Hemodialysis line site was tender. Heart had a regular rate and rhythm with S1 and S2. No murmurs, rubs or gallops. Abdomen was soft, obese, diffusely tender. No rashes. Extremities had no clubbing, cyanosis or edema. Right below-knee amputation. Tenderness to palpation bilaterally. Left foot ulcer was clean, dry and intact. Neurologically, alert and oriented times three. Strength was [**5-29**] in all extremities except hip flexion which was [**4-29**] secondary to pain (chronic). LABORATORY DATA ON PRESENTATION: Laboratory data upon presentation were as follows: Complete blood count revealed a white blood cell count of 17.5 with a differential of 87 neutrophils, no bands, 7.9 lymphocytes, and 4.3 monocytes, 0.5 eosinophils, and 0.2 basophils. Hematocrit was 39.2, platelets 184. Chem-7 revealed a sodium of 134, and was notable for a potassium of 6.8, chloride 92, bicarbonate 26, BUN 49, creatinine 7.6, glucose 113. Electrolytes revealed a calcium of 8.1, magnesium of 1.7, phosphorous of 8.6. Albumin was 3.3. Coagulation studies revealed an INR of 1.2, PT of 13.5, and PTT of 49.9. Arterial blood gas on 100% oxygen revealed a pH of 7.44, CO2 of 44, and PO2 of 135. Lactate was 1.7. Subsequent evaluation of potassium following Kayexalate and other potassium-lowering therapy revealed potassium to be 3.6. Liver enzymes were as follows: ALT of 11, AST of 18, alkaline phosphatase 100, and amylase of 23. RADIOLOGY/IMAGING: Electrocardiogram revealed peaked T waves consistent with hyperkalemia. Chest x-ray revealed right middle lobe and right lower lobe infiltrates with possible left lower lobe infiltrate. Subsequent electrocardiogram following treatment for hyperkalemia revealed that the peaked T waves had improved somewhat with the patient's rate reduced to 93. HOSPITAL COURSE: The patient was admitted initially to the Medical Intensive Care Unit for treatment of her hyperkalemia and presumed sepsis. Blood cultures were drawn on presentation and subsequently revealed methicillin-resistant Staphylococcus aureus. 1. INFECTIOUS DISEASE: The patient was continued for a time on ceftriaxone for her pneumonia as well as Flagyl for possible aspiration, as the patient had vomited on the day of presentation. The patient was also continued on vancomycin for presumed line infection and her history of methicillin-resistant Staphylococcus aureus. The patient received gentamicin as well for line infection per Renal recommendations. Vancomycin and gentamicin levels were followed, and her vancomycin was administered with hemodialysis. The patient's blood cultures, as noted above, subsequently grew out methicillin-resistant Staphylococcus aureus. The patient was stabilized following the day on admission, and later that day her hemodialysis line was changed by the transplant team. Later that evening she was transferred to the medical floor on the [**Location (un) **] Medicine Service. Her antibiotic regimen was eventually tailored to include vancomycin and Levaquin. Her vancomycin levels were followed, and vancomycin was dosed accordingly at hemodialysis. Since transfer to the floor, the patient remained afebrile and her white blood cell count decreased to the normal range. 2. RENAL: The patient has end-stage renal disease and on hemodialysis three times a week. The Renal team followed the patient closely. As noted above, the patient's hemodialysis catheter was removed and replaced with a temporary cathether. This catheter clogged briefly during dialysis on [**10-4**] and had to be changed over a wire on that day. Also notable in terms of the patient's renal course, did become fairly hyperphosphatemic, such that her phosphorous level reached 11.5. Thus, her dose of Renagel was increased and Amphojel was added for a 5-day course as well. In terms of the patient's hyperkalemia that was soon corrected following the above-mentioned therapy as well as the dialysis sessions. On the day of discharge the patient's potassium was 5.5, and she was scheduled to receive dialysis the next day. 3. ENDOCRINE: (Type 2 diabetes mellitus) The patient's fingerstick blood sugars were fairly well controlled on a regular insulin sliding-scale and NPH. In terms of the patient's left foot ulcer, Vascular Surgery saw the patient and felt that the wound was not currently infected. They recommended wet-to-dry normal saline dressing changes t.i.d., and these were carried out. 4. PULMONARY: (Pneumonia) As above, the patient was treated with the above antibiotics and also treated with a brief course of Levaquin. She continued to improve by examination and by subjective report. She tolerated room air well. 5. OPHTHALMOLOGY: On the evening of [**10-4**], the patient admitted that she has had some visual changes over the past 36 hours or so, such that she saw black spots and black waves in both eyes. She also admitted a decreased visual acuity. Because of this an Ophthalmology consultation was called, and Ophthalmology saw the patient that evening. Ophthalmology reported finding nonproliferative diabetic retinopathy bilaterally with old vitreous hemorrhage in the left eye. Ophthalmology recommended followup with a retinal ophthalmologist, Dr. [**First Name4 (NamePattern1) 12041**] [**Last Name (NamePattern1) 32692**], as an outpatient. As noted below, this appointment was scheduled for [**10-9**] at noon in Dr.[**Name (NI) 32693**] office in [**University/College **], [**State 350**]. CONDITION AT DISCHARGE: As noted above, the patient's mental status changes abated completely and she remained afebrile following her admission. Similarly, her white count normalized. Her main medical issues at discharge included her ongoing history of methicillin-resistant Staphylococcus aureus bacteremia. For this, she was to receive vancomycin with her hemodialysis for six weeks. Another issue facing the patient was her diabetic retinopathy for which she was to see Dr. [**Last Name (STitle) 32692**] as noted above and below. Again, the patient was breathing well and tolerating room air. Her glucose levels were well controlled. DISCHARGE DIAGNOSES: 1. Sepsis. 2. Type 2 diabetes mellitus. 3. End-stage renal disease with hemodialysis. 4. Ongoing history of methicillin-resistant Staphylococcus aureus. 5. Peripheral vascular disease. 6. Diabetic retinopathy. MEDICATIONS ON DISCHARGE: (On discussion with the patient, it was found that she takes regular insulin at home rather than NPH. She denied taking any combination of regular insulin with NPH. Thus, the patient was sent home with the following prescriptions) 1. Regular Humulin insulin 40 units subcutaneous q.a.m. and 12 units subcutaneous q.p.m. 2. Renagel 1600 mg p.o. t.i.d. 3. Amphojel 30 cc p.o. t.i.d. times three days; to begin on [**2156-10-6**]. 4. Nephrocaps 1 tablet p.o. q.d. 5. Neurontin 100 mg p.o. b.i.d. 6. Zantac 150 mg p.o. q.d. 7. Niferex 150 mg p.o. q.d. 8. Senokot one to two tablets p.o. b.i.d. 9. Percocet one to two tablets p.o. q.6h. p.r.n. for leg pain, dispensed #15. 10. Lacrilube 1 to 2 drops in both eyes t.i.d. * The patient will get six weeks of vancomycin with dialysis. The Renal team called the patient's home dialysis unit to arrange this. DISCHARGE FOLLOWUP: As noted above, the patient was to follow up with her home dialysis unit where she will receive vancomycin for six weeks for her ongoing methicillin-resistant Staphylococcus aureus. Also, the patient was to follow up with Dr. [**First Name4 (NamePattern1) 12041**] [**Last Name (NamePattern1) 32692**] (telephone number [**Telephone/Fax (1) 32694**]). The patient was to see Dr. [**Last Name (STitle) 32692**] on Saturday, [**10-9**], at 12 o'clock in his [**University/College **] office. The patient has been told to contact her nephrologist, ophthalmologies or primary care physician if she noted any acute or emergent changes in her overall condition. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D., 12-948 Dictated By:[**Last Name (NamePattern1) 1550**] MEDQUIST36 D: [**2156-10-5**] 14:29 T: [**2156-10-9**] 04:24 JOB#: [**Job Number 32695**]

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icd9cm

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6939

Discharge summary

report

Admission Date: [**2179-10-23**] Discharge Date: [**2179-11-3**] Date of Birth: [**2136-2-6**] Sex: M Service: [**Last Name (un) **] REASON FOR ADMISSION: Liver transplant. HISTORY OF PRESENT ILLNESS: This is a 43-year-old male with hepatitis C, cirrhosis who presented to [**Hospital1 190**] on [**2179-10-23**] for orthotopic liver transplant. Patient underwent an orthotopic cadaveric liver transplant on [**2178-12-1**] for hepatitis C-related cirrhosis. However, he rapidly developed recurrent hepatitis C and experienced 2 episodes of acute rejection. Since that time he has experienced chronic rejection with progressive liver dysfunction. He was relisted for liver transplantation. On [**2179-10-23**] a donor was identified and patient was notified. PAST MEDICAL HISTORY: Hepatitis C, cirrhosis, orthotopic liver transplant [**11/2178**], history of VRA, history of thrombocytopenia. PAST SURGICAL HISTORY: Orthotopic liver transplant [**11/2178**] and multiple biliary stents. SOCIAL HISTORY: Positive for alcohol abuse. Patient reportedly quit 20 years ago. Positive tobacco use. Positive illicit drug use. Patient reportedly quit 17 years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Sucralfate 2. Ambien 10 mg at bedtime 3. Ursodiol 600 mg b.i.d. 4. Nystatin 5 q.i.d. 5. Protonix 40 mg once daily 6. Hydroxyzine 25 mg p.r.n. 7. Bactrim Single Strength once daily 8. Prednisone 5 mg once daily 9. Reglan 10 mg t.i.d. 10. FK 2 mg b.i.d. 11. Rifaximin 200 mg b.i.d. 12. Lasix 20 mg once daily 13. Lactulose 30 t.i.d. 14. Aldactone 50 mg once daily 15. Oxycodone 1 to 2 tablets q. 6h. 16. Calcitonin 200 b.i.d. REVIEW OF SYSTEMS ON ADMISSION: Patient reports feeling well. He denies fever, chills, nausea, or vomiting, short of breath, chest pain, dysuria, recent stool changes. PHYSICAL EXAMINATION: Vital signs: 96.6, 79, 110/72, 16, 99 percent on room air. General: Patient is alert and oriented times 3. Does appear somewhat somnolent but is nontoxic. HEENT: Positive scleral icterus; no jugular venous distention or lymphadenopathy noted. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. Abdomen: Soft, mildly distended, and nontender to palpation. Rectal exam: Normal tone, guaiac negative. LABORATORIES ON ADMISSION: CBC: White blood cell count 6.5, hematocrit 33.9, platelets 82. Chemistries: Sodium 129, potassium 4.0, chloride 97, bicarbonate 19, BUN 41, creatinine 1.2, ALT was 210, AST 392, alkaline phosphatase 2628, total bilirubin was 34.9. BRIEF HOSPITAL COURSE: Patient presented to [**Hospital1 346**] [**2179-10-23**] for orthotopic liver transplant. After complete preop patient underwent orthotopic cadaveric liver transplant. Patient tolerated procedure well. After recovery in the Post Anesthesia Care Unit patient was transferred to a monitored bed, intubated, on a propofol drip in the Intensive Care Unit. Patient remained intubated and clinically stable until postop day 2, at which time he was extubated. He tolerated extubation well and remained clinically stable. He did require 1 unit of packed red cells on postop day 2 for hematocrit of 28.2. His hematocrit subsequently rose to 32.6 post transfusion. On [**2179-10-26**] he also required 1 unit of packed cells for hematocrit of 28.9 to keep his hematocrit above 30. On postop day 2 he was transferred to the floor in a very stable condition. Once on the floor Mr. [**Known lastname 6359**] began ambulating with Physical Therapy. He continued to remain afebrile and clinically stable. His liver enzymes continued to trend downward. He began to tolerate regular diet by postop day 4. His wound continued to heal nicely with some minimal drainage but minimal serosanguineous drainage from the wound. Throughout Mr. [**Known lastname 6362**] hospital course he remained on immunosuppression including MMF, tacrolimus, and prednisone. His levels were monitored diligently and his dosages adjusted accordingly. On [**2179-11-3**] with the patient tolerating a regular diet, liver enzymes of AST 12, ALT 21, alkaline phosphatase 160, and a total bilirubin of 2.3, now ambulating easily, and with his wound continuing to appear well healing, Mr. [**Known lastname 6359**] was discharged to home. Mr. [**Known lastname 6359**] will have the assistance of his aunt and uncle, and also [**Name (NI) 269**] to help with his care. Mr. [**Known lastname 6359**] is to follow up with the Transplant Center the evening after discharge. He is to follow up with Dr. [**Last Name (STitle) **] and Dr.[**Name (NI) 670**] office soon after discharge. He is to seek immediate medical attention if he experiences fever, chills, nausea, vomiting, or abdominal pain. DISCHARGE MEDICATIONS: 1. Fluconazole 200 mg 2 tablets p.o. once daily 2. Bactrim Single Strength 1 tablet p.o. once daily 3. Zolpidem tartrate 5 mg 1 tablet p.o. at bedtime 4. Percocet 1 to 2 tablets p.o. q.4-6 hours 5. Prednisone 20 mg p.o. once daily 6. Indomethacin 500 mg 2 tablets p.o. b.i.d. 7. Tacrolimus 1 mg 2 tablets p.o. b.i.d. for 2 doses, then to be instructed thereafter by the Transplant team which dose to take. 8. Protonix 40 mg p.o. once daily 9. Colace 100 mg p.o. b.i.d. 10. Ursodiol 300 mg 2 capsules p.o. b.i.d. 11. Lasix 40 mg p.o. once daily 12. Valacyclovir 450 mg p.o. once daily 13. Aluminum magnesium hydroxide 225-200 mg/5 ml suspension, 30 ml, p.o. q.i.d. 14. Insulin glargine 9 units subcutaneous at bedtime 15. Regular sliding scale DISCHARGE INSTRUCTIONS: Outpatient lab work: Patient is to have a CBC, Chem-7, calcium, magnesium, phosphate, AST, ALT, alkaline phosphatase, total bilirubin, and tacrolimus trough level in a.m. q. Monday and Thursday. These results are to be faxed to the Transplant Center at [**Telephone/Fax (1) 697**]. DISCHARGE CONDITION: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 16264**] MEDQUIST36 D: [**2179-11-4**] 03:37:30 T: [**2179-11-4**] 15:11:09 Job#: [**Job Number 26100**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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40,819

193,610

38228

Discharge summary

report

Admission Date: [**2167-9-11**] Discharge Date: [**2167-9-20**] Date of Birth: [**2105-12-26**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 3016**] Chief Complaint: dizziness, near syncope, orthostasis, loose bowel movements Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 61 yo man with PMHx sig. for pancreatic cancer s/p Whipple on [**2167-5-20**] who presented to the ED with weakness. . After diagnosis with pancreatic cancer, he was found on laparotomy to have non-resectable disease, and then liver disease. He as also diagnosed with diabetes, presumed secondary to pancreatic disease, and was admitted with hyperglycemia from [**Date range (1) 26595**]. He started chemotherpy 2 weeks ago and had a dose on Monday of this week. Over the past 2 days, he started to feel "icky". He was dizzy with standing and felt short of breath and panicky with standing. He reported loose stools in the past couple of days, yesterday [**Location (un) 2452**], and today cherry red. This was associated with abdominal pain, particularly in his lower abdomen. No nausea or vomiting. He has had chronic abdominal pain in his RUQ since surgery. His appetite has been poor (weight from 204 to 140 since diagnosis). His urine output has been dark and dribbling, with poor force. His blood sugars have been in the 80s to 90s in the morning and 120s to 180s during the day. He has had a sore on his buttock from sleeping on his back, being dressed by the VNA (last on Tuesday). . In the ED, initial VS were: 98.8 122 75/30 100%. He was orthostatic. His BP improved with IVFs. Labs were notable for WBC 1.6, HCT 31.9, plt 63. CXR showed no acute pulmonary process. CT abd showed "Acute pancolitis , likely infectious origin, but inflammatory cannot be excluded , and less likely ischemic cause due to diffuse pattern. No free air or free fluid." The patient received cefepime, vanc, and flagyl; he also received dilaudid. He was evaluated by Surgery and was not felt to require any further surgical interventions. GI was consulted. Vitals prior to transfer to the floor were: 98.8, 85, 107/76, 18, 100RA. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, or wheezes. Denies nausea, vomiting, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: Past Medical History; -Psoriasis -Pancreatic cancer -"Pressure ulcer" on coccyx per VNA -Diabetes mellitus, secondary, diagnosed on last visit in [**8-28**] Past Surgical History: -Left testicular hydrocoelectomy [**2162**] -s/p exploratory laparotomy for staging pancreatic head cancer, open cholecystectomy, Roux-en-Y hepaticojejunostomy, and gastrojejunostomy [**5-/2167**] Social History: Lives alone, soon to move in with his nephew. Worked as super market manager for 40 years, but on disability since [**4-26**] for osteoarthritis. Smoked 1-1.5 packs per day for 40 years. Quit [**2167-4-18**]. Denies EtOH and ilicit drugs. Family History: Type 2 DM in grandmother. [**Name (NI) **] family history of malignancy. Physical Exam: VS: 98.6 88 118/80 20 97% RA GEN: frail, pale male in NAD HEENT: PERRLA, EOMI, OP clear Cardiovascular: RRR normal s1, s2, no murmurs appreciated Respiratory: clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: normoactive bowel sounds, soft, well healed RUQ scar, no TTP Extremities: trace edema RLE, with hyperpigmentation and scaling rash on R>L LE, 2+ DP pulses Neurological: cranial nerves II-XII grossly intact, sensation intact, strength 5/5 throughout Skin: scaling plaques on back, and bilateral lower extremities, coccyx with stage 1 ulcer Psychiatric: appropriate, pleasant, not anxious Pertinent Results: Admission Labs: [**2167-9-11**] 12:00PM BLOOD WBC-1.6*# RBC-3.48* Hgb-11.3* Hct-31.9* MCV-92 MCH-32.5* MCHC-35.4* RDW-15.2 Plt Ct-63*# [**2167-9-11**] 12:00PM BLOOD Neuts-17.7* Bands-0 Lymphs-78.2* Monos-1.0* Eos-1.4 Baso-1.7 [**2167-9-11**] 12:00PM BLOOD PT-13.9* PTT-24.5 INR(PT)-1.2* [**2167-9-11**] 12:00PM BLOOD Gran Ct-288* [**2167-9-11**] 12:00PM BLOOD Glucose-208* UreaN-24* Creat-1.2 Na-128* K-4.2 Cl-89* HCO3-25 AnGap-18 [**2167-9-11**] 12:00PM BLOOD ALT-29 AST-34 AlkPhos-277* TotBili-1.1 [**2167-9-11**] 12:00PM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.2 Mg-1.3* . CT Abdomen and Pelvis ([**9-11**]): 1. Acute pancolitis extending up to the rectum is likely due to infectious process, but inflammatory causes should be considered. Pseudomembranous colitis should be considered. Ischemic causes are less likely due to diffuse pattern of colonic involvement. 2. Cholecystectomy, gastrojejunostomy and choledochojejunostomy changes without evidence of surgical complications. 3. Pancreatic mass is without significant change from prior [**2167-8-18**]. 4. Multiple diffuse liver lesions are likely stable in number with slightly increase in size of the largest lesion in the right lobe. 5. Colonic diverticulosis without diverticulitis. 6. Stable ectasia of the intrarenal abdominal aorta and aneurysmal changes at the bifurcation of the right common iliac artery. . CXR ([**9-11**]): No acute pulmonary process. No free air under the diaphragm is detected. . Interval Results: . Abdominal XR ([**9-13**]): Three views of the abdomen including left lateral decubitus are submitted. Air is present in several dilated small bowel segments. Small bowel diameter reaches 3.3 cm. Air is also present in the transverse colon. No free intraperitoneal air is identified. Unclear if the small bowel dilatation represents developing small-bowel obstruction or ileus. However, anastomotic sutures are present adjacent to the small bowel dilatation, raising concern for possible obstruction. Continued close follow up recommended. . Abdominal XR ([**9-14**]): Nonspecific small bowel gas pattern with interval resolution of gaseous distention. No definitive evidence of obstruction on this examination. Air is seen in the distal colon without significant large bowel dilation. . Scrotal US ([**9-15**]): 1. Mild scrotal skin thickening. 2. Normal testes. . Abdominal XR ([**9-17**]): 1. Nonspecific small bowel gas pattern not suggestive of obstruction. No evidence of free air to suggest perforation. 2. Interval removal of femoral catheter compared to the prior study. 3. No other significant change compared to prior. . Discharge Labs: [**2167-9-20**] 11:30AM BLOOD WBC-25.2* RBC-3.48* Hgb-10.4* Hct-31.2* MCV-90 MCH-29.9 MCHC-33.3 RDW-14.9 Plt Ct-47* [**2167-9-20**] 11:30AM BLOOD Neuts-62 Bands-3 Lymphs-18 Monos-5 Eos-0 Baso-0 Atyps-2* Metas-5* Myelos-1* Promyel-2* Blasts-2* NRBC-1* [**2167-9-20**] 05:08AM BLOOD PT-16.3* PTT-31.3 INR(PT)-1.4* [**2167-9-20**] 05:08AM BLOOD Gran Ct-[**Numeric Identifier 22857**]* [**2167-9-20**] 11:30AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-137 K-3.8 Cl-103 HCO3-24 AnGap-14 [**2167-9-20**] 05:08AM BLOOD ALT-10 AST-16 AlkPhos-225* TotBili-0.4 [**2167-9-20**] 11:30AM BLOOD Calcium-8.2* Phos-1.7* Mg-2.7* . Lower Extremity US ([**9-20**]): No evidence of DVT. Brief Hospital Course: 61 yo man with metastatic pancreatic cancer who presented with bloody diarrhea, was found to have pancolitis on CT and was C. diff toxin positive. . # C. diff colitis: Patient was admitted having recently completed gemcitabine/cisplatin with bloody diarrhea. Abdominal CT revealed pancolitis that was most concerning for infectious colitis. Meropenem, Flagyl IV and Vancomycin PO were started initially to cover GNR/Pseudomonas and C. diff. Stool studies were sent and patient was found to be C. diff toxin positive on the third specimen. Infectious Diseases followed the patient throughout his stay. Flagyl was discontinued several days after patient was found to be C. diff positive. Meropenem was initially kept on but was discontinued several days prior to discharge. Patient was discharged on Vancomycin PO to complete a 14-day course. . # Pancreatic/duodenal adenocarcinoma with metastases to the liver: Patient had previously had resection. Patient had completed two cycles of palliative chemotherapy with gemcitabine/cisplatin. Cancer was deemed unresectable. No chemotherapy was provided during the hospitalization. Patient was discharged home with Hematology-Oncology follow-up appointments. . # Pancytopenia. Most likely due to chemotherapy, as decrease in all cell lines. Patient was to receive Filgastrim until his ANC was greater than 1000 for two days. ANC jumped from 207 to 3080 to 9150 over two days at which time the Filgastrim was stopped. The ANC continued to climb and was [**Numeric Identifier 22857**] at discharge. Patient did experience some back pain following the injections. Platelets slowly trended down to approximately 19K, at which time the patient received a platelet transfusion. Platelets remained stable at approximately 30K for several days following transfusion and climbed to 47K at discharge. The patient's hematocrit was 31.2 on admission but slowly trended down to the low 20s. Patient was transfused to maintain a hematocrit > 25. Discharge hematocrit was 31.2. . # Pain control: Patient initially received IV Morphine for pain control. A possible ileus was detected on abdominal x-ray so patient was managed on Tramadol for several days. Palliative care was consulted for worsening pain. Morphine was reinitiated in small doses. Patient was ultimately discharged on Methadone 1 mg PO TID and Morphine sulfate IR 5 mg Q4H for breakthrough pain. Pain medications were to be titrated as needed as an outpatient. . # Right lower extremity edema: Patient presented with mild right lower extremity edema. Several days prior to discharge the RLE was warm to the touch and mildly erythematous. A bilateral LE ultrasound showed no evidence of DVT. . # Scrotal fullness: There was concern for possible hydrocele versus hernia. Scrotal ultrasound was negative. . # Insulin dependent diabetes mellitus: Patient was maintained on a Humalog ISS while inpatient. Home Lantus was restarted at discharge. . # Psoriasis: Patient was managed with topical agents. Methotrexate was held due to concern for infection and pancytopenia. . # Coccyx ulcer: Wound care was consulted. Wound was managed per their recommendations. Medications on Admission: Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Percocet 2 tabs q 6-8 hours Megestrol 400 mg/10 mL (40 mg/mL) Suspension 2 tsps daily Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) for 2 weeks. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Fourteen (14) units Subcutaneous at bedtime. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Methotrexate Sodium 10 mg Tablet Oral weekly (friday or saturday) Dovenex cream Clobetasol cream Zofran prn (after chemotherapy). Discharge Medications: 1. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for sleep. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 6 days. Disp:*22 Capsule(s)* Refills:*0* 5. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four Hundred (400) mg PO once a day. 6. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fourteen (14) Units Subcutaneous At Bedtime. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 1 weeks. Disp:*28 Tablet(s)* Refills:*2* 8. Methadone 10 mg/5 mL Solution Sig: 0.5 mL PO every eight (8) hours. Disp:*1 50 mL bottle* Refills:*2* 9. Morphine 10 mg/5 mL Solution Sig: 2.5 mL PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*1 200 mL bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Primary Diagnosis: Low Blood Pressure Abdominal Pain Clostridium difficile colitis Anemia (low blood counts) Neutropenia (low white blood cells) Thrombocytopenia (low platelet count) Secondary Diagnoses: Duodenal/Pancreatic Cancer Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **]: You were admitted to the hospital for low blood pressure and diarrhea. Laboratory tests revealed an infection in your colon (C. difficile colitis). You were started on antibiotics and your infection improved. You will need to take antibiotics for another 7 days after being discharged from the hospital. The following changes were made to your medications: -- You will need to complete another 7 days of Vancomycin (an antibiotic) 125 mg by mouth every six hours -- Stop taking your Dilaudid 2 mg tablets, [**12-20**] every four hours as needed for pain until you follow up with your outpatient gastroenterologist or hematologist -- Start taking Methadone 1 mg by mouth every eight hours a day for pain -- Start taking Morphine sulfate 5 mg by mouth every four hours as needed for breakthrough pain -- Both the Methadone and the Morphine will be increased as needed by your hospice -- Do not take the Senna or Docusate sodium for now as you have been having loose stools. Once your diarrhea resolves, you may resume these medications (which your hospice should instruct you to do) to prevent constipation from the Metadone and Morphine Followup Instructions: Please keep all of your outpatient appointments as described below: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2167-9-21**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2167-9-21**] at 11:30 AM With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2167-9-21**] at 1 PM With: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**] Completed by:[**2167-9-22**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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7447, 10597

335, 341

12790, 12790

4123, 4123

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11489, 12428

12526, 12526

10623, 11466

12941, 14107

6757, 7424

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12731, 12769

2242, 2721

236, 297

369, 2223

4139, 6741

12545, 12710

12805, 12917

2743, 2901

3139, 3380

46,105

126,246

36869

Discharge summary

report

Admission Date: [**2111-3-7**] Discharge Date: [**2111-3-13**] Date of Birth: [**2040-5-17**] Sex: M Service: MEDICINE Allergies: Gabapentin / Plavix / Meclizine / Olanzapine / Tobramycin / Meropenem Attending:[**First Name3 (LF) 2297**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 70 yom with TBI and CVA with trach. Pt. has hx of recurrent PNA, UTI, and sepsis ([**5-20**]) presented to [**Hospital 8**] Hospital on [**2111-2-27**] with fever, hypoxia, hypercarbia, hypotension from [**Hospital1 **]. At [**Hospital1 **] he had a temp to 102 and there was concern for trach collar leak. En route to [**Hospital1 18**] he was found to be unstable with hypotension and re-routed to [**Hospital 8**] Hospital. . In the ED at [**Hospital1 8**], initial vs were: T 102 BP 102/49 R 35 O2 sat 100%. Patient was given vancomycin, ertapenem, and toradol. His ABG there was 7.29/55/84 on AC 14/450/100%. . In the ICU there he was started on vanco/cefepime/amikacin for presumed VAP, although pt. has >18 decubitus ulcers that were also thought to be possible sources of infection. CXR concerning for RML consolidation and pt. found to have MRSA bacteremia, MRSA and pseudomonas PNA, MRSA/Klebsiella UTI. ECHO was negative for vegetations and showed an EF of 55%, mild LVH, mild RV enlargement, mild thickened aortic valve, and small pericardial effusion. ID was involved and pt. was changed to vanc/aztreonam/zosyn. . In terms of his respiratory status and hypoxia, it was attributed to PNA. Pt. also had trach cuff leak. ENT was consulted and trach was replaced with #10 Shiley on [**3-1**] however he continued to have a leak. Flexible Boniva trach placed on [**3-2**] with decreased leak. . Pt. also treated for his ARF. CRI since [**2111**] with baseline Cr in low 2 range. ARF attributed to hypovolemia, but despite TF and fluids, the Cr continued to rise. US showed no hydronephrosis, small renal stone. Renal team there did not feel he was a candidate for HD. . At baseline, the patient is nonverbal. He opens his eyes, but does not follow commands, respond to questions, or track. He has multiple stage 4 decubitus ulcers with history of osteomyelitis. Had R foot xray at OSH c/w osteomyelitis. Pt. also found to have thrombocytopenia and as a result heparin, ASA, and pepcid DC'd, HIT labs were negative. Per PCP, [**Name10 (NameIs) **] workup for TTP/HUS was negative. . Pt. transferred to [**Hospital1 18**] for second opinion regarding dialysis. Past Medical History: s/p CVA, intracerebral hemorrhage chronic and recurrent respiratory failure secondary to aspiration severe malnutrition type II DM GERD h/o VRE, MRSA and C diff infections severe contractures and multiple decubiti (most stage 4) h/o sacral osteomyelitis Social History: Lives at [**Hospital **] Rehab currently, vent dependent. Health care proxy is daughter. Family History: NC Physical Exam: Vitals: T: 96.4 BP: 97/50 P: 93 A. Fib R: 24 O2: 98% CMV 500/20/60%/5 General: pt. staring off, NAD HEENT: Sclera anicteric, Trach in place, NGT in place, Neck: JVP not elevated, no LAD Lungs: coarse/rhonchorus to auscultation bilaterally CV: irregularly irregular Abdomen: soft, non-tender, non-distended, bowel sounds hypoactive, J tube in place GU: foley in place Ext: pulses intact, pt. has multiple decubitus ulcers over extremities and back, stage 4 Pertinent Results: Micro: Cultures from OSH show MRSA bacteremia, MRSA/pseudomonas in sputum, MRSA/klebsiella UTI . TTE ([**3-9**]): The left atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is dilated with depressed free wall contractility. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. 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. IMPRESSION: dilated and hypokinetic right ventricle with moderate pulmonary artery systolic hypertension. Normal LV size and function. Mild mitral regurgitation. . CXR ([**3-9**]) IMPRESSION: 1. Uninterpretable abdominal radiograph with nonspecific bowel gas pattern. 2. Possible left lower lung consolidation. . CXR ([**3-9**]) IMPRESSION: 1. Multifocal pneumonia, with superimposed edema. 2. Overinflated ETT cuff. 3. NGT at GEJ, recommend advancing by a few centimeters. Brief Hospital Course: 70M with traumatic brain injury, CVA, s/p trach and PEG, chronic pressure ulcers who was transferred from an outside hospital with VAP, UTI, MRSA bacteremia. He was admitted to the MICU for further management. He was initially started on daptomycin, cefepime, metronidazole and ciprofloxacin . The infectious disease service was consulted and this regimen was changed to vancomycin, cefepime, metronidazole, and ciprofloxacin to cover for MRSA bacteremia, sputum with MRSA and pseudomonas with abnormal CXR, urine culture with MRSA and Klebsiella. The likely soure of bacteremia was thought to be skin given multiple ulcers. The wound care service was consulted for recommendations. Trans-thoracic echocardiogram was obtained that showed no evidence of vegetations but a significantly dilated and hypokinetic ventricle. He was continued on pressure support requiring three vasopressors. The renal team was consulted to discuss initiation of hemodialysis. Given the patient's significant co-morbidities and very limited functional status hemodialysis was not offered to the patient. His hospital course was complicated by atrial fibrillation with ventricular rates in the 90s, anemia, and thrombocytopenia. After discussion with the patient's daughter, his code status was changed to DNR/DNI with no escalation of care beyond current antibiotic therapy. He became hypotensive on three vasopressors and went into asysole and expired on [**2111-3-13**]. Medications on Admission: MEDS ON TRANSFER Zosyn 4.5g q6h IV Aztreonam 1g q6h IV Combivent Peridex Albuterol Lactulose 10g q8h Morphine 2mg IV q4h prn pain/debridement Novolin ISS Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "96.72", "99.15" ]

icd9pcs

[ [ [] ] ]

6492, 6501

4799, 6255

336, 342

6552, 6561

3441, 4776

6617, 6627

2942, 2946

6460, 6469

6522, 6531

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6585, 6594

2961, 3422

290, 298

370, 2541

2563, 2819

2835, 2926

43,472

151,797

40888+58412

Discharge summary

report+addendum

Admission Date: [**2178-7-10**] Discharge Date: [**2178-8-7**] Date of Birth: [**2096-9-26**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Pronestyl / Penicillins Attending:[**First Name3 (LF) 2145**] Chief Complaint: agitation Major Surgical or Invasive Procedure: right chest tube tracheostomy replacement History of Present Illness: 81 year old male with history of basilar artery aneurysm w/ICH from [**Hospital **] rehab in [**Location (un) **]. Had ventricular decompressions here. . Patient was h/o agitation since admission there ~2mos ago, recently stopped ativan 1 day PTA as family was worried masking repeat ICH. Sent to [**Hospital1 **] today b/c family concerned that pt was "rubbing at his face" and may have a repeat bleed with increased agitation. RN at [**Hospital1 **] reports no actual change in MS recently. Nonverbal at baseline. Documented strife between staff and daughter. On [**2178-7-9**] the PA writes in a PN that daughter states "it is ilegal if you give any kind of meds (sedative) to my father." "I want my father to send out (to [**Hospital3 **] Hospital) if get anxiety." On this note, his BP was 169/102. Was on Promote TF at 90cc/hour and IVF NS 100cc/hr. As it turns out, there are progress notes from [**2178-7-6**] (the earliest provided), that say "cont NS at 100 ml/h). . In the ED, initial VS: 97.2 110 94/68 28 95%. Noted to have total body fluid overload, including pleural effusions. Stable Head CT without bleed. CXR with increased L pleural effusion and new R. HR 90-100 until 7pm when went to 110s-120s, BP 150/100. Started on nitro gtt and given ativan 2mg IV for concern of benzo withdrawal. Chronically trached for respiratory failure. . On transfer, 134/87 on nitro drip with HR 102-120. 97%, 15/5, 30% Fi02. . On the floor, patient appears comfortable. He open his eyes to voice and is able to nod once that he does not have pain. Otherwise he is non responsive but withdraws to pain R>L. The daughter states that she has been unhappy with care at [**Hospital1 **] as his BP, edema have not been well controlled. Past Medical History: - Coronary artery disease - Hypertension - Congestive Heart Failure, further details unknown - Atrial Fibrillation on Coumadin - Left shoulder injury - Right knee replacement - Prior cerebral aneurysm with hemorrhage 3-4 years ago, details unknown - this possibly resulted in mild left arm and leg weakness - Questionable seizure in past Social History: He is retired and lives with his daughter in [**Name (NI) 3844**]. He ambulates with a cane and is independent of his ADLs. He still drives. No smoking, drinking, or alcohol use. Family History: Mother still alive at age [**Age over 90 **]. Daughter not aware of any family history of brain hemorrhages. Physical Exam: Vitals: 147/102, 105, 96% General: NARD HEENT: Sclera anicteric, MMM, oropharynx clear, R>L pupil 3mm vs 2mm both reactive Neck: supple, JVP not elevated Lungs: decreased at bases b/l CV: irregularly irregular, no mrg Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. GTube in place GU: foley discontinued Ext: warm, well perfused, without B/L LE edema neuro: left facial droop, withdraws to pain, moves right side more spontaneously than left DISCHARGE EXAM: 99.2 100 SysBP (range of SBPs from 80's to 120's systolic), HR 102, RR 22 Sating 100% on 35% Trach mask Irreg,irreg, transmitted trach sounds on lung auscultation, GTube in place, trach in place, abdomen soft, Lower Ext w/o edema. neuro: left facial droop, withdraws to pain, moves right side more spontaneously than left Pertinent Results: ADMISSION LABS: ================= [**2178-7-10**] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2178-7-10**] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [**2178-7-10**] 08:20PM URINE RBC-1 WBC-33* BACTERIA-FEW YEAST-NONE EPI-0 [**2178-7-10**] 08:20PM URINE MUCOUS-RARE [**2178-7-10**] 04:35PM GLUCOSE-117* UREA N-25* CREAT-0.8 SODIUM-140 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2178-7-10**] 04:35PM estGFR-Using this [**2178-7-10**] 04:35PM ALT(SGPT)-47* AST(SGOT)-32 CK(CPK)-31* ALK PHOS-297* TOT BILI-0.5 [**2178-7-10**] 04:35PM LIPASE-16 [**2178-7-10**] 04:35PM cTropnT-<0.01 [**2178-7-10**] 04:35PM CK-MB-3 proBNP-9363* [**2178-7-10**] 04:35PM ALBUMIN-3.0* CALCIUM-8.6 [**2178-7-10**] 04:35PM WBC-7.7 RBC-3.20* HGB-10.5* HCT-32.9* MCV-103*# MCH-32.8* MCHC-32.0 RDW-17.2* [**2178-7-10**] 04:35PM NEUTS-88.5* LYMPHS-5.0* MONOS-5.1 EOS-1.0 BASOS-0.5 [**2178-7-10**] 04:35PM PLT COUNT-338 [**2178-7-10**] 04:35PM PT-13.3 PTT-28.5 INR(PT)-1.1 DISHCARGE LABS: ================ [**2178-8-6**] 06:10AM BLOOD WBC-8.5 RBC-4.00* Hgb-12.5* Hct-37.6* MCV-94 MCH-31.4 MCHC-33.4 RDW-15.1 Plt Ct-394 [**2178-8-7**] 06:20AM BLOOD PT-32.0* PTT-37.3* INR(PT)-3.2* [**2178-8-7**] 06:20AM BLOOD Glucose-131* UreaN-19 Creat-0.5 Na-135 K-3.7 Cl-98 HCO3-30 AnGap-11 [**2178-8-7**] 06:20AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 [**2178-8-1**] 4:24 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2178-8-2**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2178-8-2**]): Reported to and read back by [**First Name8 (NamePattern2) 8031**] [**Last Name (NamePattern1) **] AT 0421 [**2178-8-2**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). CT HEAD W/O CONTRAST Study Date of [**2178-8-1**] 9:00 PM IMPRESSION: 1. No acute intracranial hemorrhage. 2. Encephalomalacia along the right frontal ventriculostomy tract and in the right basal ganglia (site of prior hemorrhage). CHEST (PORTABLE AP) Study Date of [**2178-8-1**] 5:57 PM CHEST AP: Comparison film [**2178-7-28**]. There are low lung volumes, limiting interpretation. Tracheostomy tube is present. No evidence of failure is seen. Left effusion is present. Neither base can be adequately evaluated and infiltrates in these regions cannot be excluded. IMPRESSION: Limited study, Basal infiltrates cannot be excluded. Portable Trans Thoracic Echo (Complete) Done [**2178-7-11**] at 12:00:06 PM FINAL Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30 %) with inferior akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-1**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 81 year old male with history of basilar artery aneurysm w/ich from [**Hospital **] rehab in [**Location (un) 5583**] with agitation and total body fluid overload. . Systolic Congestive Heart Failure Exacerbation: He was diuresed aggressively initially with IV furosemide with improvement in breathing/anasarca. Negative 11 liters for MICU length of stay. He was initially started on spironolactone 25 mg for medical management of heart failure in addition to his lisinopril and metoprolol. TTE showed EF of 30% with unknown baseline with left ventricular hypokinesis and inferior akinesis. In the setting of his diarrhea, his blood pressures have been running in the 90s systolic overnight and therefore his lisinopril was decreased to 2.5mg daily, metoprolol decreased to 50mg [**Hospital1 **], and spironolactone and Lasix was discontinued altogether for now. He should be weighed daily and his diuretics (Lasix/spironolactone) should be restarted if he gains 2 pounds from one day to the next. . Tracheostomy/Respiratory Support: Patient with chronic tracheostomy status post basilar artery stroke. Had intermittent respiratory distress requiring pressure support on the vent with occassional AC ventilation due to respiratory fatigue. Breathing improved with diuresis and patient was able to maintain tracheal mask ventilation. Later in hosptial course found to have a right sided pneumothorax of unknown etiology requiring IP placement of pleural catheter. Pneumothorax resolved without further complciations. Regarding tracheostomy tube, noted to have issues with hardware including pressure cuff requiring tracheostomy tube replacement. Inteventional pulmonology replaced the tubing with the proper cuff on [**2178-7-22**]. He pulled out his trach several days prior to discharge, and this was replaced without any respiratory decline with a size 7 (from a size 8). He is currently in bilateral mitt restraints. Afib with RVR: Known atrial fibrillation. Initially off anticoagulation given known intracranial hemorrhage prior to admission. Removed diltiazem from regimen given recurrent hypotension. Decreased metoprolol dosing for similar reason. Restarted coumadin after confirming with patient's neurologist it was safe given prior ICH. His dose was changed from 4mg daily to 2.5mg on [**2178-8-6**]. His INR on discharge is 3.2 and should continue to be monitored at his facility. Pseudomonas Aeuriginosa UTI: Urine culture grew pansesnitive P.Aeuriginosa. Completed a 10 day course of ciprofloxacin. Had lactobacillus later cultured from urine but this was not treated given likely he is colonized with this. Agitation: Episodes of agitation from likely from exacerbations of baseline dementia. Had poor response to Ativan and was trialed on Zyprexa qhs prn for symptomatic treatment. Ultimately, he was switched to trazadone for agitation at night. Hypertension: Adjusted home regimen given episodes of hypotension in house. Discharge regimen was 2.5 mg lisionpril daily and metoprolol 50mg [**Hospital1 **]. Lasix, spironolactone, and diltiazem were all discontinued due to hypotension. Prior ICH: Had CT head on [**7-10**] that showed no acute intracranial process. Areas of encephalomalacia in the right basal ganglia and right frontal lobe c/w prior basal ganglia hemorrhagic infarction. Clostrium Difficile gastroenteritis: was diagnosed and treated with IV flagyl - treatment which finished on [**2178-7-29**]. He then developed more diarrhea, and found to have positive CDiff again, treated with 125mg PO Vancomycin q6h. His treatment course began on [**2178-8-1**] and should end on [**2178-8-15**]. Code Status: Patient is currently full code however daughter is contemplating DNR/DNI. Also daughter is considering transitioning to hospice care. Pending: daily INRs pending facilities adjustments. Transition of care: continuing trach care. Recent INR is 3.2 on [**2178-8-7**] (Coumadin dose was decreased from 4mg on [**2178-8-5**] down to 2.5mg given on [**2178-8-6**]. He was discharge on 2.5mg with next INR check to be on [**2178-8-8**]). Discharge weight on [**2178-8-7**] is 84kg by bedscale. Medications on Admission: per rehab paperwork Lisinopril 20mg daily Metoprolol 50 mg Q6H Ipratropium 4 puff Q4H Gabapentin 100mg Q8H Insulin regular 200ml Q8H fiber docusate 100mg [**Hospital1 **] asa 81 mg daily polyethylene glycol 17G daily Terazosin 5mg daily Heparin SC 5000U Q8H Bisacodyl prn [**Doctor Last Name **] 5ml [**Hospital1 **] Tylenol 650 mg Q6H prn. Discharge Medications: 1. gabapentin 250 mg/5 mL Solution Sig: Two (2) cc (100 mg) PO TID (3 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. warfarin 1 mg Tablet Sig: 2.5 mg PO Once Daily at 4 PM: INR goal [**3-5**]. 4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 5. ipratropium bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) (17 gram) PO DAILY (Daily) as needed for constipation. 7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 8. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name **] cottage Discharge Diagnosis: Acute on chronic systolic heart failure Urinary tract infection Atrial Fibrillation with RVR Clostridium Difficile Colitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure providing care for you during this hospitalization. You were admitted to the hospital for signs of heart failure (fluid building up into your lungs). You were given medications that helped you urinate the extra fluid. This improved your breathing. You were also found to have an infection of your urinary tract. You were given antibiotics for this infection. You also had collapse of your lung which required a chest tube placement that was ultimately taken out. You were also found to have diarrhea and C. Difficle colitis and treated with antibiotics for this. Medication Changes: START: You were started on warfarin 2.5mg daily (to be titrated for INR [**3-5**]) for atrial fibrillation, trazadone 50 mg at night for agitation, vancomycin 125mg PO every 6 hours until [**8-15**] STOP: Diltiazem, Terazosin, Lasix, and spironolactone given low blood pressures. CHANGE: Metoprolol tartrate dose changed to 50mg twice daily given low blood pressures. Lisinopril reduced to 2.5mg daily given low blood pressures. Please resume your other medications as usual. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2178-8-11**] at 11:45 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please schedule appointment for him to be seen by patient's PCP [**Name Initial (PRE) 176**] 2 weeks of discharge from [**Hospital1 18**], Name: [**Last Name (LF) 89291**],[**First Name3 (LF) **] E Address: [**Street Address(2) 86225**], [**Location (un) **],[**Numeric Identifier 89292**] Phone: [**Telephone/Fax (1) 89293**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2178-8-7**] Name: [**Known lastname 14168**],[**Known firstname 917**] Unit No: [**Numeric Identifier 14169**] Admission Date: [**2178-7-10**] Discharge Date: [**2178-8-7**] Date of Birth: [**2096-9-26**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Pronestyl / Penicillins Attending:[**First Name3 (LF) 839**] Addendum: Clarification: 1) Patient with multiple medical problems, transferred from OSH of altered mental status which appears to attributable to several factors. He had a toxic metabolic encephalopathy (multifactorial) due to Pseudomonas UTI as well as CHF exacerbation and gross volume overload, in the setting of already compromised mental status from his stroke earlier this year. Additionally he had episodes of agitation both at OSH and here, possibly medication related delirium as well as toxic metabolic encephalopathy as above. These sx appear to have improved significantly over the course of his hospitalization and he was able to make several coherent statements near the end of his stay, though his cognition remains compromised from hx stroke with additional aphasia. 2) Pt has chronic respiratory failure, s/p trach, with acute exacerbation of his respiratory failure due to gross volume overload as well as right sided pneumothorax (discovered later in his admission, etiology uncertain). He intermittently required pressure support ventilation in the MICU but this has now resolved. He is now on regular trach mask. Please see main d/c summary for details of trach replacement due to pt's self-removal. Discharge Disposition: Extended Care Facility: [**Doctor First Name **] cottage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 841**] Completed by:[**2178-9-29**]

[ "599.0", "428.0", "V58.61", "427.1", "349.82", "401.9", "518.84", "337.1", "292.81", "414.01", "428.23", "276.52", "512.1", "041.7", "416.0", "438.83", "438.89", "438.11", "V43.65", "427.31", "729.89", "008.45", "519.02", "250.60" ]

icd9cm

[ [ [] ] ]

[ "33.21", "96.6", "96.72", "34.04", "97.23" ]

icd9pcs

[ [ [] ] ]

16834, 17013

7599, 11754

328, 371

13118, 13118

3703, 3703

14407, 16811

2708, 2818

12146, 12869

12972, 13097

11780, 12123

13298, 13884

2833, 3344

3360, 3684

13904, 14384

278, 290

399, 2133

3719, 7576

13133, 13274

2155, 2495

2511, 2692

28,428

104,869

32600

Discharge summary

report

Admission Date: [**2170-11-2**] Discharge Date: [**2170-11-11**] Date of Birth: [**2108-6-17**] Sex: M Service: UROLOGY Allergies: Synvisc Attending:[**First Name3 (LF) 824**] Chief Complaint: hematuria, obstructed foley Major Surgical or Invasive Procedure: s/p cystectomy, urostomy History of Present Illness: 62M s/p TURBT for recurrent hematuria, foley obstruction with blood clots, now s/p cystectomy and urostomy. Past Medical History: diabetes, type 2 hypertension stroke [**2165**], no residual sx bladder cancer [**2166**] former smoker 20py Physical Exam: afebrile, vital signs normal NAD, NCAT, EOM full Chest clear Heart regular, no murmurs/rubs/gallops Abdomen obese, soft, NT, ND, NABS; urostomy pink, slightly retracted, yellow urine Penis with foley in place LE with trace pitting edema Pertinent Results: [**2170-11-2**] 09:11PM BLOOD WBC-28.8*# RBC-4.25* Hgb-12.4* Hct-36.9* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.2 Plt Ct-397 [**2170-11-3**] 03:17PM BLOOD Hct-31.6* [**2170-11-4**] 12:23AM BLOOD Hct-28.5* [**2170-11-4**] 03:52AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.3* Hct-29.8* MCV-88 MCH-30.5 MCHC-34.5 RDW-14.5 Plt Ct-240 [**2170-11-4**] 01:07PM BLOOD WBC-16.7* RBC-3.96* Hgb-11.9* Hct-35.5* MCV-90 MCH-30.0 MCHC-33.5 RDW-14.4 Plt Ct-249 ---------------- CHEST (PORTABLE AP) [**2170-11-3**] 5:17 AM CHEST (PORTABLE AP) Reason: evaluate ET tube placement and evaluate for volume overload [**Hospital 93**] MEDICAL CONDITION: 62 year old man intubated s/p cystoprostatectomy REASON FOR THIS EXAMINATION: evaluate ET tube placement and evaluate for volume overload PORTABLE CHEST, [**2170-11-3**] AT 05:59 HOURS. COMPARISON STUDY: [**2170-11-2**] CLINICAL INFORMATION: ET tube placement, question volume overload FINDINGS: There are low lung volumes. There is mild bibasilar atelectasis and mild prominence of central pulmonary vasculature which may indicate a small degree of volume overload. The endotracheal tube terminates at the thoracic inlet. The nasogastric tube courses below the diaphragm but the tip is not seen. IMPRESSION: Low lung volumes, and mild volume overload. ---------------- [**2170-11-9**] 09:00AM BLOOD WBC-10.6 RBC-3.87* Hgb-11.4* Hct-33.8* MCV-87 MCH-29.5 MCHC-33.8 RDW-13.8 Plt Ct-453* ----------------- PORTABLE ABDOMEN [**2170-11-9**] 1:38 AM PORTABLE ABDOMEN Reason: portable KUB requesting for possible post-op ileus [**Hospital 93**] MEDICAL CONDITION: 62 year old man with upper epigastric pains REASON FOR THIS EXAMINATION: portable KUB requesting for possible post-op ileus INDICATION: _____ ? postop ileus. COMPARISON: No abdominal films for comparison. There are dilated loops of small bowel which are consistent with ileus. No evidence of free air on this supine view. There are surgical clips in the pelvis. There are staples in the overlying skin. The limited views of the bones show osteophytes in the lumber spine. IMPRESSION: _____ consistent with postoperative ileus. Followup radiographs recommended. DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] PORTABLE ABDOMEN [**2170-11-10**] 7:53 AM PORTABLE ABDOMEN Reason: ileus vs obstruction [**Hospital 93**] MEDICAL CONDITION: 62M s/p cystectomy, ileal conduit, now emesis REASON FOR THIS EXAMINATION: ileus vs obstruction EXAMINATION: Portable supine abdomen, one view. INDICATION: Status post cystectomy with ileal conduit presenting with emesis. COMPARISON: Comparison is made with the previous portable abdomen from [**2170-11-9**]. FINDINGS: There are diffuse and dilated loops of both small and large bowel which are relatively unchanged when compared to the previous radiograph and are consistent with ileus. This is a supine radiograph and an assessment of free air cannot be made. Surgical clips are seen in the pelvis with some staples overlying the skin. IMPRESSION: Dilated loops of both small and large bowel which are unchanged and appearances are consistent with ileus. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: SUN [**2170-11-11**] 11:03 AM -------------- [**2170-11-11**] 06:10AM BLOOD WBC-7.3 RBC-3.61* Hgb-10.4* Hct-31.3* MCV-87 MCH-28.7 MCHC-33.1 RDW-13.9 Plt Ct-532* [**2170-11-11**] 06:10AM BLOOD Glucose-87 UreaN-17 Creat-1.0 Na-140 K-3.4 Cl-104 HCO3-26 AnGap-13 Brief Hospital Course: GU: Admitted postoperatively after cystectomy and urostomy creation. Ureteral stents into ileal conduit and visible through stoma. Immediately postop, good urine output with some mucous. IVF were discontinued on POD5 and he was allowed to auto-diurese, producing good urine output even while off IVF and taking only sips on POD7-8. CV: Immediately postop, the pt went to the ICU and was hypotensive, requiring pressors through POD1. By POD2, pressors were weaned and the pt was hemodynamically stable, returning to baseline hypertension; he was transferred to the floor and started on IV lopressor. On POD4, he was started on his home diuretics and metoprolol 12.5 [**Hospital1 **], remaining normotensive. On POD6, after an episode of LUQ pain and emesis an EKG was done, which demonstrated stable findings when compared to his pre-operative EKG from [**10-10**]. The pt was continued on perioperative beta-blockade through POD8 after which the metoprolol was discontinued. Pulm: Pt was weaned off O2 by POD1 and did not require supplemental O2 after this time. Saturations remained >94% on RA. He did require occasional nebulizer treatments for intermittent wheezing during this hospitalization. GI: The patient passed flatus on POD3 and on POD4 he was started on sips and advanced to clears. By POD 5, after a small bowel movement, he was advanced to a regular diet without any problems. [**Name (NI) **] continued to pass flatus. On POD6, the pt developed LUQ abdominal pain that did not resolve with simethicone or morphine. He had two episodes of non-bloody emesis, after which the pain resolved. KUB demostrated no obstructions, but dilated loops throughout, consistent with ileus. On POD7, his diet was limited to sips of clears. On POD9, after being emesis free for 40 hours, his diet was advanced to clears then regular diabetic diet, which he tolerated well. Prior to admission, the pt had one loose and one formed bowel movement. Heme: Intraoperatively, difficult procedure with EBL of 3L; pt was transfused 8 units of red cells in the OR, and required an additional 2 units of red cells on POD1 for a hematocrit that was trending down to 28.5 at its lowest point. It remained stable at 32-33 for the remainder of the hospitalization. ID: Pt was on ancef perioperatively and did not require additonal antibiotics. His wound became minimally erythematous by POD5, but this slowly resolved without antibiotics. TLD: Pt was discharged with urostomy and bag in place; teaching was done in-house and follow up with a visiting nurse was arranged upon discharge. Discharge Medications: 1. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two (2) Cap PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 976**] VNA Inc Discharge Diagnosis: bladder tumor s/p cystectomy, urostomy, postop ileus Discharge Condition: good Discharge Instructions: You may shower but do not bathe, swim or otherwise immerse your incision. Do not lift anything heavier than a phone book. Do not drive or drink alcohol while taking narcotic pain medications. Resume all of your home medications, but please avoid aspirin and motrin/advil for 1 week. Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up appointment in [**12-5**] weeks, or if you have any questions. If you have fevers> 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up appointment in [**12-5**] weeks, or if you have any questions. Follow up with your primary care provider [**Last Name (NamePattern4) **] 1 week.

[ "518.5", "285.1", "E878.6", "V10.51", "595.0", "V43.65", "188.8", "274.9", "V15.82", "V12.54", "250.00", "997.4", "560.1", "276.6", "401.9", "998.11", "458.29" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.04", "57.71", "56.51", "96.71", "00.17", "40.3" ]

icd9pcs

[ [ [] ] ]

7951, 8013

4708, 7302

295, 322

8110, 8117

864, 1446

8757, 8989

7325, 7928

3300, 3346

8034, 8089

8141, 8734

606, 845

228, 257

3375, 4685

350, 459

481, 591

6,206

149,317

11537

Discharge summary

report

Admission Date: [**2133-12-28**] Discharge Date: [**2134-1-5**] Date of Birth: [**2098-3-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: Neck mass and abdominal distension for 1 day Major Surgical or Invasive Procedure: Bronchoscopy Esophagogastroduodenoscopy Right subclavian line placement History of Present Illness: 35 yo M w/ hx muscular distrophy w/ chronic resp failure on home mechanical ventilation a/w abd distention and neck mass s/p trach placement. Patient first had a trach placed in [**11-30**] [**3-2**] skin break down w/ BiPAP. He subsequently had trach replacement on [**2133-10-1**] and was treated w/ azithromycin [**3-2**] tracheal infection diagnosed by purulent drainage from trach. In [**9-2**] pt was treated w/ 10d course of Keflex from ED. At home yesterday, patient's cuff blew out and his family attempted replacement w/ his old trach which didn't work. Subsequent replacement w/ his back-up trach worked, however increased abdominal distention was noted and air expelled from his PEG. Pt was brought to [**Hospital3 417**] MC. Neck XR there showed no air, CXR negative, and abd XR showed dilated bowel loops w/out free air. Pt remained HD stable throughout this course of events and was transferred to [**Hospital1 18**] for further evaluation. Additionally a new soft tissue neck mass was noted to be gradually increasing over the past 4 months. It was noted on [**2133-10-7**] at his clinic visit w/ Dr. [**Name (NI) **]. At that time, pt was also noted to have increased secretions and a therapeutic bronchoscopy was done [**3-2**] increased ventilatory pressures. After the procedure, which included removal of secretions, pt's airway pressures dropped significantly from 70's to 20-30's. Pt communicates via laser pointer w/ chart, understands via writing on dry erase board. He reports some SOB this am, now improved. Reports increased secretions over time (c/w prior clinic notes ~ 1 mo ago) and reports improvement of his SOB post-suctioning. Additionally, reports his hearing has deteriorated significantly over the past several months. In [**Name (NI) **] pt requested multiple suctioning and was con't on his home vent settings: CMV 750 x 14 x 5; FIO2 50%. Past Medical History: 1. Fasciouscapulohumoral Muscular dystrophy w/ chronic mech resp failure on home vent 18/8. BiPAP x 9 yrs s/p trach placement [**11-30**] [**3-2**] skin breakdown from nasal pillows now on mech vent at AC 750 x 14 x5 30-40% FIO2; LMS bronchus stent [**10-1**] 2/2 L main stem airway compression, replaced [**10-31**] supraglotting bstruction (clin insignificant given trach) [**12-2**] 2. s/p PEG [**2121**] 3. b/l congenital hearing loss w/ hearing aids 4. Seasonal allergies 5. Occ macular rash ? etiology, per father assoc w/ "stress" Social History: Lives at home w/ his parents and sister. [**Name (NI) **] hx EtOH, tobacco use. Communicates via laser pointer. Family History: No FH of MD; FH + breast ca. Physical Exam: Vitals: 98.4 HR 106 BP 123/82 RR 15 96% on AC TV 750 f 14 PEEP 5 FIO2 50% Gen: cauc young M severely contracted lying on stretcher in NAD w/ laser pointer in R hand and trach in place Neck: 4x6 cm mass under trachea, non-fluctuant, no calor, rubor, or induration; air sounds audible over mass; non-tender; Heart: RRR, S1, S2 ,no m/r/g Lungs: coarse BS b/l, L ant bronchial breath sounds over L main stem stent; occ coarse crackles, no wheezing; Abd: PEG in place, cachectic, post-spine easily palpable on abd exam; no masses, non-distended, nontender; no masses Ext: extremely cachectic, no edema, no rash Pertinent Results: LABORATORY DATA ON ADMISSION: [**2133-12-28**] 11:41AM BLOOD WBC-7.0 RBC-4.30* Hgb-12.6* Hct-36.2* MCV-84 MCH-29.4 MCHC-34.8# RDW-14.9 Plt Ct-318 [**2133-12-30**] 04:11AM BLOOD Neuts-87.7* Lymphs-9.0* Monos-3.0 Eos-0.1 Baso-0.2 [**2133-12-28**] 11:41AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.3 [**2133-12-28**] 11:41AM BLOOD Glucose-100 UreaN-33* Creat-0.3* Na-143 K-3.0* Cl-103 HCO3-22 AnGap-21* [**2133-12-28**] 05:16PM BLOOD Glucose-101 UreaN-34* Creat-0.3* Na-144 K-3.7 Cl-108 HCO3-19* AnGap-21* [**2133-12-28**] 11:41AM BLOOD ALT-17 AST-23 AlkPhos-154* Amylase-143* TotBili-0.6 [**2133-12-28**] 11:41AM BLOOD Lipase-49 [**2133-12-28**] 11:41AM BLOOD Albumin-4.5 Calcium-10.2 Phos-3.6 Mg-2.6 ------ PERTINENT STUDIES IN HOSPITAL: CT neck [**12-28**]: FINDINGS: Small scattered cervical lymph nodes are identified. Muscles of mastication and parotid glands are symmetric. Thyroid gland enhances homogeneously throughout. Tracheostomy tube is noted and terminates approximately 4.3 cm above the level of the carina. There is marked gaseous distention of the tracheostomy balloon consistent with placement of an oversized device. The stent is seen in the left main stem bronchus. There is gaseous distension of the esophagus. The tracheostomy balloon corresponds to the palpable abnormality identified in the patient's anterior neck. Visualized lung fields demonstrate patchy parenchymal opacities, most confluent in the right upper lobe. These are grossly unchanged since the prior study from [**2131-7-31**] and most likely represent chronic aspiration pneumonia. IMPRESSION: 1) Tracheostomy balloon appears to correspond to the palpable swelling in the neck. 2) Stable appearance of patchy parenchymal opacities, most confluent at the right upper lobe, consistent with chronic aspiration pneumonia. ------ CT chest/[**Last Name (un) 103**]/pelvis [**2133-12-31**]: CT CHEST WITH IV CONTRAST: As before, there is a very small AP diameter of the chest and abdomen. Tracheostomy tube is noted in satisfactory position above the level of the carina. There is proximal gaseous distension of the trachea and proximal esophagus. The airways appear patent. No pathologically enlarged mediastinal, hilar, or axillary lymph nodes are identified. No mediastinal inflammatory changes are identified to suggest underlying mediastinitis. The heart, pericardium, and great vessels appear grossly normal. Evaluation of the lung parenchyma again demonstrates patchy consolidation, most confluent within the right upper lobe, consistent with aspiration. There is a trace amount of right pleural fluid. CT OF ABDOMEN WITH IV CONTRAST: There is vicarious contrast within the gallbladder. A small stone is visualized, but there are no seconday signs of cholecystitis. The liver, spleen, pancreas, kidneys, and adrenal glands are grossly normal in appearance. Percutaneous gastrostomy tube is noted within the stomach. There are prominent fluid-filled loops of small bowel within the left hemiabdomen with more collapsed loops distallu without evidence of a true transition point or frank obstruction. There is no bowel wall thickening or surrounding inflammatory change. Small to moderate amount of free ascites is present. There is no free air. CT OF PELVIS WITH IV CONTRAST: A small amount of gas is visualized within a Foley-containing urinary bladder. There is a moderate amount of free ascites within the pelvis. Visualized collapsed pelvic loops of bowel appear grossly normal. BONE WINDOWS: There is diffuse osteopenia of the visualized osseous structures. Soft tissues are notable for profound cachexia and muscle atrophy. IMPRESSION: 1. Patchy parenchymal consolidation, most confluent within the right upper lobe. This most likely reflects aspiration pneumonia and is unchanged since the prior CT chest. 2. Gaseous distension of the trachea and proximal esphagus as above, not significantly changed since the prior study. 3. Small to moderate amount of free fluid within the abdomen and pelvis. 4. Prominent, fluid-filled loops of small bowel within the left hemiabdomen with relatively collapsed loops distally. This could represent a partial small bowel obstruction or evolving obstruction. Clinical correlation is recommended. ----- Echo [**2133-12-31**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. ----- EGD [**2133-12-30**]: Findings: Esophagus: Excavated Lesions A fistula was found in the esophagus at 20cms. There was yellowish mucus seeping from the fistula into the esophagus. Stomach: A gastrostomy tube was seen in the stomach body. Duodenum: Not examined. Impression: Esophageal fistula. Brief Hospital Course: Mr. [**Known lastname 2979**] hospital course will be reviewed by problems. 1. Neck mass: In the ICU, the patient's lung mechanics were suggestive of high airway resistance with elevated PIPs and plateaus 15-17. In AM [**12-29**], the patient was noted to have increased work of breathing, with desaturation. A bedside flexible bronchoscopy was performed and revealed 80% occlusion of the tracheostomy tube with secretions, which were removed. Pressures subsequently improved. Also on [**12-29**], a rigid bronchoscopy was performed which showed tracheal distension at the cuff pressure site, with posterior tracheal wall necrosis. The site was bypassed with a longer trach repositioned above the carina. A small air leak was left to avoid further airway damage. 2. Leukocytosis, hypothermia, tachycardia: In the ICU, the patient was noted to be hypothermic, with rising WBC. Cultures were sent and empiric antibiotic coverage was started with Vanco/Levo/Flagyl. A CT chest ruled out mediastinitis, but revealed chronic RUL destructive changes and query LLL infiltrate. CT [**Last Name (un) 103**] was without intraabdominal infection. Lactate 1.7, MVo2 nl. Antibiotics were continued until direction of care clarified. 3. TE fistula: On [**12-29**], the patient was noted to have abdominal distension, with gastric distension evident on abdominal films. Distension relieved with intermittent suction of PEG tube. TEF became was a concern, but available studies were limited given that the patient could not swallow or tolerate lying prone for a airway CT. Of note, a CT [**Last Name (un) 103**] on [**12-30**] revealed small to moderate amount of ascites, no free air or obstruction. An EGD was performed on [**12-31**], which confirmed the presence of a tracheoesophageal fistula visualized at 20 cm from teeth. No intervention was possible by IP or GI. CT surgery was informed. Options were reviewed with the family. Per family's wishes, the decision was taken not to proceed with surgery and to institute comfort measures only. Hence, antibiotics, IVFs and nutrition were D/C'd on [**2134-1-1**] and the patient was made CMO. He was continued on his home ventilator. Psychosocial support was offered, with involvement of the social worker, palliative care and Dr. [**Last Name (STitle) 4261**]. On [**2134-1-5**], per family's wishes, mechanical ventilation was stopped and the patient expired. Medications on Admission: Zoloft 50mg po qd Pepcid KCl 1tsp qd Ativan 0.5mg po qd prn Duralgesic q72h placed Sat [**2133-12-26**] Hyoscyamine 1ml q8h on hold Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Muscular dystrophy Chronic mechanical ventilation Trachoesophageal fistula Tracheal necrosis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2134-1-6**]

[ "519.02", "560.9", "276.0", "787.3", "789.5", "507.0", "530.89", "V44.0", "574.20", "733.90", "359.1", "389.9", "518.83" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.56", "45.13", "96.72", "97.23" ]

icd9pcs

[ [ [] ] ]

11438, 11447

8818, 11223

359, 432

11584, 11593

3732, 3748

11649, 11777

3060, 3090

11406, 11415

11468, 11563

11249, 11383

11617, 11626

3105, 3713

275, 321

460, 2354

3763, 8795

2376, 2915

2931, 3044

29,579

157,597

33027

Discharge summary

report

Admission Date: [**2177-6-25**] Discharge Date: [**2177-7-9**] Date of Birth: [**2112-11-4**] Sex: M Service: MEDICINE Allergies: Glyburide / Sulfonylureas Attending:[**First Name3 (LF) 5552**] Chief Complaint: R Hip Pain Major Surgical or Invasive Procedure: CT guided right iliac biopsy History of Present Illness: 64 M w/ pmhx of colon cancer s/p resection [**2175**] w/ colsotomy, ESRD, developed abdominal abscess in 20/08. Then fell in [**4-12**] during a dialysis session, w/ R hip fx w/o surgical correction given abscses at that time, CT scan supported metastatic disease. Later a biopsy was performed which demosntrated possible spindle cells. He is being tx to the [**Hospital1 18**] for further oncology managment by Dr. [**Last Name (STitle) **]. He states that since his hospital admission in [**3-14**] he has been at rehab, and has had RLE weakness and been unable to ambulate, he also has had a chronic o2 requirement since [**3-14**]. He otherwise has chronic pain in his right hip, and R>L leg weakness, chronic numbness in his lower extremities, is anuric, has an ostomy, no saddle anesthesia. o/w denies cp/f/c/n/v. Past Medical History: O2 requirement 2.5L since [**3-14**] DM II ESRD from post-surgical ATN from which pt never recovered - currently on dialysis MWF Colon Ca CHF Hyperlipidemia HTN Gout Afib . PSH: AV fistula for dialysis access L arm colon ca resection [**2175**] with J pouch c post-op Chemo/XRT temporary diverting ileostomy subsequently taken down. Social History: Social History: Lives with wife, quit smoking 22 years ago but smoked 3 ppd x ?20 years (60 pack-years), quit etoh 2 years ago (drank on weekends, denies heavy use), denies illicit drug use. Family History: Family History: Mother alive and healthy, father deceased when pt a baby, unknown cause, son healthy, no siblings. Physical Exam: VS 96.6 70 20 97 58 3LNC GEN: NAD, pleasant speaking in full sentences, comfortable HEENT: PERRL EOMI, OP clear, No LAD CV: RRR SEM III/VI greatest LUSB radiating to axilla CHEST: crackles left lung fields 1/2 up ABD: +BS soft nt/nd ostomy, hemorrhoids, no decub. EXT: no c/c/e NEURO: AAOx3, motor LLE [**5-10**], RLE [**4-9**], UE [**6-9**] symmetric LABS: See below Pertinent Results: [**2177-6-26**] 07:55AM BLOOD WBC-8.2 RBC-3.57*# Hgb-9.7* Hct-31.3* MCV-88 MCH-27.1 MCHC-30.9* RDW-18.5* Plt Ct-514* [**2177-6-29**] 06:45AM BLOOD WBC-9.3 RBC-3.48* Hgb-9.3* Hct-30.4* MCV-87 MCH-26.7* MCHC-30.5* RDW-17.7* Plt Ct-539*# [**2177-6-26**] 07:55AM BLOOD Glucose-72 UreaN-42* Creat-3.4*# Na-138 K-5.2* Cl-93* HCO3-29 AnGap-21* [**2177-6-29**] 06:45AM BLOOD Glucose-86 UreaN-42* Creat-3.6* Na-136 K-4.4 Cl-95* HCO3-27 AnGap-18 [**2177-6-26**] 07:55AM BLOOD Calcium-8.6 Phos-5.5* Mg-1.7 [**2177-6-29**] 06:45AM BLOOD Calcium-8.7 Phos-5.8* Mg-1.9 [**2177-6-27**] 07:00AM BLOOD calTIBC-179* Ferritn-1026* TRF-138* [**2177-6-27**] 07:00AM BLOOD CEA-4.6* PSA-0.4 . BILAT HIPS (AP,LAT & AP PELVIS) [**2177-6-26**] 6:32 PM BILAT HIPS (AP,LAT & AP PELVIS Reason: Please eval fracture [**Hospital 93**] MEDICAL CONDITION: 64 year old man with rectal cancer, s/p R hip fracture in [**Month (only) 958**] [**2177**] REASON FOR THIS EXAMINATION: Please eval fracture BILATERAL HIPS [**2177-6-26**]: CLINICAL INFORMATION: Rectal cancer status post right hip fracture marginally. FINDINGS: AP view of the pelvis and two coned down views of the right hip are submitted. Comparison is made with the CT of the abdomen and pelvis from [**2177-3-30**] which demonstrates a lytic destructive lesion of the right acetabulum. Since the prior study, there has been interval progression of the destructive lesion within the right acetabulum and iliac bone. There is now destruction of the acetabular wall with medial migration of the femoral head. There is medial displacement of the acetabular wall into the pelvis. There is a lucency at the femoral head-neck junction which may represent a non-displaced fracture. Further evaluation with CT or MRI is recommended. Evaluation for fine osseous detail is limited by the osteopenia. There are multiple lytic lesions throughout the osseous pelvis and the left femur as well. There is old osseous deformity of the left proximal femur. There is severe degenerative change in the lower lumbar spine. IMPRESSION: 1) Progression of large lytic destructive lesion in the right acetabulum and iliac bone with fracture of the medial acetabular wall with displacement of fracture medially into the pelvis. 2) Question non-displaced fracture of the femoral neck at the subcapital region. 3) Old fracture deformity of the left proximal femur. Further evaluation with CT or MRI is recommended. . BILAT LOWER EXT VEINS [**2177-6-27**] 10:32 AM BILAT LOWER EXT VEINS Reason: BILATERAL LEG EDEMA, ?DVT [**Hospital 93**] MEDICAL CONDITION: 64 year old man with colon Cancer, pathalogic fracture of hip, bilateral lower extremity swelling, R>L. REASON FOR THIS EXAMINATION: DVT? INDICATION: Bilateral lower extremity swelling, right greater than left. COMPARISON: None. BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: The right and left common femoral, greater saphenous, superficial femoral, popliteal demonstrate wall- to-wall flow and normal compressibility and response to Valsalva and augmentation. Wall-to-wall flow is seen in the posterior and tibial veins bilaterally. Edema is seen in both legs. IMPRESSION: No son[**Name (NI) 493**] evidence for DVT; edema. Bone Scan: Whole body images of the skeleton and planar views of the thorax were obtained in anterior and posterior projections. Images show focal abnormal uptake of tracer in the right acetabulum and right inferior pubic ramus. Increased uptake is seen within the left proximal femur diaphysis associated with bony deformity. Additionally there is focal uptake in the bilateral shoulders, right greater than left, as well as the bilateral knees, right greater than left consistent with degenerative changes. Focal uptake within the distal ends of the 11th and 7th left ribs is likely secondary to prior trauma. The above described findings are consistent with focal tracer uptake within the known lytic lesion in the right acetabulum as well as within the right inferior pubic ramus, concerning for metastatic disease. The kidneys and urinary bladder are visualized, the normal route of tracer excretion. IMPRESSION: 1. Focal tracer uptake within the known lytic lesion of the right acetabulum and pubic symphysis, concerning for metastatic disease. 2. Likely degenerative changes of the bilateral shoulders and knees. CT guided biopsy: PROCEDURE/FINDINGS: The risks and benefits of the procedure were explained to the patient and informed written consent was obtained. Preprocedural timeout was performed confirming the patient's identity and the procedure to be undertaken. The patient was placed in the left lateral decubitus position on the CT scanner. The patient was prepped and draped in the usual sterile fashion. Using 10 cc of 1% lidocaine for local anesthesia, under direct CT fluoroscopic guidance, a 14-gauge coaxial needle was inserted into the destructive lytic lesion within the right ilium. Subsequently, five core biopsy samples were obtained with a 15-gauge biopsy gun device with the samples were placed in formalin. Additionally, one core biopsy sample was placed in CytoLite for cytology analysis. Patient tolerated the procedure well and there were no immediate post-procedural complications. Dry sterile dressing was placed. Moderate sedation was provided by administering divided doses of Versed and fentanyl throughout the total intraservice time of 10 minutes during which the patient's hemodynamic parameters were continuously monitored. A total dose of 25 mcg of fentanyl and 0.5 mg of Versed were administered. The procedure was performed by Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 76802**] Dr. [**First Name (STitle) **], the attending radiologist, present and supervising throughout. IMPRESSION: Technically successful CT-guided core biopsy of right iliac bone lesion Biospy: DIAGNOSIS: Right iliac lytic lesion, biopsy (A): Connective tissue, scant fragments of bone and fibrin. No malignancy identified in this specimen CT Torso: CT CHEST WITH IV CONTRAST: Bilateral pleural effusions and associated atelectasis are greater on the right than the left. There is associated volume loss on the right, with segmental collapse. The right lower lobe bronchus remains patent. The trachea and left bronchi are patent to the subsegmental level. The aorta and its branches and the coronary arteries demonstrate heavy calcifications. The heart, aorta, and great vessels are otherwise unremarkable. There is mild thyroid enlargement without a discrete thyroid nodule identified. There is no supraclavicular, axillary, or mediastinal lymphadenopathy. There is a soft tissue mass involving the right rotator cuff muscles and causing erosion into the right humeral head, which demonstrates pathologic fracture. There is no apparent involvement of the glenoid fossa. CT ABDOMEN WITH IV CONTRAST: A 2.2 x 1.9 cm adrenal nodule (3:57) is low in attenuation and unchanged since prior studies, likely representing an adrenal adenoma. The kidneys are atrophic bilaterally. A 3.9 x 2.2 cm exophytic cyst is identified arising from the interpolar region of the left kidney (3:60A), and a simple renal cyst is identified arising from the inferior pole of the right kidney (3:60A). The liver, spleen, pancreas, right adrenal gland, large bowel, and small bowel are unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy, and no intra-abdominal free air or fluid is identified. The abdominal aorta and its branches are heavily calcified. CT PELVIS WITH IV CONTRAST: The left lower quadrant demonstrates sigmoid colostomy. A rectosigmoid anastomosis site is identified. There is a small amount of calcification in the prostate gland. The rectum and bladder are unremarkable. No pelvic or inguinal lymphadenopathy is identified. There is a 4.4 x 2.1 cm fluid collection anterior to the inferior sacrum and posterior to the rectum (axial 3:107; coronal 7:47). There is diffuse edema and soft tissue enlargement involving the right flank, right psoas muscle, and iliopsoas, with erosion of a soft tissue mass into the right acetabulum and femoral head. Although previously involving the right acetabulum, there has been progression of pathologic fracture of the acetabulum as well as femoral head. The left iliopsoas muscle is also enlarged, indicative of a soft tissue mass with pathologic fracture of the left acetabulum and extensive lytic lesions of the left femoral head without definite cortical breakthrough. The origin of the left hamstring muscle is asymetrically enlarged with obliteration of the fat planes at the medial aspect of the posterior thigh (3:130). IMPRESSION: 1. Soft tissue metastases with bony erosion and pathologic fracture involving the right humeral head, right femoral head and acetabulum, and left acetabulum. Lytic lesions without definite cortical breakthrough involving left femoral head. 2. Bilateral pleural effusions, right greater than left, with associated atelectasis and volume loss. 3. No lymphadenopathy in the chest, abdomen, or pelvis. 4. Left adrenal adenoma. 5. Bilateral renal cysts. 6. Significant atherosclerotic disease involving the aorta and its branches. Brief Hospital Course: 64 M w/ pmhx of rectal cancer presented for evaluation of likely pathologic right hip fracture. The patient had undergone an IR guided needle biopsy of his right iliac crest in order to obtain [**Last Name (un) 12621**] for diagnosis. The initial examination hsowed predominantly fibrosis with spindle cells, raising the possibiltity that the pathalogic fracture may be from a new primary sarcoma, as opposed to metastatic rectal cancer. The biopsy specimen was sent to [**Hospital1 **] and woman's hospital for further examination. On arrival to [**Hospital1 18**], Pelvis X-Ray showed widespread metastatic involvement of the bony pelvis. Orthopedics evaluated the patient and found his hip unable to be surgically repaired. They recommended the patient be seen by radiation oncology for treatment of his metastatic disease. However, radiation oncology deferred until pathology on his planned biopsy returned. Furthermore, he had previously received radiation therapy at an outside provider and they recommended that if radiation was needed, he should return there as they have his previous mapping. They also recommended the patient get a bone scan in order to find other metastatic sites which may be easily accesible for further biopsy and identification. The bone identified the lesions in the right hip that were suspicious and he underwent a CT guided biopsy of the right ilium by orthopedic oncology on [**7-4**]. However, this biopsy show no malignancy. Furthermore, and SPEP and UPEP were negative. His right hip lesion may be severe bony disease in a patient in a patient on hemodialysis. In discussion with the orthopedic oncologist and his primary oncologist, the decision was made to observe the patient in one month with a repeat CT scan. If his disease has progressed at that time, the orthopedic oncologist will pursue an open biopsy. He will follow up with his primary oncologist, Dr. [**Last Name (STitle) **], and the orthopedic oncologist, Dr. [**First Name (STitle) 4223**]. He should also be evaluated by his nephrologist to evaluate his metabolic status in regards to his bone health. His pain was controlled with Oxycontin . On [**7-1**], after receiving more extensive IV fluids prior to his bonescan, the patient developed respiratory distress and subsequent hypercarbic respiratory failure. He was transferred to the medical ICU. He was briefly placed on non-invasive ventilation and emergently dialyzed to remove fluid. The previous day, his long acting Oxycontin was also increased from 20mg [**Hospital1 **] to 40mg [**Hospital1 **]. It is felt that both the volume overload and the increase in his narcotics contributed to his respiratory failure. He continued to have fluid removed by HD and improved. He presented with a chronic oxygen requirement of approximately 2.5L. He was using 3L NC at the time of discharge and this may continue to be weened as more fluid is removed at hemodialysis at it is felt that the cause of his oxygen requirement is continued volume overload. . # ESRD- on HD MWF- Continued on nephrocaps and calcium acetate. He will continue on an oral fluid restriction as outlined above. . # Afib- He was continued on his home doses of amiodarone, metoprolol, and diltiazem with good effect. His LFTs and TFTs were normal here. The patient may benefit from PFTs as an outpatient. . # Ischemic cardiomyopathy: Continued on ASA, metoprolol, and statin with fluid removal at hemodialysis . # Gout - continued renally-dosed allopurinol . # DM- continued humalog ISS . # Depression- continued home celexa . # PPx: cont PPI, sc heparin . # FEN: Renal Diet as tolerated, monitor lytes . # CODE: Full Code (confirmed with wife on transfer) Medications on Admission: Oxycontin 20mg [**Hospital1 **] Oxycodone 10mg Q4HR PRN Nephrocaps Prilosec 20mg Daily Crestor 5mg Daily Diltiazem 30mg QID Amiodraone 200mg Daily Metoprolol 100mg Daily ASA 325 Daily Allopurinol 100mg Daily Citalopram 40mg Daily Lorazepam 1mg PO Q6HR PRN ISS Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Hold for SBP<100, HR<60. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for SBP<100, HR<60. 11. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 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. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. 16. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 18. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 19. Insulin Lispro 100 unit/mL Solution Sig: See sliding scale Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Health Care Center Discharge Diagnosis: Rectal carcinoma Pathologic hip fracture End Stage Renal Disease on hemodialysis Diabetes Type 2 Hyperlipidemia Hypertension Gout Atrial Fibrillation Discharge Condition: All vital signs stable Discharge Instructions: You were admitted to the hospital for evaluation of your hip fracture. You had a biopsy done which showed no cancer. You will follow up with Dr. [**First Name (STitle) 4223**] and Dr. [**Last Name (STitle) **] for further observation. If the problem has progressed, Dr. [**First Name (STitle) 4223**] would consider an open biopsy. Your hip problem may be from severe osteooporosis caused by your dialysis. You should discuss this with your kidney doctor. You also have accumulated more fluid which will continue to be taken off at dialysis. . Please continue to take your medications as prescribed. . Please follow up as described below. . Please call your doctor or return to the hospital if you experience any worrisome symptoms. Followup Instructions: Please call Dr.[**Name (NI) 8949**] office at ([**Telephone/Fax (1) 5562**] to schedule a follow up appointment towards the end of [**Month (only) 205**]. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-8-4**] 9:40 Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-8-4**] 10:00

[ "V10.05", "428.22", "250.00", "427.31", "518.81", "585.6", "414.8", "733.14", "274.9", "198.5", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95", "77.49", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

17214, 17279

11478, 15175

296, 327

17474, 17499

2283, 3072

18281, 18707

1777, 1877

15485, 17191

4856, 4960

17300, 17453

15201, 15462

17523, 18258

1892, 2264

246, 258

4989, 11455

355, 1181

1203, 1537

1569, 1745

27,616

149,052

34701

Discharge summary

report

Admission Date: [**2103-2-3**] Discharge Date: [**2103-2-11**] Date of Birth: [**2050-2-1**] Sex: F Service: MEDICINE Allergies: Aspirin / Ibuprofen / Gabapentin / Tylenol Attending:[**Male First Name (un) 5282**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 58871**] is a 52 yoF with ESLD secondary to HepC & EtOH with recently banded esophageal varices, who presents with a two day history of melena. Prior to this, she has not had a known GIB. On [**2103-1-12**] she had an EGD that showed grade II varices, which were banded. She had a scheduled repeat EGD on [**2103-1-31**] which showed three cords of grade II-III varices in the lower third of the esophagus as well as two post-banding ulcers seen in the lower esophagus; no active bleeding was noted though it was recommended that she return in [**3-28**] wks for "slowly healing banded ulcers." . The morning after the procedure on [**2103-2-1**] she developed melena with approximately 7 BM's throughout the day and night. The afternoon of [**2103-2-2**] prior to going to the [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **], she noted BRB on the TP, but otherwise has not had BRBPR. In addition, on [**2103-2-1**] she had a single episode of a small volume of coffee-grounds emesis. Of note, she has been on Lovenox [**Hospital1 **] for portal vein thrombosis (dx [**1-1**], see below). She was transferred to [**Hospital1 18**] for further work-up and care. . In the ED, VS were BP 93/57 (baseline SBP ~110's), HR 75, T 97.6, RR 14, 100% RA. Hct was noted to be 20.0 with a baseline in the mid to upper 20's (last checked on [**1-22**] and was 27.8). Platelets were 60 (baseline ~70); INR 1.6. Two 20 g PIV were placed; 1L NS was given and two units RBC were ordered. The ED staff spoke with the GI fellow who recommended ocreotide/IV PPI and scope in the am. . ROS: * positive for RUQ pain (few weeks), dizziness/lightheadedness (improved now after IVF and blood in the ED), epigastric "cramping" (gets with lactulose use) and neuropathic pain in LE b/l. * negative for CP, SOB, HA, fevers, anorexia Past Medical History: - Polysubstance abuse: etoh, benzodiazepine, cocaine. - Cirrhosis, c/bencephalopathy, ascites, and stage 4esophageal varices (but has not had a history of GI bleeding) She reports having a history of SBP in the past, treated @ [**Hospital3 **] - Hepatitis C (she reports from tatoos) - Diabetes Mellitus, Type 1? - Neuropathy - Thrombocytopenia - Depression - Anxiety Social History: Lives alone, though her neighbor [**Name (NI) **] is closely involved in her care. History of cocaine use and alcohol abuse. Endorses current sobriety. Unemployed and on disability. Family History: Multiple family members with alcohol/substance abuse. Mother with scleroderma. Multiple siblings with diabetes. Physical Exam: VS in the ED: BP 93/57, HR 75, T 97.6, RR 14, 100% RA VS on arrival to the MICU: General: comfortable appearing, thin, pleasant/conversant Lungs: crackles at right base; otherwise CTA b/l, no wheezes, no rales Cardio: RRR, no m.r.g Abd: hyperactive bowel sounds, soft, NTND, no fluid waves appreciated Skin: no rashes, somewhat dry, no petechiae Extremities: no [**Location (un) **] Neuro: AA, Ox3, somewhat slowed speech but comprehensible; neg asterixis; CN II - XII in tact, moving all extremities Pertinent Results: [**2103-2-3**] 08:30PM HCT-22.3* [**2103-2-3**] 03:14PM HCT-22.3* [**2103-2-3**] 08:31AM HCT-22.4* [**2103-2-3**] 03:15AM GLUCOSE-156* UREA N-59* CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13 [**2103-2-3**] 03:15AM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-2.0 [**2103-2-3**] 03:15AM WBC-2.7* RBC-2.40* HGB-8.1* HCT-22.2* MCV-93 MCH-33.7* MCHC-36.4* RDW-17.1* [**2103-2-3**] 03:15AM PLT COUNT-52* [**2103-2-3**] 03:15AM PT-17.7* PTT-41.2* INR(PT)-1.6* [**2103-2-2**] 10:33PM PT-17.6* PTT-42.2* INR(PT)-1.6* [**2103-2-2**] 09:00PM GLUCOSE-199* UREA N-62* CREAT-1.1 SODIUM-135 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 [**2103-2-2**] 09:00PM estGFR-Using this [**2103-2-2**] 09:00PM ALT(SGPT)-16 AST(SGOT)-32 ALK PHOS-70 TOT BILI-1.4 [**2103-2-2**] 09:00PM ALBUMIN-3.2* [**2103-2-2**] 09:00PM WBC-3.5* RBC-2.09*# HGB-7.1*# HCT-20.0*# MCV-95 MCH-34.0* MCHC-35.7* RDW-16.9* [**2103-2-2**] 09:00PM NEUTS-80* BANDS-1 LYMPHS-15* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2103-2-2**] 09:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ OVALOCYT-1+ [**2103-2-2**] 09:00PM PLT SMR-VERY LOW PLT COUNT-60* Brief Hospital Course: 53 yo female with history of Hep C cirrhosis, portal vein thrombosis admitted for UGIB. (#) GIB: Upper GI bleed requiring initial ICU stay. EGD showed erosion of varices that extended through the GE junction, no indication for banding per GI. The patient??????s Hct remained stable s/p 2 units of PRBCs, although lower than baseline, BP has remained stable. Maintained active T&S, two large bore IV's, and a right IJ triple lumen which was removed prior to floor transfer. Hct checked q6H, goal Hct 21. Did not require platelet or FFP transfusion, however given Vit K 5mg X1 orally. Continued octreotide drip and IV PPI. Abdominal US showed consistent portal vein thrombosis. No TIPS persued. . (#) ESLD, PORTAL VEIN THROMBOSIS: from EtOH & Hep C; currently being evaluated for liver [**Year/Month/Day **] (not listed yet). Monitored for hepatic encephalopathy with GIB; no evidence of HE. Continued lactulose titrated to 3 BM's per day. Continued cipro 250 mg QD PPX for SBP. Held lasix, spironolactone and nadolol in setting of hypotension with bleed. Held lovenox for PVT while GIB. . (#) DIABETES: Continued SSI + home dose glargine 44 units QHS (half dose when NPO) . (#) NEUROPATHY: stocking glove; likely [**2-26**] DM -- cont home oxycodone 5 mg [**Hospital1 **] . (#) Coping: Consulted SW . (#) ACCESS: 2 x 20 g PIV . (#) NUTRITION: Clears only per GI . (#) PPX: IV PPI; pneumoboots; lactulose for bowel regimen . (#) CODE: full . (#) COMMUNICATION: with patient Medications on Admission: Enoxaparin [**Hospital1 **] (was supposed to be switched to coumadin at soem point) Furosemide 40 mg [**Hospital1 **] Spironolactone 50 mg [**Hospital1 **] Lactulose TID titrated to 4 BM's daily Nadolol 20 mg QD Fluticasone-Salmeterol 250-50 one puff [**Hospital1 **] Ergocalciferol (Vitamin D2) 50,000 unit QWeek Folic Acid 1 mg QD Sucralfate 1 gram QID (to be taken through [**2103-1-26**]) Zolpidem 5 mg QHS Lidocaine 5 %Patch on legs b/l for neuropathic pain (not using any more) Nortriptyline 25 mg QHS Ciprofloxacin 250 mg QD Oxycodone 5 mg [**Hospital1 **] Omeprazole 40 mg [**Hospital1 **] Glargine 44 units QHS + SSI Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for pain. 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 2 weeks. Disp:*60 Tablet(s)* Refills:*0* 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Insulin Glargine 44 units at night with sliding scale Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute blood loss anemia Varices Peptic ulcer disease End stage liver disease Hepatitis C Discharge Condition: Hemodynamically stable, hematocrit stable, not encephalopathic. Discharge Instructions: You were admitted with bleeding from your esophogus and stomach. You were treated in the ICU and the bleeding was controlled. . It is critical to your recovery that you take all of your medications exactly as prescribed. Contact your doctors if [**Name5 (PTitle) **] have any questions. We have discontinued your Lovenox. . Please come to the hospital immediately if you develop black or bloody stools, vomiting black or bloody material, confusion, or any other worrisome signs. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] as listed below. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2103-2-14**] 9:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2103-2-14**] 9:00 Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2103-2-16**] 8:40 Completed by:[**2103-4-16**]

[ "357.2", "571.2", "285.1", "070.44", "V12.51", "250.61", "572.3", "533.90", "789.59", "303.90", "456.20", "300.4", "287.4", "571.5", "070.54" ]

icd9cm

[ [ [] ] ]

[ "99.05", "38.93", "54.91", "45.13", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

7957, 8014

4704, 6193

320, 325

8146, 8211

3467, 4681

8740, 9195

2818, 2931

6870, 7934

8035, 8125

6219, 6847

8235, 8717

2946, 3448

266, 282

353, 2211

2233, 2602

2618, 2802

66,244

111,288

3357

Discharge summary

report

Admission Date: [**2141-3-3**] Discharge Date: [**2141-3-31**] Date of Birth: [**2069-2-9**] Sex: M Service: MEDICINE Allergies: Penicillins / Ambien Attending:[**First Name3 (LF) 4765**] Chief Complaint: Dyspnea. Major Surgical or Invasive Procedure: Endotracheal Intubation Transesophageal Echocardiogram History of Present Illness: Mr [**Known lastname **] is a 71-year-old man with a PMHx significant for systolic HF (EF 20-25%), old anterior wall MI, paroxysmal AV block, atrial fibrillation, ventricular tachycardia, history of ventricular fibrillation in the past, status post eventual BiV ICD implantation with subsequent revisions due to the presence of malfunctioning Fidelis lead, who presented to the ED this morning with a chief complaint of dyspnea. The patient reports that he began having a cough productive of dark beige sputum for the past week. He also had some low-grade temps at home (Tm 99.8) earlier this week. He called his cardiologist on [**2141-2-28**], complaining of this cough and LE edema. He was told to increase his lasix to 60mg TIW and 40 mg daily the rest of the week. He then presented to gerontology clinic on [**2141-3-1**] with similar complaints. CXR and CBC done that day were unremarkable. He then developed dyspnea over the past 24-36 hours. He called cardiology clinic this morning and was instructed to present to the ED. On arrival to the ED, the patient's VS were 97.1 80 100/60 22 96. He was noted to have crackles half-way up bilaterally. CXR reportedly showed changes c/w pulmonary edema as well as a ? LLL opacification. In the ED, he received Levofloxacin 750mg, Vancomycin 1g, Ondansetron 4mg, and Furosemide 40mg. He was admitted to the CCU for further management. On arrival to the CCU, the patient's VS were T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP. He reported that his dyspnea was improved. He stated that the chest pressure that he experienced earlier had resolved. He endorses recent worsening DOE and PND. He also reports some chest pressure last night and this morning, which was located across his chest, did not radiate, and has since resolved. He reports recent 5-pound weight gain. He also reports recent loose stools and stable urinary frequency. On review of systems, he denied any prior history of stroke. He did report a questionable history of TIA. He denied any history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denied recent chills or rigors. He denied exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of palpitations or syncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Hypertension 2. CARDIAC HISTORY: - Anterior wall myocardial infarction in [**2126**] with ventricular tachycardia and complete heart block requiring pacemaker - Systolic heart failure (EF 20-25%) - Atrial fibrillation 3. OTHER PAST MEDICAL HISTORY: PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. Anemia. 4. Irritable bowel syndrome. 5. Constipation. 6. Obesity. 7. Hearing loss, requiring bilateral hearing aids. 8. Squamous cell carcinoma of the left lower eyelid. 9. Vitamin D deficiency. 10. Cerebral infarct. 11. Falls. 12. Compression fractures. 13. History of Whipple operation, with subsequent E. coli and Klebsiella bacteremia 14. History of possible C3-C4 osteomyelitis 15. Abdominal hernia secondary to Whipple procedure PAST SURGICAL HISTORY: 1. Placement of pacemaker and ICD. 2. Knee surgery. 3. Removal of squamous cell carcinoma of his left lower eyelid. 4. Recent Whipple's procedure for which he was diagnosed with dysplasia. Social History: Teaches history at [**University/College 15559**]. Divorced, 2 children. Lives in [**Location **], but is staying intermittently in [**Location (un) **] with his [**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Former pipe and cigarette smoker (quit >10 years ago). Used to smoke 1ppd X 30 yrs. Drinks [**12-24**] glasses of wine/day. No drugs. Health Care Proxy: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Family History: Strong family history of vascular disease with father deceased of CVA at 59, Mother with MI at 70, Brother with MI and CABG in 50's. Also reports a family history of diabetes. Physical Exam: Admission Exam: VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink. NECK: Supple. Unable to appreciate JVP. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated. LUNGS: Resp were unlabored, no accessory muscle use. Pt with high-flow neb O2 mask on. Crackles noted [**12-24**] to [**2-23**] of the way up bilaterally. Scattered wheezes as well. ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral hernia present. EXTREMITIES: No significant LE edema noted. No calf pain. DP pulses palpable bilaterally. Pertinent Results: Admission Labs [**2141-3-3**] 10:15AM BLOOD WBC-7.1 RBC-3.71* Hgb-11.9* Hct-35.3* MCV-95# MCH-32.0 MCHC-33.7 RDW-14.4 Plt Ct-166 [**2141-3-3**] 10:15AM BLOOD Neuts-78.8* Lymphs-13.5* Monos-5.0 Eos-2.3 Baso-0.5 [**2141-3-3**] 10:15AM BLOOD PT-24.2* PTT-33.2 INR(PT)-2.3* [**2141-3-3**] 10:15AM BLOOD Glucose-152* UreaN-28* Creat-1.1 Na-135 K-4.4 Cl-99 HCO3-25 AnGap-15 [**2141-3-3**] 10:15AM BLOOD ALT-27 AST-36 CK(CPK)-126 AlkPhos-139* TotBili-0.6 [**2141-3-3**] 10:15AM BLOOD Lipase-64* [**2141-3-3**] 10:15AM BLOOD cTropnT-<0.01 [**2141-3-3**] 10:15AM BLOOD CK-MB-4 proBNP-3057* [**2141-3-3**] 10:15AM BLOOD Albumin-4.1 [**2141-3-3**] 10:25AM BLOOD Lactate-2.0 [**2141-3-3**] 11:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2141-3-3**] 11:10AM URINE Blood-NEG Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2141-3-3**] 11:10AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 CXR ([**2141-3-3**]) - IMPRESSION: Increased pulmonary edema. Superimposed infectious process in the left lower lobe cannot be excluded. Recommend follow-up post diuresis. CT Chest ([**2141-3-7**]) - IMPRESSION: 1. No intrathoracic abscess. Bilateral non-hemorrhagic small-to-moderate pleural effusions, minimally loculated, if at all, on the right. 2. Severe lower lobe and moderate upper lobe atelectasis. Minimal pneumonia cannot be excluded. 3. Mediastinal lymphadenopathy, likely reactive. CT Head ([**2141-3-11**]) - IMPRESSION: No evidence of infectious or other acute process. CT Abd/Pelvis ([**2141-3-11**]) - IMPRESSION: 1. No evidence of infectious process in the abdomen or pelvis. 2. Ground-glass opacity in lung bases may partially be explained by fluid overload, although an infectious component should be considered. 3. Slightly increased bilateral small pleural effusions with associated atelectasis. 4. Unchanged postoperative findings related to prior Whipple and hepatojejunostomy, with soft tissue in the postoperative bed, which appears stable, of unclear significance. 5. Apparently new rectus muscle herniation containing non-obstructed bowel. 6. Unchanged compression fracture of L1. TEE ([**2141-3-14**]) - No atrial septal defect is seen by 2D or color Doppler. There is moderate to severe regional left ventricular systolic dysfunction with septal, inferoseptal and inferior hypokinesis. There are complex (>4mm) 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. No mass or vegetation is seen on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. Moderate to severe [2+] tricuspid regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No vegetations seen on the pacemaker/ICD leads (at least 4 wires identified in the right atrium) or on the valves. Depressed left ventricular systolic function. Moderate to severe mitral regurgitation. At least mild pulmonary hypertension. Complex atheroma in descending aorta. Brief Hospital Course: 71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI in '[**26**], paroxysmal AV block, atrial fibrillation, h/o v.tach and v.fib s/p ICD implantation, who presented to the ED this morning with a chief complaint of dyspnea, likely due to CHF exacerbation. Respiratory Failure Pt's respiratory distress initially was thought to be related to CHF exacerbation in the setting of possible dietary indiscretion. He was given IV lasix initially with good urine output. However, later on the evening of admission, he became febrile and CXR was c/w possible PNA. Pt was started on vanc/cefepime and was continued on azithromycin (started in ED) as broad coverage for a possible PNA. On the following evening ([**2141-3-4**]), pt had worsening respiratory status and was intubated. Thus, respiratory failure was attributed to both decompensated congestive heart failure as well as pneumonia. Despite being on broad spectrum abx, the patient continued to spike fevers, and his abx were eventually switched to meropenem monotherapy (see below). Bronch was performed but did not reveal an obvious infective process. With diuresis and abx therapy, pt's respiratory status improved. He was ultimately extubated on [**2141-3-14**]. He was subsequently re-intubated for pacemaker procedure on [**2141-3-23**] and extubated the following day on [**2141-3-24**]. He did not have any respiratory comlpications following this. Fevers As above, the patient began to spike fevers on the evening of admission. At that time, he was started on vanc/cefepime/azithromycin as broad coverage for a suspected PNA. When he continued to spike fevers on this regimen, viral screens were sent and his antibiotic regimen was changed to meropenem. ID was consulted, as the patient has a complex medical history involving chronic cefpodoxime for ongoing suppression after high-grade viridans streptococcal bacteremia as well as suspected Klebsiella pneumoniae ICD/pacer lead endocarditis during a prior bacteremia. The patient's pacer was interrogated, and it was found that his ICD was not functioning properly. Despite recurrent fevers, even when he was on meropenem, the patient did not have any positive culture data, aside from yeast in the sputum and one positive blood culture (which was a likely contaminant). TEE was performed and did not show any evidence of vegetation. The patient's fevers ultimately subsided. With no positive culture data to guide therapy, his antibiotics were d/c'ed and he was placed back on his chronic cefpodoxime regimen per his infectious disease physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3197**] whom he will follow up with this month. ICD Malfunction As explained above, the patient's pacer was interrogated early in his hospital course, and it was noted to not be working properly. On the afternoon of [**2141-3-12**], he went into to VT and was unable to be paced out of it by his pacer. He then went into VF arrest, and his ICD did not shock him out of it. Consequently, he received approximately 2 minutes of CPR and 1 external defibrillation with return of a perfusing rhythm. On the morning of [**2141-3-17**], the patient had an additional episode of VF, for which he required external defibrillation and CPR. After this, his pacer was set at a higher rate to avoid fast-slow-fast sequences that may have precipitated the episode of ventricular tachycardia. Throughout all of this, the patient was followed by the EP service. Plans were made to take the patient to the OR for possible removal and replacement of his leads. The patient's dose of amiodarone was also briefly increased in an attempt to prevent episodes of VT; his metoprolol was also increased. On [**2141-3-23**] the patient underwent two lead extractions (R ventricular and R atrial) and ICD implant without complications. He was extubated the following day. He was discharged with increased doses with amiodarone and metoprolol. Altered mental status Patient exhibited aggitation consistent with ICU delerium post-intubation. He was pan cultured, but did not have evidence of infection. It was thought that he may have also sufferred anoxic brain injury during his multiple v fib arrest/v tach. However, over a few days his mental status dramatically improved. He then went for his ICD lead revision and following extubation became acutely aggitated again. He received ativan .5 mg IV x 2, which worsened his delerium. Small doses of haldol and zydis were tried, but did not have good effect either. The patient was started on seroquel standing dose at night plus PRNs and he had drastic improvement in his mental status. His paxil was also weaned down to 20 mg a day and should continue to be weaned off slowly over the next few weeks. He is being discharged on 6.26 mg seroquel Q HS. He required one extra PRN dose the night before discharge and was slightly disoriented the morning of discharge. However, overall his mental status has improved dramatically, and this is likely the result of his prolonged ICU stay. All labs have remained normal and there are no signs of infection or metabolic abnormalities. Coronary Artery Disease Pt with a history of an anterior wall MI in [**2126**]. Of note, the patient did report some chest pressure prior to admission. However, on arrival to the CCU, he denied any chest pain. He ruled out for ACS with three sets of CE's. He was continued on metoprolol and aspirin. Atrial Fibrillation Pt with a history of a.fib, for which he takes coumadin. In anticipation for possible procedures regarding his ICD, the patient was taken off of coumadin and placed on a heparin gtt in the meantime. He was restarted on coumadin 3 mg once a day and his INR was elevated to 3.4. His coumadin was subsequently decreased to 2 mg a day. His INR will need to be checked daily and his coumadin adjusted as needed for a goal [**1-25**]. He may require a lower dose still given he is now on amiodarone which can interact with INR. Hypotension Normotensive on presentation. On pressors (levophed) for a short time after he was intubated. After he was weaned off of pressors, his beta blocker was able to be restarted. On [**3-27**] - [**3-28**] he was noted to have hypotension to the 70's systolic when sitting/standing up. This was thought to be due to poor PO intake and volume contraction. The patient continued to mentate well despite the hypotension. He was given IV fluid boluses with response in his blood pressure. As he continues to improve his PO intake this is expected to resolve. He should continue to have holding parameters on his beta blocker to prevent hypotension in the meantime. He was not ressztarted on an ACE inhibitor due to the low blood pressures. This may be restarted at a later date by his PCP/cardiologist if his blood pressures will tolerate it. Congestive Heart Failure As stated above the patient will continue on his regimen of aspirin and metoprolol with holding parameters. His ACEi was held as stated above due to hypotension and may be restarted at low dose (2.5 mg) in the future as blood pressure tolerates it. Nutrition and Dysphagia The patient was on tube feeds while he was intubated and sedated. Following each intubation he had profound aggitation and delerium. He failed his swallow studies several times and had to have a dobhoff tube placed. Due to his aggitation he self-removed his dobhoff tube and his nutrition was interrupted several times. On day 5 following his intubation, discussions were held whether he should have a bridled NGT placed versus a PEG tube. It was decided that he would get a PEG tube as this was thought to be less disturbing to the patient versus a long term bridled NGT that he might try to pull out, and it would only be temporary until his dysphagia improved. However, that morning he passed his swallow study. He was restarted on a pureed diet with nectar thick liquids. It is anticipated that his swallow function will continue to improve during rehab. Increased CK Pt was noted to have elevated CK, peaking at 2723. CK-MB and troponin were unremarkable. His statin was held, and his CK's were trended. They continued to improve. Hypothyroidism The patient's levothyroxine was continued at 50 mcg daily. Anemia Pt with a history of anemia, baseline Hct of approx. 33-35. Pt currently near his baseline. He was continued on iron supplementation. S/p Whipple Was continued initially on pancreatic enzyme repletion, which were stopped when the patient was on tube feeds. These were restarted when he was able to take PO again. CODE: FULL CODE, confirmed with patient and his HCP [**Name (NI) **]: HCP is [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 15561**]) Medications on Admission: AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth Tues/[**Last Name (un) **]/Sat/Sun and 1.2 tabs (60mg) on M/W/F LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth 3x/day METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth [**2-23**] times/day swish in mouth and swallow PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth DAILY PAROXETINE HCL [PAXIL] - 30 mg Tablet - 1 (One) Tablet(s) by mouth once a day SIMVASTATIN [ZOCOR] - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a day TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Start with 1/2 pill. [**Month (only) 116**] increase to 1 pill if needed; may increase to total of 2 pills as needed WARFARIN - 1 mg Tablet - 1 (One)-3 Tablet(s) by mouth as directed by MD ACETAMINOPHEN - (OTC) - Dosage uncertain ASCORBIC ACID - (Prescribed by Other Provider) - 250 mg Tablet - 1 Tablet(s) by mouth daily ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day FERROUS SULFATE [SLOW FE] - 142 mg (45 mg Iron) Tablet Sustained Release - 1 (One) Tablet(s) by mouth every other day LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - Dosage uncertain MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pancrease MT 10 10,000-30,000 -30,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO TIDAC. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO once a day. 11. Slow Fe 142 mg (45 mg Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 12. Lactobacillus Acidophilus Miscellaneous 13. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 14. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary - Acute on Chronic Heart Failure - Ventricular Fibrillation / Cardiac Arrest - Hospital acquired pneumonia - Delerium Secondary: - coronary artery disease - hyperthyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the ICU with worsening of your heart failure. Soon after admission, your respiratory status worsened, and you were intubated. It was felt that you might also have a pneumonia, so you were started on antibiotics. Additionally, while you were in the hospital, you had 2 episodes of abnormal heart rhythms for which you required CPR and electrical shocks. Your internal defibrillator was interrogated and was felt to not be functioning properly so it was replaced. You also developed some delerium in the ICU and had trouble swallowing food. Your mental status is now improving and you are able to take pureed food. CHANGES TO YOUR MEDICATIONS: **Increase amiodarone to 200 mg once a day **Increase metoprolol to 25 mg once a day **Decrease Paxil to 20 mg once a day **Decrease coumadin to 2 mg a day **Stop lasix **Stop simvastatin **Stop trazodone Please weigh yourself every morning and call your doctor if you weight goes up more than 3 lbs. Followup Instructions: Please follow-up with: Cardiology: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-4-13**] 3:00 Infectious disease: Provider: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD Date/Time:[**2141-4-4**] 2:00 Primary care provider: [**Name10 (NameIs) 357**] call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to schedule a follow up appointment after you leave rehab. The phone number is: [**Telephone/Fax (1) 719**]

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icd9cm

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icd9pcs

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34174

Discharge summary

report

Admission Date: [**2122-2-25**] Discharge Date: [**2122-2-27**] Date of Birth: [**2093-12-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Headache Major Surgical or Invasive Procedure: none History of Present Illness: 28 year old Somalian female with a history of PRES, HTN, CRI, seizures and small infarcts related to hypertension and visual changes at baseline presents with headache and worsening visual changes and CT findings concerning for worsening PRES. Patient has had left frontal headache for one week and worsening. Headache is diffuse worse in the occipital area on the left side. She has a hard time qualifying her headache. This headache is different from her usual migraine headache. She does not experience photophobia or phonophobia. Patient has noticed blurry vision in bilateral eyes in the last two days. Her right sided vision is worse the the left side. She has had two episoded of chest pain and shortness of breath in the middle of the night lasting two minutes in the last three days. Chest pain is located in bilateral sternal area. She denies any fever, chills, nightsweats, nausea, vomitting, abdominal pain, diarrhea, constipation, dysuria, neck stiffness. She has experienced urgency in the last few days. Two days ago she had left jaw and eye pain which has now resolved. . In [**Hospital1 18**] ED her vitals were T 97.9 BP 116/76 HR 80 RR 16 100% on RA. Patient was also found to be in renal failure with Cr 3.6 (last known Cr from [**Hospital1 112**] was 1.8). Past Medical History: - Hypertension, including hypertensive emergencies, workup in the past include nl TSH/cortisol/[**Male First Name (un) 2083**]/catecholamines. Abd MRI/A in [**2112**] showed nl kidneys, adrenals, no evidence of RAS. Small bilat arteries arising inf to main renal arteries, likely lumbar arteries but cannot exclude small accessory renal arteries. - h/o CVA in [**1-8**] secondary to uncontrolled HTN, tiny infarcts including cortical and subcortical areas of ACA, MCA PCA and watershed areas - h/o generalized tonic-clonic seizure in the setting of uncontrolled - [**4-8**] PRES in the setting of hypertensive emergency - Moderate LVH with EF 65-70% - Migraine headaches - Vitamin B12 deficiency - Chronic renal insufficiency with baseline Cr 1.8. - Previous hypercoag work-up negative except for B2 glycoprotein, also negative sicle celltrait. Social History: She is originally from Smolia, moved to the US 12 years ago. She lives with her sister in [**Name (NI) 669**]. She is unemployed. Denies tobacco, ETOH, street drugs. Family History: 2 maternal uncles who died of MI in 20's - 30's. Multiple family members with HTN. Physical Exam: Gen: alert and awake, in NAD, pleasant lady following commands HEENT: PERRL, MMM, OP clear Heart: S1S2 with II/VII SEM Lungs: CTAB Abdomen: soft NTND, left CVA tenderness Neuro: CN III-XII intact, right visual fields defecits, strength [**5-5**] bilat, sensation is intact Pertinent Results: [**2122-2-25**] 02:50AM BLOOD WBC-4.6 RBC-3.56* Hgb-10.3* Hct-29.8* MCV-84 MCH-28.9 MCHC-34.6 RDW-15.3 Plt Ct-216 [**2122-2-25**] 02:50AM BLOOD Neuts-59.8 Lymphs-32.7 Monos-5.2 Eos-1.6 Baso-0.6 [**2122-2-25**] 08:09PM BLOOD PT-13.0 PTT-24.3 INR(PT)-1.1 [**2122-2-25**] 08:09PM BLOOD ESR-51* [**2122-2-25**] 02:50AM BLOOD Glucose-107* UreaN-29* Creat-3.6* Na-134 K-3.3 Cl-98 HCO3-26 AnGap-13 [**2122-2-25**] 02:50AM BLOOD CK(CPK)-58 [**2122-2-25**] 02:50AM BLOOD CK-MB-2 cTropnT-0.02* [**2122-2-25**] 08:09PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2122-2-25**] 08:09PM BLOOD CRP-2.0 [**2122-2-25**] 02:50AM BLOOD [**Doctor First Name **]-NEGATIVE . Urine Culture [**2122-2-25**]: mixed flora . [**2122-2-25**] ECG: Sinus rhythm. Left ventricular hypertrophy with diffuse repolarization abnormalities consistent with left ventricular strain. No previous tracing available for comparison. . [**2122-2-25**] HEAD CT: Multiple asymmetrical subcortical regions of low attenuation with mass effect, concerning for acute vasogenic/interstitial edema; there is no hemorrhage. Given the history and somewhat posterior distribution, acute hypertensive encephalopathy (PRES) is the leading diagnostic consideration. Comparison with previous ([**Hospital1 112**]) studies, and dedicated non-contrast MRI (given the patient's GFR) would be helpful for further investigation. . [**2122-2-25**] HEAD MRI/MRA: Diffuse signal change in the periventricular and subcortical frontal white matter which given the history may represent residual changes from PRES but clinical correlation is recommended. Findings were discussed with Dr. [**Last Name (STitle) **] (Medicine) on the day of the study. Comparison with prior outside films maay help for further evaluation. . [**2122-2-25**] RENAL U/S: 1. No evidence of hydronephrosis or renal artery stenosis. 2. Small and echogenic right kidney which may be related to underlying medical renal disease. . Brief Hospital Course: Ms. [**Known lastname 78754**] is a 28yo F w/hx of HTN, PRES, CRI, seizures, CVA who presented with headache, blurred vision, chest pain, jaw pain and was admitted to the MICU for PRES and control of hypertensions. MRI on admission was consistent with PRES. She required no anti-hypertensives while in the MICU. Neurology was consulted and thought this was consistent with PRES; recommended checking [**Doctor First Name **], ANCA, ESR, CRP. She was also found to be in renal failure with a creatinine of 3.6 (baseline 1.8). She was seen by opthalmology who diagnosed her with hypertensive retinopathy. . While in the MICU, she was monitored but blood pressures were in the 120s-150s. On arrival to the floor, her blood pressures were in the 120s systolic. Her antihypertensives were initially held due to her acute renal failure. As her renal failure improved, her Lisinopril was added to her regimen. Her headaches improved but she had some residual intermittent headaches controlled with Morphine IR. On the day of discharge, her creatinine had improved to 1.4. She was restarted on her antihypertensive medications with instructions to follow-up with her PCP and Nephrologist at [**Hospital1 112**]. Medications on Admission: Lisinopril 25 mg daily Ferrous sulfate 325 mg daily Aldactazide 25/25 mg daily Vitamin B12 injections? Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headache. 3. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Spironolacton-Hydrochlorothiaz 25-25 mg Tablet Sig: One (1) Tablet PO once a day. 5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive Emergency 2. PRES 3. Acute Renal Failure 4. Hypertensive Retinopathy Discharge Condition: afebrile, hemodynamically stable, Blood pressure 120s-130s systolic. Discharge Instructions: You were admitted to the hospital with high blood pressure and headache. Your blood pressure was controlled. An MRI showed that there was some swelling in your brain. This should resolve over time. You had some worsening of your renal failure which resolved. You should be seen by your nephrologist on Monday, [**3-9**] at your previously scheduled appointment. You should follow-up with your primary care doctor, Dr. [**First Name (STitle) 732**] at [**Hospital6 13185**] on [**3-12**]. You should return to the hospital or see your PCP for any worsening headaches, vision changes, chest pain, shortness of breath, abdominal pain, fevers > 101, chills, night sweats, or any other symptoms that concern you. You should avoid salty foods and try to stay hydrated to protect your kidneys. Followup Instructions: Please see your nephrologist on [**2122-3-9**] at [**Hospital1 756**] and [**Hospital 44770**] Hospital. Please see your primary care doctor, Dr. [**First Name (STitle) 732**] on [**2122-3-12**] at [**Hospital6 1708**]

[ "345.90", "348.39", "585.9", "346.90", "362.11", "280.9", "266.2", "V12.54", "584.9", "403.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6889, 6895

5053, 6270

323, 330

7043, 7114

3099, 4001

7957, 8180

2706, 2790

6424, 6866

6916, 6916

6296, 6401

7138, 7934

2805, 3080

275, 285

358, 1638

4010, 5030

6935, 7022

1660, 2507

2523, 2690

76,835

127,279

14061

Discharge summary

report

Admission Date: [**2172-2-14**] Discharge Date: [**2172-2-19**] Date of Birth: [**2097-10-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2265**] Chief Complaint: ICD Firing Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname 25268**] is a 74 year old genetleman with history of CAD s/p CABG, MI, ICD placement atrial fibrillation on coumadin whop resented today after a firing of his ICD. He was in his USOH taking a shower today when the ICD suddenly fired. He denied any symptoms of light headedness, chest pain, or palpitations prior. He called his wife who sat him down and shortly afterwards EMS arrived. He never lost consciousness. He was taken to an OSH where he developed mild respiratory distress resolved with 2L O2,CXR showed mild CHF. EKG showed NSR @ 92 with LVH and ST changes consistent with inferolateral ischemia. CPK 162, CKMB 26, CI 16, BNP 18,295, Trop 0.68. He was referred for a cath. . He had a similar episode in [**2164**] where device fired due to atrial fibrillation. The ICD was reprogrammed afterwards and he has not had any ICD firings until today. . Of note he was hospitalized at [**Hospital1 112**] from [**2172-2-1**] to [**2172-2-8**] for urosepsis secondary to obstructive nepholithiasis s/p L percutaneous neprhostomy tube and L utereral stent placement, multifocal pneumonia, afib with RVR and NSTEMI. On arrival, he was started on pressors and intubated. He was treated with ceftriaxone for pansensitive Ecoli fromt he urine and also for CAP. He developed afib with RVR conrolled on amiodarone. On [**2172-2-2**] he was extubated, folliwing he developed AMS and flash pulmonary edema which resolved with BiPAP and diuresis. He also had an NSTEMI not heparinized given supratherapeutic INR. TTE showed global hypokinesis with EF of 45%. On [**2-4**], he returned to IR for replacement of nephrostomy tube, went into PEA arrest in the setting of induction. Puse returned and he was medically managed with pressors. On [**2-6**] he was taken tot he OR for placement of a left ureteral stent, left nephrostomy tube was removed. He was extubated again on [**2-6**]. . . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: [**2143**], recurrent MI in [**2155**] - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: ICD [**2155**] 3. OTHER PAST MEDICAL HISTORY: afib on coumadin Fem [**Doctor Last Name **] bypass in [**2147**] colon cancer s/p SBR in [**2155**] skin cancer s/p resception and chemotherapy Social History: - Tobacco history: 30pack years, quit in [**2143**] - ETOH: none - Illicit drugs: none Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=98 BP=131/89 HR=88 RR= 23 O2 sat= 100% GENERAL: 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 of 10cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Soft systolic murmur at apex. No thrills, lifts. No S3 or S4. LUNGS: Bibasilar rales to [**1-27**]. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. 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+ dopplerable DP/PT [**Name (NI) 2325**]: Carotid 2+ dopplerable DP/PT Pertinent Results: ADMISSION LABS: . [**2172-2-14**] 04:40PM BLOOD WBC-7.6# RBC-3.52* Hgb-10.2*# Hct-31.5* MCV-89 MCH-28.9 MCHC-32.3 RDW-18.4* Plt Ct-451*# [**2172-2-14**] 04:40PM BLOOD PT-21.4* PTT-29.3 INR(PT)-2.0* [**2172-2-14**] 04:40PM BLOOD Glucose-139* UreaN-12 Creat-0.8 Na-139 K-3.9 Cl-102 HCO3-27 AnGap-14 [**2172-2-14**] 04:40PM BLOOD ALT-151* AST-72* CK(CPK)-182 AlkPhos-74 TotBili-1.3 [**2172-2-14**] 04:40PM BLOOD CK-MB-27* MB Indx-14.8* cTropnT-1.05* [**2172-2-14**] 04:40PM BLOOD Albumin-3.6 Calcium-8.9 Phos-2.7 Mg-1.8 . ECHO: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral akinesis. The basal to mid lateral wall and distal inferior wall are moderately hypokinetic. Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated The right ventricular cavity is dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-26**]+) 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. . IMPRESSION: Severe focal LV hypokinesis, consistent with prior inferior/inferolateral infarction. Hypertrophied, dilated and depressed right ventricle with moderate pulmonary artery systolic hypertension. At least mild to moderate mitral regurgitation. Dilated thoracic aorta. . DISCHARGE LABS: . [**2172-2-19**] 06:20AM BLOOD WBC-4.3 RBC-3.34* Hgb-9.7* Hct-29.0* MCV-87 MCH-29.1 MCHC-33.6 RDW-17.9* Plt Ct-514* [**2172-2-19**] 06:20AM BLOOD PT-26.3* INR(PT)-2.5* [**2172-2-19**] 06:20AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-137 K-4.5 Cl-98 HCO3-34* AnGap-10 Brief Hospital Course: 74 year old male with history of CAD s/p CABG, recurrent MI in [**2165**], VT with ICD, PAF with inappropriate ICD response, who presents with inappropriate ICD firing after prolonged hospitalization for urosepsis and respiratory distress. . # Afib with RVR: Patient was previously on nadolol 80mg which was recently changed to metoprolol 25mg daily. This reduction in dose was likely secondary to hypotension in the setting of sepsis. He subsequently had 2 episodes of Afib with RVR requiring IV lopressor and dilt. His standing dose was then increased to 25mg PO TID. He was started on amiodarone 200 mg TID and discharged on metorpolol succinate 50 once a day. INR remained therapeutic throughout admission. . # CHF: Patient extremely volume overloaded on admission. Echo showing EF 25-30%. It appears that he has had some depression of his cardiac function since his prior outpatient ECHO. this may be secondary to NSTEMI associated with PEA arrest. It may also be a critical illness myopathy that would take time to resolve. He was diuresed throughout his admissions several liters and eventually discharged on lasix 40 once a day. . # Elevated troponin - likely secondary to ischemic injury caused by defibrillator firing. MB trended down. He was continued on home. ASA, BB, Statin Medications on Admission: Simvastatin 80mg daily Coumadin 2mg daily Metoprolol XL 25mg daily Lisinopril 2.5mg daily Avalxon 400mg daily, just finished Xalatan 0.005% daily Brimonidine 0.2% daily Stopped Nadolol 80mg daily, Captopril 25mg tid Discharge Medications: 1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks: Ten decrease to twice daily for 2 weeks, then decrease to once daily indefinitely. Disp:*75 Tablet(s)* Refills:*0* 4. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 5. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Outpatient Lab Work please check INR and Chem-7 on Friday [**2172-2-21**] with results to the [**Hospital3 **] at [**Location (un) 2274**] in [**Location (un) 1468**]. 7. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Atrial fibrillation with Rapid Ventricular response Acute systolic congestive heart Failure Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Your ICD fired for a rapid atrial fibrillation rhythm. We started you on amiodarone to slow the rate and keep you in a regular sinus rhythm. You will take the amiodarone three times a day for 2 weeks, then twice daily for two weeks, then decrease to once daily from then on. Dr. [**First Name (STitle) **] also adjusted the ICD settings so it can better distinguish between atrial fibrillation and a dangerous rhythm. Your echocardiogram showed that your heart function is weaker than before and you developed some fluid overload in your lungs and legs. We gave you high doses of a diuretic, Furosemide (lasix) to get rid of the excess fluid. You will go home on furosemide pills to keep the fluid off. Please watch your legs and your breathing pattern to see if the fluid is reaccumulating. Weigh yourself every morning, call Dr. [**Last Name (STitle) 6512**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please also call Dr. [**Last Name (STitle) 6512**] if the swelling in your legs worsens or if you are short of breath. . We made the following changes to your medicines: 1. Decrease your warfarin to 1mg daily starting on thursday [**2-20**]. please check your INR on Friday [**2172-2-21**] with results to the [**Hospital3 **] at [**Location (un) 2274**] in [**Location (un) 1468**]. 2. Decrease Simvastatin to 40 mg daily. 3. Start amiodarone as above 4. Increase Metoprolol to 50 mg daily 5. Start furosemide at 40 mg daily Followup Instructions: Name: [**Last Name (LF) 41941**],[**First Name3 (LF) **] J. Location: [**Location (un) 2274**]-[**Location (un) **] Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**] Phone: [**Telephone/Fax (1) 31019**] Appt: Friday [**2-21**] at 3:50pm Name: [**Last Name (LF) 6512**], [**Name8 (MD) **] MD Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Appt: [**2-28**] at 10:10am [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]

[ "414.00", "414.8", "250.00", "V45.02", "365.9", "427.31", "V45.81", "428.0", "401.9", "428.23" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9163, 9220

6504, 7798

316, 323

9369, 9369

4287, 4287

10998, 11627

3302, 3419

8064, 9140

9241, 9348

7824, 8041

9520, 10975

6212, 6481

3434, 4268

2885, 3005

266, 278

351, 2781

4303, 6196

9384, 9496

3036, 3182

2803, 2865

3198, 3286

26,901

179,730

24113

Discharge summary

report

Admission Date: [**2185-10-7**] Discharge Date: [**2185-10-17**] Date of Birth: [**2160-11-6**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 759**] Chief Complaint: AMS, hyperglycemia, hypertension Major Surgical or Invasive Procedure: intubation, central line placement History of Present Illness: History of Present Illness: 24-year-old gentleman with poorly controlled Type I diabetes with ESRD recently started HD, hypertension, retinopathy, with three separate admissions this past week who was referred to the ED from dialysis for elevated blood sugar and vomiting. Per patient's family, patient took am dose of insulin today. He had awoken feeling unwell and had been vomiting prior to going to dialysis. He reportedly was not febrile. He reportedly did not take his am BP meds. . In the ED, initial vs were: T98 HR:88 BP:193/113 RR:16 O2Sat:100RA. Serum glucose on arrival was 818 with AG of 21. He received 10 units of regular insulin. He received less than 1 liter NS. For BP got total of 30 mg IV labetolol. Pt acting confused and agitated requiring total 10mg IM Haldol, Ativan 2mg. Given his extreme agitation he was intubated and transferred to MICU for further management. . On the floor,patient intubated and sedated. He appeared comfortable on the ventilator. . Review of systems: (unable to obtain) Past Medical History: - Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly controlled with past DKA. Complicated with retinopathy, nephropathy - Hypertension, poorly controlled - Chronic kidney disease - Chronic constipation - Chronic Anemia (baseline hematocrit 30-35) Social History: Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age 16. Denies recent alcohol use. Denies illicit drug use, now or in the past. Family History: Father, grandmother with diabetes mellitus. No relatives currently on dialysis. Physical Exam: Vitals: T:99 BP:184/106 P:104 R:14 CMV Tv 500 RR 16 PEEP 5 FiO2 100% General: sedated, intubated HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [**2185-10-6**] 05:35AM WBC-8.2 RBC-2.98* HGB-8.5* HCT-26.6* MCV-89 MCH-28.6 MCHC-32.0 RDW-15.3 [**2185-10-6**] 05:35AM GLUCOSE-151* UREA N-27* CREAT-6.4* SODIUM-138 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12 [**2185-10-7**] 04:30PM PLT COUNT-329 [**2185-10-7**] 04:30PM NEUTS-77.6* LYMPHS-17.3* MONOS-3.1 EOS-1.5 BASOS-0.4 [**2185-10-7**] 09:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2185-10-7**] 11:11PM URINE RBC-0-2 WBC-[**7-13**]* BACTERIA-OCC YEAST-NONE EPI-<1 [**2185-10-7**] 11:11PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG Micro: [**2185-10-9**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2185-10-9**] URINE URINE CULTURE-PENDING INPATIENT [**2185-10-8**] CSF;SPINAL FLUID GRAM STAIN-negative; FLUID CULTURE-PRELIMINARY INPATIENT [**2185-10-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2185-10-7**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT Imaging: CT head ([**10-7**]) IMPRESSION: No acute intracranial process. Sinus disease. CXR ([**10-10**]) FINDINGS: There is a right IJ line with tip at the cavoatrial junction. There is volume loss in the left lower lobe. The heart is moderately enlarged, similar to prior. There is no focal infiltrate. MRI Head Stroke Protocol ([**10-14**]): 1. No acute intracranial abnormality; specifically, there is no evidence of either acute or previous ischemic event. 2. Unremarkable cranial MRA, with no flow-limiting stenosis. \ EEG ([**10-11**]): IMPRESSION: This is a mild to moderately abnormal routine EEG in the waking and drowsy states secondary to diffuse attenuation of signal over the left hemisphere and overall mildly slow and disorganized background. There were no epileptiform features noted. Brief Hospital Course: This is a 24 yo male with type I DM, ESLD on HD, resistant HTN who presents with hyperglycemia and emesis and found to have significantly elevated blood pressures. # Fever/Mental Status Changes/? delirium: When patient arrived to the hospital, he was agitated and required intubation for airway protection. He does have a history of oppositional defiant disorder. Was agitated and confused on admission. Pt was laughing and crying inappropriately. Head CT read neg for any acute IC process. Infectious w/u was negative though pt was febrile on admission, and LP and blood cx were negative. Pt was covered for bacterial and HSV meningitis until cx results returned. [**Month (only) 116**] also have had some component of uremic encephalopathy, and pt underwent dialysis in-house. All electrolyte abnormalities have been aggressively corrected. Glucose management as [**First Name8 (NamePattern2) **] [**Last Name (un) **] (see below). Neuro was consulted and recommended MRI to r/o PRES and/or stroke, particularly given RUE weakness, and MRI stroke protocol was negative. Pt was started on ASA 81mg and Simvastatin 20mg for preventative measures. Psych consulted in light of ODD; he was deemed not to have capacity due to lack of insight and lack of cooperation, and pt was restrained from leaving AMA by security on two occasions. However, on the mental status improved during hospitalization back to baseline, per family, and pt was re-evaluated by psychiatry and was deemed to have capacity, after which he signed out AMA (with close f/u arranged prior to sign out). . # Hyperglycemia: On initial presentation, pt in HHS given no ketonemia, though AG present, liekly [**3-7**] insulin non-compliance. AG resolved after only 10 units of IM regular insulin, but blood glucose remained difficult to control give pt's irregularly timed eating habits, during which he does not receive insulin (as insulin is regularly scheduled with mealtimes, during which times pt does not eat). [**Last Name (un) **] followed pt and sliding scale and lantus was adjusted, but sugars remained in 200's prior to discharge. Infectious workup was all negative. f/u with [**Last Name (un) **] was scheduled prior to pt's signing out AMA. . # Anion Gap Acidosis: Resolved after only 10 units of IM insulin. Tox screen positive only for opiates. Lactate 1. Most likely [**3-7**] renal failure. # Hypertension: BP >200's/100's on admission. Has run similarly high on previous admissions. Was on labetalol drip and home doses of metoprolol, lisinopril, and amlodipine. Anti-hypertensive regimen was changed to labetolol [**Hospital1 **], lisinopril, nifedipine and clonodine patch. Clonodine patch and labetolol are new on this admission and the lisinopril was doubled on this admission. Pt's home amlodipine was switched to nifedipine per renal, and dosed at night as pt typically had high BP's during the night. . # ESRD on HD: Received HD in-house, but all HD sessions were terminated prematurely due to pt's inability to tolerate due to symptoms. Renal followed, started pt on sevelamer. . #Anemia: s/p 1 unit PRBC. Likely [**3-7**] chronic renal failure (baseline about 25). Patient received epo after dialysis sessions. Medications on Admission: Glargine 10 units qHS Humalog SS Humalog 2 units after each meal Metoprolol succinate 200mg daily Metoclopramide 5mg PO Q6 Omeprazole 20 mg Capsule PO DAILY Ondansetron HCl 4 mg Tablet Q8PRN Docusate Sodium 100 mg Capsule [**Hospital1 **]:PRN B Complex-Vitamin C-Folic Acid 1 mg daily Amlodipine 10 mg Tablet daily Lisinopril 10 mg Tablet DAILY Sevelamer HCl 800 mg Tablet TID with meals Aspirin 81 mg Tablet daily Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*5 Patch Weekly(s)* Refills:*2* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. Disp:*30 Tablet Sustained Release(s)* Refills:*2* 7. Labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN as needed for constipation. 10. Ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO q8h PRN as needed for nausea. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed: Please follow the instruction for insulin doses from your sliding scale. Discharge Disposition: Home Discharge Diagnosis: Type I Diabetes Mellitus Hypertension End Stage Renal Disease Discharge Condition: Inadequate blood pressure and blood glucose control. Not medically stable, advised patient not to leave the hospital but patient wished to leave against medical advice. Discharge Instructions: You were admitted for confusion, high blood pressures, and high blood sugars. You were intubated due to your confusion. An extensive workup failed to find a cause of your confusion, but your mental status improved. Your blood pressure medications were changed in order to better control your blood pressure. Your insulin regimen was also adjusted to better manage your blood sugars. Eating regular meals at intervals at least 4 hours apart and taking your insulin prior to eating will help regulate your blood sugar. . The following changes were made to your medications: - Metoprolol was stopped - Amlodipine was stopped - Lisinopril was increased to 40mg daily - Labetalol 300mg twice daily was added - Nifedipine 90mg daily AT NIGHT was added - Clonidine patch 0.2mg/24hr 1 patch every Wednesday was added - Atorvastatin 20mg daily was added - Your insulin scales were adjusted (please see attached sheet) . Please come to the emergency department or call your primary care physician if you have confusion, severe headaches, change in vision, chest pain, fevers, chills, or any other concerning symptoms. Followup Instructions: You have scheduled the following appointments: . Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] at [**Last Name (un) **] Diabetes Center ([**Telephone/Fax (1) 2378**]) Tuesday [**2185-10-25**] @ 3:00pm . Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-10-27**] 3:20 . Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2185-11-21**] 1:40 . Dr. [**Last Name (STitle) 14166**] (Phone [**Telephone/Fax (1) 14167**]) on [**10-30**] at 8:30 PM. You are also scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Thursday [**10-20**] at 1:30 PM.

[ "362.01", "403.01", "276.2", "583.81", "250.53", "369.4", "276.1", "276.7", "599.70", "V49.83", "285.21", "585.6", "518.82", "729.89", "348.39", "780.60", "250.43", "276.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "39.95", "03.31", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9496, 9502

4367, 7580

301, 337

9608, 9780

2482, 2487

10940, 11695

1853, 1934

8046, 9473

9523, 9587

7606, 8023

9804, 10917

1949, 2463

1364, 1385

229, 263

393, 1345

2502, 4344

1407, 1665

1681, 1837

18,254

109,106

47964

Discharge summary

report

Admission Date: [**2193-5-23**] Discharge Date: [**2193-6-7**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 22401**] Chief Complaint: Hypertensie Urgency Major Surgical or Invasive Procedure: Intubation due to acute respiratory distress . Hemodialysis History of Present Illness: 58 y/o female with h/o ESRD on HD, s/p renal tx in [**2173**] with acute on chronic rejection in [**2193-1-20**], initially presenting with a 4-5 days episode of severe frontal headaches, N/V/D and decreased appetite. Pt reports symptoms started on [**5-18**] after she had received dialysis that day. She missed her HD 2 days prior to admission due to severe HA and malaise. Pt denies having had changes in vision, numbness or weaknesses, syncopes, SOB, CP, anuria or edema during that time. During her next HD session on [**5-23**] it was noted that pt had SBP >200-250 patient was also c/o headache and sent to ED for HTN management. Pt was admitted to the ED for severe hypertensive crisis, given captopril, labetolol 20mg, 40mgx2, 80mg then started on nitro and labetolol gtt. She also received dilaudid for her HA and she was transferred to the MICU for hypertensive urgency and fevers (102). . MICU She had two seizures on [**5-24**] in the early morning hours, most likely due to hypertensive leucoencephalopathy. The first tonic-clonic convulsion (at 4AM, lasting for about 3min) was witnessed, a respiratory code was called but the intubation failed (esophagus). At 6AM the pt awoke, was disoriented, agitated and started screaming. Shortly after she suffered from a second seizure which stopped after Lorazepam 2mg iv, pt was then successfully intubated and entered brief post-ictal coma (with intact brain stem reflexes). Pt was transferred to the floor 48 hours later for optimalization of her BP. Past Medical History: #S/p renal transplant in [**2173**], acute on chronic rejection in [**1-25**], now ESRD on HD. . #IgA nephropathy in [**2169**], 7-8months HD prior to transplant . #HTN . #Depression . #s/p rheumatic fever in childhood Social History: Lives alone with cats. No family in the area. Denies tob/EtOH/IVDU/substances. Works part-time as asst. coffee shop manager. Unable to obtain health insurance for past year, which has limited her access to f/u medical care for her transplant. Family History: Father died age 80. Mother with lung Ca, died @64. Many aunts/uncles with Ca. Sister with breast Ca, survived. No family hx renal problems. Physical Exam: T 99.6 BP 174/75 (146/66-190/96) HF 91 bpm (83-105 RR 18 (18-24) O2-Sat 100%(97%)on 2l I/Os: 1012/275, after midnight 1132/0 General Alert, orientated, cooperative; pleasant; Skin Warm, good color, normal turgor; no signs of ulcers, petechiae, erythema or jaundice; Pt has bruises on her back (left lower chest) and arms; Mild bilat. LE edemas; HEENT No visual impairment, no conjunctival injections, anicteric sclerae; Moist gums and tongue; Lymph No signs of lymphadenopathy; Neck Good carotid pulses, no bruits; Respir No use of accessory muscles, no retractions, symmetrical thorax expansion, both lungs are equally ventilated, no wheezes, crackles over both lower lobes l>r, decreased BS over LLL; Cardio Rhythmic, HR 91bpm, S1+ S2, systolic crescendo-decrescendo [**2-25**] murmur, no gallops or rubs; Abdomen No skin liver signs, normal bowel sounds over all four quadrants, no pain on light or deep palpation, no guarding, no masses; no hepatospleno-megaly, no flank pain; Pulses Good palpable carotic, radialis, ulnaris, dorsalis pedis and tibialis pos. pulses; MuscSkel No swelling of joints, no redness, no warmth; normal range of motion; Neuro Coherent, alert and orientated; normal CN II to XII, normal strength [**5-24**],normal sensory on both arms and legs; Pertinent Results: [**2193-5-23**] 07:00PM GLUCOSE-86 UREA N-18 CREAT-5.4*# SODIUM-142 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-30 ANION GAP-17 [**2193-5-23**] 07:00PM ALT(SGPT)-11 AST(SGOT)-14 CK(CPK)-67 ALK PHOS-58 AMYLASE-61 TOT BILI-1.0 [**2193-5-23**] 07:00PM LIPASE-27 [**2193-5-23**] 07:00PM cTropnT-0.04* [**2193-5-23**] 07:00PM CK-MB-NotDone [**2193-5-23**] 07:00PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.3# MAGNESIUM-1.6 [**2193-5-23**] 07:00PM WBC-3.4* RBC-3.17* HGB-9.9* HCT-29.8* MCV-94 MCH-31.4 MCHC-33.3 RDW-19.1* [**2193-5-23**] 07:00PM NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4 BASOS-0.3 [**2193-5-23**] 07:00PM NEUTS-69.5 LYMPHS-23.5 MONOS-5.3 EOS-1.4 BASOS-0.3 [**2193-5-23**] 07:00PM ANISOCYT-2+ MACROCYT-1+ MICROCYT-1+ [**2193-5-23**] 07:00PM PLT SMR-VERY LOW PLT COUNT-44*# [**2193-5-23**] 07:00PM PT-12.4 PTT-23.4 INR(PT)-1.1 . Upon d/c: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2193-6-7**] 04:50AM 5.6 3.76* 11.4* 33.9* 90 30.3 33.5 18.4* 148* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2193-5-29**] 05:17AM 55.4 33.1 6.5 4.1* 1.0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Bite Fragmen [**2193-5-29**] 05:17AM 1+ 1+ 1+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**Name (NI) 11951**] [**2193-6-7**] 04:50AM 148* MISCELLANEOUS HEMATOLOGY ESR [**2193-6-4**] 07:00PM 7 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2193-6-7**] 04:50AM 80 22* 4.0*# 140 3.5 101 27 16 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2193-6-6**] 05:00AM 281* OTHER ENZYMES & BILIRUBINS Lipase [**2193-5-29**] 05:17AM 33 CPK ISOENZYMES CK-MB cTropnT [**2193-5-23**] 07:00PM 0.04* [**2193-5-23**] 07:00PM NotDone CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2193-6-7**] 04:50AM 8.6 4.3 1.7 HEMATOLOGIC Folate Hapto [**2193-6-6**] 05:00AM <20* OTHER CHEMISTRY Ammonia [**2193-5-29**] 05:17AM 19 PITUITARY TSH [**2193-6-1**] 06:20AM 2.0 OTHER ENDOCRINE Cortsol [**2193-6-2**] 06:00AM 18.7 ANTIBIOTICS Vanco [**2193-5-29**] 05:17AM 14.3* NEUROPSYCHIATRIC Phenyto Valproa Phenyfr %Phenyf [**2193-6-4**] 04:50AM 68 LAB USE ONLY GreenHd Prblm RedHold [**2193-6-5**] 07:15AM AMARIE & J . ADAMTS 13: negative Metanephrines Serum - wnl HIT - negative . CT Head [**5-24**]: IMPRESSION: Unchanged appearance of CT compared with the prior examination obtained earlier on the same day. No hemorrhage is seen. Hypodensities are again noted in the white matter bilaterally. If hypertensive encephalopathy is clinically suspected, MRI would be helpful for further assessment. . EEG [**5-25**]: IMPRESSION: This is an abnormal portable EEG due to the presence of intermittent right central parietal and left temporal and central sharp transients. This finding appears to be independent and more frequent over the right side. Additionally, there are prolonged bursts of generalized slowing, bifrontally predominant and slow and disorganized background rhythm. This abnormality suggests cortical dysfunction over the right central parietal region and possible left central and temporal region. The bursts of the generalized slowing and the background slowing suggests a deep, midline subcortical dysfunction and are consistent with an encephalopathy. There was no seizure activity recorded. . Echo [**5-28**]: Conclusions: There is moderate 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 valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. . MRI abdomen: FINDINGS: Both native kidneys are markedly atrophic. Single renal arteries are identified bilaterally, without evidence for stenosis. The transplant renal artery rises from the right external iliac artery. There is no evidence for stenosis within the renal transplant artery. This artery trifurcates approximately 1.4 cm from its origin. The aorta is normal in caliber without evidence for atherosclerosis. The common iliac, external iliac and visualized portions of the common femoral arteries are widely patent. The transplanted kidney is identified in the right hemipelvis, measuring 10.7 cm in length. There is severe cortical thinning. The urothelium of the renal pelvis is abnormally thickened and edematous and demonstrates enhancement on post-gadolinium imaging. This finding is nonspecific, however, can be seen in both rejection and infection. There is no significant hydronephrosis of the transplanted kidney and no focal renal lesions are identified. The partially visualized liver is unremarkable. There is no intra- or extrahepatic biliary dilatation. The pancreas and adrenal glands are unremarkable. The spleen is abnormally low in signal on T1-weighted imaging, consistent with iron deposition. The visualized bowel is normal and there is no significant lymphadenopathy. IMPRESSION: 1. No evidence for renal artery stenosis in either the native kidneys or transplant kidney. 2. Severe cortical thinning of the transplant kidney. Abnormally thickened and edematous renal transplant urothelium. This is a nonspecific finding that can be seen in rejection and infection. Findings were discussed with Dr. [**Last Name (STitle) 6812**] at the time of the examination. . MRI of the head: IMPRESSION: 1. No interval change in multiple nonspecific foci of increased FLAIR signal intensity throughout both cerebral hemispheres, non-specific. 2. Apparent FLAIR-hyperintensity in the sulcal subarachnoid spaces. This finding may represent a technical artifact, or less likely blood products, cells or protein within the subarachnoid space. 3. Normal MRA of the circle of [**Location (un) 431**]. . Carotid US: FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaques identified. On the right, peak systolic velocities are 106, 60, 87 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.6. This is consistent with less than 40% stenosis. On the left, peak systolic velocities are 75, 72, 78 in the ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This is consistent with less than 40% stenosis. There is antegrade flow in both vertebral arteries. IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. Brief Hospital Course: 58 y.o. F admitted for malignant hypertension after missing HD session and nonadherent with her medications. Patient with subsequent seizures due to severe hypertension and slowly resolving confusion due to reversible hypertensive leukoencephalopathy. Patient was also found to be in microangiopathic thrombotic anemia with platelet consumption. Her symptoms, confusion and cbc returned to her normal baseline upon control of her blood pressure. . # Confusion The pt presented with waxing and [**Doctor Last Name 688**] episodes of confusion when she was transferred from the MICU to the floor. She was disoriented to location, time and suffered from post-ictal amnesia. The possible DDx included post-ictal vs. IC bleeding (CT scan was negative) vs. secondary to leukoencephalopathy vs. sepsis vs. delirium vs. medication. Since the pt mental status improved steadily parallel to BP control, it was thought to be reversible changes secondary to hypertensive leukoencephalopathy. The pt has been stable over the past days and is discharged with a fully recovered mental status. . # Fevers Pt spiked temperature when still on the MICU and started on 7 day course of Ceftriaxone. Since the pt had signs of LLL atelectasis on CXR a possible PNA could not be fully excluded. The pt also just had been intubated and had central lines in place. The obtained sputum showed Strep. pneumoniae and she was treated empirically for that with ceftriaxone. Drug fever was also in the differential since the pt showed no other signs of infections (chills, elevated WBC, SOB) but remained with intermittent fevers. She was newly started on phenytoin. After she was changed to Valproic acid, pt remained afebrile over the [**4-24**] prior to discharge and without any signs of active infection. . #. Seizures: Pt presented at MICU with new onset seizures, 2 generalized clonic episodes (each about 3min), which required intubation. Pt was monitored throughout post-ictal state and transferred to the floor after she was stable. She has been seizure-free since then. Initial seizures likely [**2-21**] HTN emergency - hypertensive leukoencephalopathy. Patient did not have evidence of trauma, systemic infection, no electrolyte abnormalities especially with ESRD, no evidence of acute bleed with underlying thrombocytopenia. - Head CT negative x 2 on [**5-24**] negative for hemorrhage or mass, MRI was not thought to be necessary at this point, neuro recs. - EEG impression: Suggests cortical dysfunction over the right central parietal region and possible left central and temporal region. The bursts of the generalized slowing and the background slowing suggests a deep, midline subcortical dysfunction and are consistent with an encephalopathy. There was no seizure activity recorded. Pt was initially started on phenytoin for seizure prophylaxis to which she responded well. However, pt developed a fever which was thought to be drug induced (eosinophilia accompanied febrile episode). Therefore phenytoin was d/c and pt was started on valproic acid instead. Her valproic acid have been monitored closely to titrate dosage, currently she is on Valproic acid 500mg po bid standing, last valproic level on [**6-3**] was 75. Pt will f/u with neurology as an outpatient to adjust further treatment. . #. Hypertension: Pt was admitted for hypertensive urgency with end organ damage - hypertensive leukoencephalopathy and microangiopathic hemolytic anemia. Obtained secondary hypertension work-up was negative (incl. MRI Abdomen, TSH, Cortisol - serum epinephrine and metanephrine were within normal limits). She has a history of not taking her medications, missing HD may also have complicated situation along with worsening renal failure/hypoperfusion/high RAAS. History from previous admission of bp elevated >200s but responded to Lasix and labetalol. Pt in ED initially was started on nitro gtt and nipride gtt in ED. Drips were stopped after seizures and improved BP control. There were no ECG changes or evidence of cardiac ischemia. BP was hard to control at first but stabilized over the past 72h under enforced treatment with Labetalol, Lisinopril, Clonidine, Nifedipine and intermittent Hydralazine (which was d/c on [**6-2**], due to orthostatic symptoms). Repeated adjustments in BP-regimen were made to optimize current treatment and prevent hypotensive episodes. Pt is discharged on Lisinopril 40mg po to qhs, Clonidine TTS 3 patch qthurs, Labetalol 800mg po bid and Nifedipine 120mg po qhs. The set goal for her SBP is 120-170, since the pt probably has a history of long-standing maltreated HTN and is used to high pressures. She complains about light-headedness and dizziness once pressures get too low. However, given her recent hypertensive episode it is essential for her to be well controlled. Also considering a component of non-compliance it is important that the pt will f/u with PCP and for monitoring of compliance. . #. ESRD Pt is s/p renal transplant in [**2173**] and tx rejection in [**Month (only) 404**] [**2193**], now back on HD, 3 times a week. Pt received HD throughout her hospital course and will be followed by renal as an outpatient, receiving HD at the [**Hospital1 18**]. She will be continued on her prednisone taper for immuno suppression with her graft. There was no evidence of compromising renal artery stenosis on the MRI. HD per their schedule, next HD sessioned for [**6-8**]. . #. CN III palsy Pt had two episodes of right sides ptosis/lat. deviation/diplopia and mydriasis (reactive to light), accompanied by right hemicranial HA during HD on [**6-4**] - resolving within 10 minutes. Initial DDx included Arteritis temporalis (ESR 7) vs. TIA vs. right posterior artery aneurysm. The obtained work-up included MRI/MRA (questionable subarachnoidal bleeding), carotid duplex (minimal bilat. stenosis <40%) and LP (no xanthocromia,clear and colorless). Since the clinical findings (ptosis, lat. deviation, mydriasis or diplopia)totally resolved and the work/up was negative, the intermittent CNIII palsy is thought to be secondary to transient ischemia due to hypotension. Pt will f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 575**], neurologist as an outpatient. . #. Severe Headache Pt presented with severe fronto-facial HA, accompanied by N/V on [**6-6**] (day after LP). She reported that the HA was similar to the one on her initial presentation. The HA was thought to be triggered by pt not following instruction after LP, such as bed-rest and high pressure overnight (up to 220s SBP. HA resolved throughout the day, initially treated with Oxycodone-Acetaminophen and Fioricet for HA, as well as Dolasetron for nausea. Neuro saw pt and did not find signs for focal lesion or papilledema, which could be indicative for post-LP complications. Pt is asymptomatic on day of discharge, denying HA, N/V, dizziness or blurry vision this am. . #. Anemia - Normocytic. Pt initially presented with Hct of 29.8, normocytotic. The anemia is thought to be secondary to ESRD (not treated with EPO previously) vs. occult bleeding vs. hemolysis. Retic count in [**Month (only) 404**] was 1.4%, indicating an impaired production. The hemolysis studies obtained revealed an elevated LDH and a decreased haptoglobin, which are found in hemolysis. The anemia is thought to be secondary to ESRD and initial microangiopathic hemolytic anemia induced by hypertensive urgency. Hct slightly decreased over the days prior to discharge, 32.3 on [**6-2**] to 25.6 on [**6-6**]. Hemolysis labs obtained revealed elevated LDH (not compared to previous days), Haptoglobin <20 (measured twice), normal direct and total Bili. No signs of active bleeding, pt is asymptomatic (denies SOB, not tachycardic, no dizziness) nor signs of severe hemolysis (jaundice, splenomegaly). Anemia and decrease in Hct is thought to be due to ESRD, ACD and hospital course (HD, frequent blood draws). However, labs indicate an additional hemolytic component. Pt was given 2 Units of Blood on [**6-6**] at HD, in addition to usual Epoetin administration during HD sessions. She responded adequately to transfusion, Hct rose from 25.6 to 28.1 to 33.9 in am of [**6-7**]. . #. Thrombocytopenia Pt initially presented with ptl of 44. The thrombocytopenia were thought to be either microangiopathic hemolytic anemia secondary to her hypertensive urgency vs. TTP. Indicative for an underlying TTP are the following findings are thrombocytopenia, hemolysis, schistocytes, elevated LDH, decreased haptoglobin, elevated creatinine, mental status changes and fever. However the obtained ADAMTS13 to test for TTP was negative. Given that the pt Hct stabilized once her BP was controlled better made a MHA secondary to hypertensive crisis most likely. Interestingly, the pt had a similar thrombocytopenic episode in [**2193-1-20**] when she was hospitalized for her renal tx rejection. The ptl count has been steadily increasing since [**5-24**], being 148 on day of discharge. . # Full code Medications on Admission: Meds at home: Labetalol 600 mg daily ASA Lipitor Prednisone 5mg Folic Acid . Upon Transfer: Labetalol HCl 300mg po tid Lisinopril 10mg PO daily Aspirin 81mg po daily Prednisone 5mg po daily traZODONE HCl 25mg po hs:prn Phenytoin 100mg iv q8h Oxymetazoline HCl 1 spry nu [**Hospital1 **]:prn Amoxicillin 500mg po q24h Acetaminophen 325/650mg po q4-6h:prn Senna 1 tab po bid:prn Magnesium Sulfate 2gm/100ml NS iv ONCE ISS Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache. Disp:*30 Tablet(s)* Refills:*0* 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). Disp:*240 Tablet(s)* Refills:*2* 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:*4 Patch Weekly(s)* Refills:*2* 8. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:*120 Capsule(s)* Refills:*2* 9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Disp:*90 Tablet, Chewable(s)* Refills:*2* 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO ONCE MR1 (Once and may repeat 1 time) as needed for insomnia for 1 doses. Disp:*15 Tablet(s)* Refills:*0* 11. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency with secondary leukencephalopathy and microangiopathic hemolytic anemia . ESRD, s/p renal transplantation in [**2173**], tx rejection in [**1-25**] now back on dialysis Discharge Condition: Stable Discharge Instructions: Please go to [**Hospital 101208**] Clinic tomorrow to have your blood pressure checked by a nurse. . Please see your primary care physician or present to the ED for any of the following symptoms: headaches, blurry vision, changes in vision, nausea, vomiting, chest pain, shortness of breath, swelling of your legs, weaknesses of limbs or any other symptoms that worry you. Followup Instructions: Please have your blood pressure checked at the Women's Clinic at Carny tomorrow; . Your next scheduled appointment for dialysis at the [**Hospital1 18**] is on thursday, the [**6-6**]. . Please see Dr. [**Last Name (STitle) **], [**Doctor Last Name **], Neurology on thursday, [**6-6**] at 1pm on neurology unit CC8 (SB) for seizure follow-up. [**Telephone/Fax (1) 44**]. . You have an appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 101209**], [**Known firstname **] [**Last Name (NamePattern1) 5969**] scheduled for Monday, [**6-10**] at 2.30pm, Women's Clinic at [**Hospital 101208**] hospital. [**Telephone/Fax (1) 101210**]. . You also have a set appointment with your therapist [**First Name8 (NamePattern2) 101211**] [**Doctor Last Name **] for Monday [**6-10**] at 6pm, Women's Clinic at [**Hospital 101208**] hospital. [**Telephone/Fax (1) 101210**]. Completed by:[**2193-7-2**]

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Discharge summary

report+addendum

Admission Date: [**2188-4-22**] Discharge Date: [**2188-5-3**] Date of Birth: [**2133-10-6**] Sex: M Service: NOTE: This is an interim Discharge Summary through [**2188-5-2**]. PRINCIPAL DIAGNOSIS: Bladder carcinoma. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male with known horseshoe kidney who was first seen by Dr. [**Last Name (STitle) **] in [**2187-10-21**] for a second opinion of high-grade stage T1 transitional cell carcinoma of the bladder. He had repeat biopsies that raised the question of possibly muscle invasive disease. His repeat biopsies here at [**Hospital1 1444**] revealed in fact high-grade muscle invasive transitional cell carcinoma, and the patient was then entered into a bladder-sparing protocol where he received gemcitabine, Taxol, and carboplatin chemotherapy. He received one course and was then given a second course. Following his second course, his simple cystoscopy revealed a questionable lesion on the right wall of the bladder at the bladder neck, and magnetic resonance imaging scan revealed progression of disease. The patient was then biopsied, and the repeat biopsy sent did reveal ongoing high-grade muscle invasive bladder carcinoma. He was then removed from the bladder-sparing protocol and referred for radical surgery. He was advised the risks and benefits of the surgery and wished to proceed. PAST MEDICAL HISTORY: 1. Appendectomy in [**2162**]. 2. Above-noted bladder cancer. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Proscar 5 mg p.o. every day. SOCIAL HISTORY: He lives in [**Location 47498**], [**State 3914**] with his wife. [**Name (NI) **] has one grown daughter. [**Name (NI) **] denies any smoking history. He occasionally drinks wine. FAMILY HISTORY: There is no family history of genitourinary cancer. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] and taken to the operating room on [**2188-4-22**] where he underwent radical cystoprostatectomy and bilateral pelvic lymph node dissection, multiple biopsies of his mesentery, as well as creation of an orthotopic ileal neobladder. He tolerated this procedure well and was taken to the Intensive Care Unit postoperatively. He was continued on three days of Ancef and Flagyl prophylaxis. Following his procedure, he was nothing by mouth with a nasogastric tube in place. He did have a suprapubic tube placed in the operating room as well as a urethral catheter and two ureteral stents that were brought out through a separate stab wound. All of these were draining urine well with very minimal output initially from the Foley catheter and the suprapubic tube. Throughout the beginning of his course, his urine output gradually became more increased through his Foley and suprapubic tube and less through the stents. On postoperative day two, the patient was stable and was taken from the Surgical Intensive Care Unit to the floor. His pain continued to be controlled with a morphine patient-controlled analgesia. He continued to do quite well, and flushes of his neobladder were begun with 30 cc of saline through the urethral catheter and gently aspirated. He had very minimal mucous production. On postoperative day four, the patient was started on Lovenox subcutaneously at prophylactic doses. The patient had a known deep venous thrombosis, but at this point the goal was to re-anticoagulate the patient once he was tolerating an oral diet with Coumadin and to leave his Lovenox at prophylactic doses. He was out of bed and ambulating by postoperative day two and appeared in good condition. On postoperative day two, the patient received some intravenous Toradol for pain control; however, his creatinine abruptly rose to 1.3, and the Toradol was discontinued after two doses. The patient continued to do well and was discontinued from the morphine patient-controlled analgesia. By postoperative day five, the patient was no longer requiring pain medication. He had not passed flatus yet. By postoperative day six, the patient began to pass flatus and had a bowel movement. The nasogastric tube was removed. On postoperative day seven, his diet was advanced to a regular diet. The patient tolerated this quite well and had no difficulties. On postoperative day ten, the patient was taken down to the Cystoscopy Suite; before which he was given a dose of intravenous gentamicin. Under fluoroscopic guidance, his bilateral ureteral stents were removed without difficulty. A dressing was applied, and he was left with his suprapubic tube and urethral catheter both to gravity drainage. At this point, his Coumadin was restarted on postoperative day seven; however, his INR had not bumped above 1.3 at this point. MEDICATIONS ON DISCHARGE: (His discharge medications included) 1. Colace 100 mg p.o. twice per day. 2. Percocet one to two tablets p.o. q.4-6h. as needed (for pain). 3. Coumadin (dosed on a daily regimen for an INR in the range of 2 to 3). DISCHARGE STATUS: Discharge status was to home with services. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with his local physician for monitoring of his INR. He was previously on 5 mg of Coumadin once per day with 7.5 mg twice per week prior to his operation. He may require a different dosing regimen as he has had a bowel preparation and a large abdominal operation. His current dosing will be dictated by a separate physician after his discharge. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**] Dictated By:[**Dictator Info 47499**] MEDQUIST36 D: [**2188-5-2**] 10:56 T: [**2188-5-7**] 15:21 JOB#: [**Job Number 47500**] Name: [**Known lastname 4907**], [**Known firstname 33**] Unit No: [**Numeric Identifier 8593**] Admission Date: [**2188-4-22**] Discharge Date: [**2188-5-3**] Date of Birth: [**2133-10-6**] Sex: M Service: ADDENDUM: Mr. [**Known lastname **] remained in the hospital overnight on subcutaneous Lovenox. His INR was again checked after being given 5 mg of Coumadin on Friday evening, [**2188-5-2**]. His INR on Saturday morning, [**2188-5-3**], was 1.4. He will be discharged home today after his skin staples are removed and Steri-strips. He will follow-up with his primary care doctor. He will take 5 mg of Coumadin tonight and 5 mg of Coumadin tomorrow night and follow-up with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 228**] for an INR check and Coumadin readjustment. [**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1362**], M.D. [**MD Number(1) 1363**] Dictated By:[**Name8 (MD) 8594**] MEDQUIST36 D: [**2188-5-3**] 09:19 T: [**2188-5-8**] 22:21 JOB#: [**Job Number 8595**]

[ "453.8", "185", "998.11", "790.6", "753.3", "188.2", "276.8", "V13.01", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "45.51", "59.8", "57.87", "40.3", "57.71", "54.23", "97.62" ]

icd9pcs

[ [ [] ] ]

1788, 1841

4773, 5065

1538, 1568

1860, 4746

5148, 6911

5080, 5114

266, 1385

1407, 1510

1585, 1770

72,461

177,378

49393

Discharge summary

report

Admission Date: [**2191-4-22**] Discharge Date: [**2191-5-29**] Service: MEDICINE Allergies: Sulfonamides / Olanzapine / Risperidone / Propranolol / Haloperidol Attending:[**First Name3 (LF) 338**] Chief Complaint: Dyspnea, cough Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Ms. [**Known lastname 103426**] is a 76 yo F with PMH schizophrenia, HTN, h/o colon cancer transferred from NH were she was found to be shivering with BP 120/80 HR 136-140, RR 22 and room air oxygen saturation of 88-89% up to 93% on 2L face mask. Patient reports that she has not been feeling well for the past two days primarily due to cough. She denies any chest pain, abdominal pain, nasuea, vomiting, diarrhea, rash or other symptoms. VS on arrival in the ED T98.5 BP 79/51 HR 78 RR 26 98% on NRB. On the monitor she was noted to have HR 140-150 in atrial fibrillation. She was given 5mg IV lopressor with HR to the 130's. A second dose of 5mg IV lopressor was given whith improvement in HR to 90's to 120's however BP decreased to 74/54 transiently. She was given 1 L NS wit BP 91/58 on transfer to the ICU. She had a CXR which showed LLL infiltrate. She was given ceftriaxone 1g IV, vancomycin 1gm IV and levoquin 750mg IV. She had a rectal temp of 103.8 and was given 1g tylenol pr. On arrival to the floor HR 70's, SBP 91/43 93% 3L NC. She is resting comfortably in no respiratory distress. She denies pain. Past Medical History: Schizophrenia Cellulitis HTN h/o colon cancer - T3N0M0, s/p resection in 1/98, local recurrence at site of anastomosis in 8/99 and in 9/00 requiring repeat resections. In 12/00 had transverse colon resected. latest colonoscopy in [**6-16**] nml. B12 deficiency Peripheral neuropathy Social History: lives in [**Hospital3 **] and rehab center, eats regular low salt diet, ambulates with a walker. She stopped drinking alcohol since she moved into a nursing home. She does not smoke. Family History: Father with bipolar d/o Physical Exam: VS: T 99.6 92/48 HR 72 RR 18 93% on 3L NC Gen: A&O x3, resting comfortably, no distress HEENT: NC AT EOMI PERRLA Neck: supple, JVP flat CV: RRR, s1 s2, frequent premature beats Lungs: bronchial breath sounds at the left base, no wheezing Abd: well healed midline surgical scar, ventral hernia, distended, nontender, bowel sounds positive Ext: warm, palpable DP's, trace edema Pertinent Results: Na 138 K 4.5 Cl 104 HCO 24 BUN 38 creat 1 gluc 102 CK 602 MB 4 Trop 0.03 BNP [**Numeric Identifier 103427**] WBC 9.7 (N71 B4 L13) HCT 36.3 PLT 121 Venous lactate 2 UA: small leuk, nitr positive, 0-2 RBC, >50 WBC, moderate bacteria, 0-2 epi, rare yeast. [**2191-4-22**] EKG: Afib with RVR at a rate of 153 bpm, left axis deviation, poor baseline, no apparent ischemic changes. No prior for comparision. Imaging: [**2191-4-24**] CXR: Right PICC tip can be followed only to the upper SVC. No other interval change from prior study performed the same day earlier in the morning. [**2191-4-22**] CXR: Limited study as above. There are patchy opacities in the mid and lower left lung highly consistent with pneumonia. Correlate clinically. If clinically feasible and useful for management, consider PA and lateral views in the radiology suite for further evaluation. [**2191-3-21**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is low normal (LVEF 50%). There is no ventricular septal defect. The right ventricular cavity is dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: Health Care Associated pneumonia - She presented with a large left lower lobe infiltrate on CXR. Respiratory function stable on admission, requiring 3L NC only. Borderline hypotension, fever of 103 and tachycardia c/w SIRS/sepsis. She was treated with broad coverage with vancomycin, cefepime, levofloxacin given h/o resistant gram negative organisms and that she lives in a health care facility. Urine was negative for legionella. Over her prolonged hospital course, she continued to have worsening hypoxia and consolidation of her LLL and ultimately required MICU transfer. In the MICU, she developed large pleural effusions and a trapped lung on the left. Resp status deteriorated to requiring bipap at night and high flow mask constantly. Chest CT revealed evidence of numerous distal mucous plugs. However, Bronchoscopy on [**5-7**] did not reveal large mucous plugs. She then underwent thoracentesis and drainage of transudative fluid X 1, however, it quickly reaccumulated and she received an IP placed pigtail catheter on [**5-10**] with immediate drainage of large clear transudative fluid and improvement of her resp status back down to nasal cannula. She developed a small pneumothorax which was not symptomatic. After a prolonged hospital course ethics was consulted and she was made DNR/DNI with no escalation of care after speaking with her guardian. She expired on [**2191-5-29**]. Communication: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 656**] Guardian [**Telephone/Fax (1) **] or [**Telephone/Fax (1) 103428**] Medications on Admission: Meds: from NH med list depakote ER 1500mg daily perphenazine 6mg po daily perphenazine 2mg po q4 hours prn agitation EC ASA 325mg daily Tums 2 tabs po prn loratadine 10mg po daily for 5 months vitamin c 500mg po BID aldactone 25mg po daily colace 100mg po bid prn ibuprofen 600mg po q8 hours prn atenolol 25mg po daily mtv one daily B12 100 mcg daily amlodipine 5mg po daily vitamin D 400 units po daily Eucerin cream to lower extremities Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Hospital acquired pnemonia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "514", "585.6", "041.3", "599.0", "507.0", "276.1", "414.00", "511.9", "784.7", "403.91", "427.31", "295.90", "285.9", "553.21", "288.60", "276.2", "273.8", "518.81", "780.09", "512.8", "276.6" ]

icd9cm

[ [ [] ] ]

[ "93.90", "86.07", "38.93", "34.91", "43.19", "33.23" ]

icd9pcs

[ [ [] ] ]

6016, 6025

3939, 5498

289, 310

6095, 6104

2422, 3916

6156, 6162

1984, 2010

5988, 5993

6046, 6074

5524, 5965

6128, 6133

2025, 2403

235, 251

338, 1460

1482, 1768

1784, 1968

29,066

186,837

32965

Discharge summary

report

Admission Date: [**2141-12-19**] Discharge Date: [**2141-12-22**] Service: MEDICINE Allergies: Atropine / Demerol Attending:[**First Name3 (LF) 134**] Chief Complaint: Positive stress test Major Surgical or Invasive Procedure: L heart catherization History of Present Illness: The patient is an 85-yo man with history of CAD s/p MI and CABG approx 10 years ago with unknown anatomy, PVD s/p right carotid endarterectomy approx 2-3 years ago c/b intraoperative stroke with residual left-sided weakness, who has been experiencing SOB with exertion for the past 6 months. He experiences dyspnea with activity including pushing himself in his wheelchair approx 50 yards or walking with assistance down the hallway while using a walker. He also describes intermittent chest pain that is usually not related to exertion. He had a TTE on [**2141-6-17**] that showed a non-dilated LV with mild concentric LVH and EF 60%, and mild MR, TR, and AI. By report from pt's primary cardiologist, the patient had a recent Adenosine [**Year (4 digits) 1608**], during which he had SOB and chest pressure at one minute of infusion and possible anteroischemia on imaging, although the rest was stopped prematurely. The pt was referred here for outpatient cardiac catheterization. . In the cath lab, coronary angiography showed normal hemodynamics and a right-dominant system with normal LMCA, 60-70% proximal LAD and 70% diagonal, patent LCx with occluded small OM, 30% mid-RCA, atretic LIMA-LAD, and serial 90% SVG-OM with thrombus s/p PCI but unable to deliver stents, resulting in severe no reflow refractory to drug therapy. . On arrival to the CCU, the pt feels well post-procedure without complaints. He denies chest pain, shortness of breath, lightheadedness, flushing, diaphoresis, and nausea. ROS is otherwise completely negative. . On review of symptoms, he reports + prior CVA but denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: Cardiac History: CAD s/p MI and CABG approx 10 years ago with SVG-->OM and LIMA-->LAD . Cardiac Risk Factors: -Diabetes, +Dyslipidemia, -Hypertension . Pacemaker/ICD: N/A . Other PMHx: CAD s/p MI and CABG approx 10 years ago with SVG-->OM and LIMA-->LAD PVD s/p right carotid endarterectomy 2-3 years ago complicated by intraoperative CVA with left sided weakness (primarily wheelchair bound) Hyperlipidemia GERD/esophagitis Diverticulitis Asthma Depression Leg, feet and hand spasms of unclear etiology Social History: Social history is significant for the absence of current tobacco use. The patient notes h/o smoking but quit 64 years aog. There is no current alcohol use, as the pt denies any alcohol use in 30+ years. He lives alone at an [**Hospital3 **] facility. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 96.9 F, BP 127/57, HR 65, RR 16, O2 98% on RA Gen: WD/WN elderly male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NC/AT. PERRL. Sclera anicteric, conjunctiva pink. No pallor or cyanosis of the oral mucosa. +Right eyelid and facial droop. Neck: Supple without JVD or carotid bruits. CV: RRR, normal S1-S2. No MRG. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi anteriorly. Abd: NABS, soft, NT/ND, no masses or HSM. Ext: WWP, no c/c/e. Small right femoral hematoma. 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: CK Peak: 1318 MBI Peak: 11 Trop Peak: 1.97 Cath Report: COMMENTS: 1. Selective coronary angiography in this right dominant system revealed three vessel native coronary disease. The LMCA had no angiogrpahically apparent obstructive CAD. The LAD had 60-70% proximal and 70% diag disease. The LCX was patent with a small OM. The RCA was patent with a 30% mid vessel lesion. 2. Selective venous conduit angiography revealed and SVG to OM with serial 90% lesions with thrombus. 3. Selective conduit arteriography revealed an atretic LIMA to LAD. 4. Resting hemodynamics revealed systemic hypertension with SBP of 183 mmHg. 3. Unsuccessful PTCA and stenting of the SVG-OM graft with three bare metal stents - Vision (3.5x18mm) distal; Vision (3.5x18mm) mid graft; Vision (4x18mm) ostial. Case complicated by slow/no reflow down the graft. Despite administration of multiple vasodilators downstream, flow was never successfully restored. The patient left the cath lab hemodynamically stable with mild ([**1-29**]) chest pain (See PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary disease. 2. Atretic LIMA to LAD. 3. Unsuccessful PTCA and stenting of the SVG-OM graft with three bare metal stents. Case complicated by slow/no flow down the graft. Despite administration of multiple vasodilators flow was never suceessfully restored. . TTE [**12-21**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the posterior (inferolateral) wall. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened (the noncoronary cusp is especially heavily calcified). There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: posterior myocardial infarct Brief Hospital Course: 85-yo man with CAD s/p MI and CABG [**43**] years ago with SVG-OM and LIMA-LAD, PVD s/p right CEA c/b intra-op CVA with residual left-sided weakness, who presents for close monitoring after outpatient cardiac cath showed 90% serial thrombus in the SVG-OM and unsuccessful attempt at PCI / stent placement, resulting in 0% residual with severe no reflow, concerning for distal showering of thrombus to the microvasculature of the OM distribution. . # CAD/Ischemia: Pt has known CAD with h/o MI and is s/p CABG in [**2123**] with SVG-OM and LIMA-LAD. He initially presented for evaluation of DOE, and was found to have possible ischemia on a recent Adenosine [**Last Name (LF) 1608**], [**First Name3 (LF) **] he was admitted for outpatient cardiac catheterization. During the cath, attempt was made to intervene on SVG-OM 90% serial thrombus, which resulted in 0% residual with severe no reflow, which is concerning for distal showering of thrombus to microvasculature. Post-procedure ECG concerning for posterior MI, c/w LCx distribution and probable showering of thrombus from SVG-OM. Pt asymtomatic throughout. Treated with medical management including ASA 325, Plavix 75, high-dose statin, BB, and ACE-I. Echocardiogram revealed LVEF 50% secondary to hypokinesis of the posterior (inferolateral) wall. The patient was continued on his home medications for his chronic medical conditions. He will follow up with his PCP and primary cardiologist in the next few weeks. . Full code. Medications on Admission: Aspirin 81mg daily Vitamin C 500mg daily Lipitor 10mg daily Paxil 40mg daily Plavix 75mg daily in the PM MVI daily Ocean spray 1 spray to each nostril [**Hospital1 **] Nexium 40mg daily x 7 days, hold x 3 days and start again Trazadone 50mg qhs with another ?????? PRN if he wakes up Tylenol 650mg PRN Vitamin B12 1mg daily Baclofen 10mg 2 tabs QHS PRN for spasms Fish Oil 3 capsules daily in the am Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-22**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed. 12. Omega-3 Fatty Acids 240-360-5 mg-mg-unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 6930**] [**Last Name (NamePattern1) 269**] [**Location (un) 3844**] Discharge Diagnosis: Coronary Artery Disease NSTEMI Discharge Condition: Good Discharge Instructions: You were admitted for a cardiac cath, however a stent was not able to be placed in your coronary artery. You had a small heart attack. Please continue to take all of your medications exactly as prescribed. We have increased the dose of both your aspirin and lipitor, and added medications called lisinopril and metoprolol. Call your doctor or go to the ED if you experience chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Follow up with your PCP [**Last Name (NamePattern4) **] [**11-22**] weeks. Follow up with your cardiologist this month. Please call to make these appointments.

[ "414.02", "410.71", "443.9", "530.81", "414.01", "272.4", "599.7", "311", "493.90" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "88.42", "99.20", "37.22", "00.66", "00.40" ]

icd9pcs

[ [ [] ] ]

9682, 9810

6369, 7858

248, 271

9884, 9890

3928, 4973

10381, 10545

3020, 3102

8309, 9659

9831, 9863

7884, 8286

4990, 6346

9914, 10358

3117, 3909

188, 210

299, 2207

2229, 2735

2751, 3004

61,106

136,735

4932

Discharge summary

report

Admission Date: [**2129-9-20**] Discharge Date: [**2129-10-4**] Date of Birth: [**2056-9-25**] Sex: F Service: CARDIOTHORACIC Allergies: Methimazole / Atorvastatin Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2129-9-22**] cardiac catheterization [**2129-9-23**] CABG x3(L->LAD,SVG->OM/diag)/PFO closure History of Present Illness: 72F PMH CAD (sp stent to Diag in [**2118**], stable angina, pt refuses plavix and aspirin) who presented to ED yesterday with multiple episodes CP over the past 2 weeks. Patient reports 1-2 episodes angina daily, good relief with nitro, at rest and active, worse with activity, worse with reclining (endorses multiple pillows at night). Pain occurs in center of chest, described as "squeezing," does not radiate, associated with dyspnea, lasts a few minutes. Patient endorses 1 episode emesis day prior to presentation. Patient's most recent episode subsided about an hour ago with nitroglycerine use. ED initial vitals: 97.8 99 157/75 20 100% 2L NC Vitals prior to transfer to cath lab: 98 48 148/76 12 97% Labs and imaging significant for : Labs: trop neg x2, INR 1,0, PTT 30, UA: tr protein, Na 138, K 4.3, Cl 105, Bicarb 23, BUN 17, Cr 1.2. WBC 9, HCT 37, PLT 313. Patient given: asa 325mg, pantoprazole 40mg, amlodipine 5mg, levothyroxine 25mcg Pt was admitted to ED observation for 2 sets of enzymes - both of which were negative, and then had P-MIBI this morning. P-MIBI showed 0.5-1.[**Street Address(2) 20505**] elevation was noted in leads V1, V2, and AVR and 1 mm of horizontal/slightly downsloping ST segment depression in the inferolateral leads and pt was taken to the cath lab. In the cath lab she was noted to have distal L main disease. She was evaluated by CT surgery while in the cath lab in preparation for CABG . On arrival to the floor patient is symptom free and without current complaint. REVIEW OF SYSTEMS On review of systems, s/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. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CAD s/p stent after NSTEMI [**2118**] (to FDB, which was 95% occluded on LHC). Denies CHF. Not taking prescribed anti-platelet [**Doctor Last Name 360**]. 2. Mild valvular disease (AS mild-to-mod, mild MR, TR) echo [**2127**] 3. borderline [**Last Name (un) 6879**] (echo [**2127**]) 4. h/o Hyperthyroidism s/p radioactive ablation therapy 5. hypothyroidism, on lT4 5. Hypertension (on CCB, [**Last Name (un) **]) 6. Hyperlipidemia (on statin/Zetia combo pill) 7. Depression / ?bipolar -- started on trazodone and lithium on immigrating from [**Location (un) 4551**]/[**Country 532**] to [**Location (un) 86**]/USA. Continues on trazodone; says she stopped lithium 3mos ago on the advice of her nephrologist. 8. chronic mild anemia 9. h/o MRSA bacteremia in [**2118**] in the setting of hospitalization for NSTEMI/stenting Social History: Lives with husband, both retired. Former pharmacist. Immigrated from [**Country 532**]. Denies tob/EtOH/illicits. Family History: Denies h/o early CAD/MI/stroke/hypercoag. Physical Exam: #ADMISSION PHYSICAL EXAMINATION: VS: T=98.3 BP=154/50 HR= 46 RR=14 O2 sat= 98% RA GENERAL: WDWN female 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. JVD could not be appreciated as patient is supine s/p cath. 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+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Echocardiogram: [**2129-9-22**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild anterior leaflet mitral valve prolapse. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Aortic sclerosis without frank stenosis. Mild anterior leaflet mitral valve prolapse with mild mitral regurgitation. Indeterminate pulmonary artery systolic pressure. Lower extremity Duplex [**2129-9-22**] Duplex was performed of bilateral lower extremity veins. Greater saphenous veins are patent from the groin to the ankle bilaterally with diameters as noted on the scanned worksheet. IMPRESSION: Patent bilateral greater saphenous veins. Carotid Duplex: [**2129-9-22**] Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is a small heterogeneous plaque in the ICA. On the left there is a small heterogeneous plaque seen in the ECA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 123/20, 96/18, 101/26, cm/sec. CCA peak systolic velocity is 84 cm/sec. ECA peak systolic velocity is 138 cm/sec. The ICA/CCA ratio is 1.4. These findings are consistent with 40-59% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 83/21, 88/29, 105/28, cm/sec. CCA peak systolic velocity is 88 cm/sec. ECA peak systolic velocity is 123 cm/sec. The ICA/CCA ratio is 1.1 . These findings are consistent with no stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA 40-59% stenosis. Left ICA no stenosis. . [**2129-10-1**] 02:28AM BLOOD WBC-13.6* RBC-3.53* Hgb-10.8* Hct-33.7* MCV-95 MCH-30.6 MCHC-32.0 RDW-14.7 Plt Ct-367 [**2129-9-30**] 02:19AM BLOOD WBC-11.7* RBC-3.47* Hgb-10.7* Hct-32.8* MCV-95 MCH-30.8 MCHC-32.5 RDW-15.1 Plt Ct-309 [**2129-9-29**] 03:01AM BLOOD WBC-10.8 RBC-3.26* Hgb-10.0* Hct-30.7* MCV-94 MCH-30.8 MCHC-32.7 RDW-15.1 Plt Ct-269 [**2129-10-3**] 05:19AM BLOOD Glucose-102* UreaN-32* Creat-1.5* Na-139 K-4.4 Cl-108 HCO3-24 AnGap-11 [**2129-10-2**] 05:15AM BLOOD Glucose-110* UreaN-39* Creat-1.5* Na-142 K-4.3 Cl-111* HCO3-23 AnGap-12 [**2129-10-1**] 02:28AM BLOOD Glucose-121* UreaN-51* Creat-1.9* Na-142 K-3.5 Cl-103 HCO3-26 AnGap-17 [**2129-10-3**] 05:19AM BLOOD Mg-2.3 [**2129-10-2**] 05:15AM BLOOD Mg-2.3 Brief Hospital Course: 72 F with history of CAD sp stent to Diag 1 in [**2118**] admitted for chest pain, found to have positive P-MIBI with cath showing significant left main disease, patient referred for coronary artery by-pass grafting. The patient was brought to the Operating Room on [**2129-9-23**] where the patient underwent Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery, and reverse saphenous vein graft to the obtuse marginal artery and diagonal artery. Closure of patent foramen ovale. Respiratory: successfully extubated and weaned within the 1st 24 hours. Chest tubes were removed. Remained in CVICU for increased oxygen requirements secondary to volume overload. Lasix drip was started. She continued to be hypoxic and required re-intubation on POD 4 on ventilator mode: CPAP & PS. Aggressive diuresis, pulmonary toilet, and nebs she was successfuly re-extubated on POD 7. Her oxygen requirements improved with oxygen saturations of 95% 2L nasal cannula. By POD #10 she was no longer requiring supplemental oxygen and tolerating ambulation. Cardiac: Junctional rhythm immediate postoperatively then sinus brady. Low-dose beta-blockers were started POD 2. Pacing wires were removed POD3. She tolerated beta-blockers. Hypertensive amlopdipine intiated. ID: Leukocytosis was noted POD4. Vancomycin and Cefipime was started for possible pneumonia. Vancomycin was discontinued [**2129-9-27**] with rising CRE level. Pan-cultures were negative, Cefipime stopped [**2129-9-29**] and leukocytosis resolved. GI: POD3 Dobhoff feeding tube and tube feeds started. POD 7 she tolerated a clear liquid diet and advanced to regular on POD8. Self removed feeding tube. PPI and bowel regime continued. Renal: Acute kidney injury with peak CRE of 2.3 base 0.9-1.2 improved with diuresis. On discharge her CRE was 1.5 Endocrine: insulin sliding scale and coverage to maintain BS < 150. Hypothyroid medication was continued. Neuro: Russian speaking understands English. Follows all commands. Pain well controlled with Tramadol. Disposition: She was seen by physical therapy who recommended [**Hospital 3058**] rehab. She was discharged to [**Hospital6 1643**] Center with follow-up instructions. Medications on Admission: 1. Amlodipine 10 mg PO DAILY hold for SBP < 100 2. Hydrochlorothiazide 12.5 mg PO DAILY hold for SBP < 100 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Temazepam 30 mg PO HS 6. Meclizine 12.5 mg PO PRN vertigo 7. traZODONE 50 mg PO HS 8. Ezetimibe 10 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL PRN pain 10. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES [**Hospital1 **] 11. Simvastatin 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY hold for SBP < 100 2. Ezetimibe 10 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Meclizine 12.5 mg PO Q12H:PRN vertigo 6. Simvastatin 20 mg PO HS 7. Temazepam 15 mg PO HS 8. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 9. Albuterol-Ipratropium [**1-10**] PUFF IH Q6H:PRN dyspnea 10. Aspirin EC 81 mg PO DAILY if extubated 11. Docusate Sodium 100 mg PO BID 12. Heparin 5000 UNIT SC TID 13. Lorazepam 0.5 mg PO TID:PRN anxiety 14. Losartan Potassium 25 mg PO DAILY 15. Milk of Magnesia 30 mL PO DAILY:PRN constipation 16. Nystatin Oral Suspension 5 mL PO QID 17. Sarna Lotion 1 Appl TP QID:PRN rash 18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 19. Omeprazole 20 mg PO DAILY 20. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES [**Hospital1 **] Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: -CAD, s/p D1 stenting '[**18**]. (pt declines ASA or plavix) -Stable angina. -Moderate AS-[**Location (un) 109**] 1.1 -HTN. -Hyperlipidemia. -Chronic sinus bradycardia- reportedly in the 40s outpatient and asymptomatic -Diabetes -s/p Diag 1 stent in [**2118**] -Hypothyroidism -Bipolar -Anemia -Benign positional vertigo: MRI neg in ED Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: 1+ Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions NO lotions, cream, powder, or ointments to incisions Daily weights 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 cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: FOLLOW-UP: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2129-10-27**] 2:00 Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2129-10-12**] 11:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2129-10-20**] 11:30 Please call to schedule: Primary Care Dr. [**First Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] [**Telephone/Fax (1) 2010**] in [**4-14**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2129-10-4**]

[ "518.52", "E944.4", "413.9", "401.9", "276.69", "272.4", "300.00", "V45.82", "250.00", "285.29", "486", "276.2", "424.1", "427.89", "584.9", "412", "414.01", "745.5", "296.80", "244.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.12", "35.71", "36.15", "96.71", "39.61", "96.6" ]

icd9pcs

[ [ [] ] ]

11220, 11250

7640, 9881

304, 402

11631, 11799

4496, 7617

12389, 13252

3481, 3524

10366, 11197

11271, 11610

9907, 10343

11823, 12366

3539, 3550

3572, 4477

254, 266

430, 2484

2506, 3333

3349, 3465

1,458

161,890

14746+56574

Discharge summary

report+addendum

Admission Date: [**2158-6-2**] Discharge Date: [**2158-6-6**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old male who presented to the Emergency Department on [**6-2**] complaining of chest pain radiating to this jaw. He denies shortness of breath, nausea, vomiting or diaphoresis. The pain was unrelieved by sublingual nitroglycerin. The patient took one aspirin without relief and then called 911 at 5:00 in the morning. In the Emergency Department vital signs were temperature 98.2. Blood pressure 134/93. Heart rate 66. Respiratory rate 10. 99% on 2 liters. the patient was found to have no JVD, bibasilar rales. No murmurs, rubs or gallops. Positive bowel sounds, nontender. No edema. Alert and oriented times three. No focal neurological deficits. Electrocardiogram revealed ST elevations in leads 2, 3 and AVF. The patient was given 5 mg intravenous Lopressor, 20 mg nitroglycerin and started on heparin drip prior to going to the catheterization laboratory. Catheterization revealed 100% occlusion of proximal right coronary artery n90% occlusion of mid left anterior descending coronary artery. The right coronary artery lesion being the culprit lesion was stented. The procedure was performed without any complications. The patient was started on Plavix, aspirin and Integrilin and sent to the Coronary Care Unit for admission. PAST MEDICAL HISTORY: History of colon cancer status post right colonectomy in [**2157**]. History of prostate cancer. Transient ischemic attack ten years ago. Bleeding ulcer [**2157-8-13**]. Hypertension and questionable hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Colchicine, which he reports not taking. Iron, which he also reports not taking. Aspirin, Tylenol, meprobamate prn for anxiety, Prilosec not taking anymore, Maalox, Ambien and multivitamin. SOCIAL HISTORY: The patient is able to do all activities of daily living. He lives alone. He denies alcohol use for twenty five years. He quit tobacco in [**2122**]. FAMILY HISTORY: Father who died of atherosclerosis at the age of 65. ADMISSION TO CORONARY CARE UNIT: The patient's vital signs were 98.2. Blood pressure 106/57. Heart rate 83. Respiratory rate 16. O2 sat 97% on 4 liters. The patient was an elderly gentleman in no acute distress. No JVD was appreciated. The patient had distant heart sounds. S1 and S2 regular. Lungs were clear to auscultation bilaterally. Abdomen was soft, positive bowel sounds, nontender, nondistended. The patient had a horizontal surgical scar. The patient had no evidence of edema or cyanosis. The patient had 2+ dorsalis pedis pulses bilaterally. No rashes. Neurological examination was grossly intact. PERTINENT LABORATORIES: CPK, which initially rose to above 1100 on [**6-2**] and an MB index, which reached 11.2. Hematocrit, which was initially 35.5 in the Emergency Department fell to 28.6 post procedure. HOSPITAL COURSE: The patient had guaiac negative stools on admission to the Emergency Department, but on admission to the Coronary Care Unit post procedure was noted to have guaiac positive stools with bright red blood per rectum. The patient was transfused with 2 units of packed red blood cells and started on intravenous Protonix b.i.d. Hematocrit stabilized at 33 over the following days. GI was consulted and found no need for a colonoscopy at the present time. From a cardiovascular standpoint the patient was started on enteric coated aspirin, Plavix and Lopressor. The Lopressor was titrated up from 12.5 b.i.d. to 25 b.i.d. The patient was also started on Captopril, which was titrated up from 6.25 t.i.d. to 12.5 t.i.d. and later changed to Lisinopril 10 mg q.d. for discharge. An echocardiogram was performed on [**6-5**], which revealed mild symmetric left ventricular hypertrophy, akinesis/thinning of the entire inferior wall with hypokinesis of basal inferolateral wall, mild global hypokinesis of remaining segment, trace aortic regurgitation, 2+ mitral regurgitation and an EF of 30%. Rate and rhythm wise the patient had no active issues. The patient was continued on telemetry, which revealed no evidence of arrhythmias status post myocardial infarction. Hospital course was complicated by an episode in which the patient became confused after taking Ambien and fell out of bed. Ensuing neurological examination was normal and head CT revealed no abnormalities. The patient also started having dysuria on the 23rd and urinalysis revealed evidence of urinary tract infection. The patient was started on Levaquin 250 mg po q.d. for a three day course with resolution of symtpoms. The patient still has a 90% mid left anterior descending coronary artery stenosis. This was discussed with the patient. The patient opted not to have another catheterization during this admission. The patient will be treated medically and discharged. He is being followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43392**] cardiology fellow and will likely be scheduled for PCI at a later date. DISCHARGE MEDICATIONS: Lisinopril 10 mg po q day, Metoprolol 25 mg po b.i.d., aspirin enteric coated 325 mg po q day, Plavix 75 mg po q day times thirty days, Atorvastatin 20 mg po q day, Levofloxacin 250 mg po q day times two days and Protonix 40 mg po q day times 28 days. The patient is alert and oriented times three, hemodynamically stable. His hematocrit on discharge is 34. He is being scheduled for a follow up visit with cardiology fellow Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43392**] and arrangements have been made for visiting nurse service. DISCHARGE DIAGNOSES: 1. Inferior myocardial infarction. 2. Coronary artery disease with a 90% stenosis of his left anterior descending coronary artery. 3. Congestive heart failure with an ejection fraction of 30% and 2+ mitral regurgitation. 4. Lower gastrointestinal bleed. 5. Urinary tract infection. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Doctor Last Name 11115**] MEDQUIST36 D: [**2158-6-6**] 15:52 T: [**2158-6-7**] 09:21 JOB#: [**Job Number 43393**] Name: [**Known lastname 7911**], [**Known firstname 651**] Unit No: [**Numeric Identifier 7912**] Admission Date: [**2158-6-2**] Discharge Date: [**2158-6-6**] Date of Birth: [**2073-2-15**] Sex: M Service: ADDENDUM: The patient will be followed by his primary care physician (Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) 7913**]) at [**Hospital3 4437**] Hospital and will be followed by Cardiology at [**Hospital3 4437**] Hospital; not by Cardiology fellow at [**Hospital1 536**] (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7914**]). The [**Hospital 1325**] hospital course and discharge has been discussed with Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) 7913**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 297**], M.D. [**MD Number(1) 298**] Dictated By:[**Last Name (NamePattern4) 7915**] MEDQUIST36 D: [**2158-6-7**] 16:06 T: [**2158-6-14**] 10:55 JOB#: [**Job Number 7916**]

[ "272.0", "578.9", "401.9", "V10.46", "V10.05", "414.01", "998.11", "410.41" ]

icd9cm

[ [ [] ] ]

[ "36.06", "99.20", "36.01", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

2087, 2973

5719, 7361

5135, 5698

1706, 1899

2991, 5111

114, 1392

1415, 1679

1916, 2070

20,643

138,161

4430

Discharge summary

report

Admission Date: [**2107-8-23**] Discharge Date: [**2107-8-30**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 2145**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 19017**] is a 66 year-old man with a PMHx of stage 4 COPD (FEV1 0.65L;FEV1/FVC 37% predicted in [**4-14**]) on 4L home o2 with numerous hospitalizations for COPD exacerbations and intubation, hypertension, coronary artery disease, GERD who presents with SOB and CP. He is admitted to the ICU for management of dyspnea and hypotension. . He was in his USOH until a few days ago when he started feeling worsening SOB compared to his baseline, in the setting of running out of his inhalers. At baseline, he has SOB with minimal activity. This morning, he was again feeling short of [**Date Range 1440**] while sitting in his bed and used his inhalers. Usually, they improve his symptoms, but they did not this morning. He also began experiencing acute on chronic chest pain, with paroxyms of left sided chest pressure worsened with activity. He then called EMS. Of note, he has a history of chest pressure in association with shortness of [**Date Range 1440**]. . In the ED, his initial VS were 99.3 BP 110/45, HR 95, RR 22 O2sat 94% on room air. He was given Combivent nebs, SoluMedrol 125 mg IV x1, vancomycin, and zosyn. He reported improvement of his SOB with nebs. He also had a SBP drop to the 80s while sleeping and responded to 2L of NS bolus. He was then admitted to the MICU for further management of dyspnea and hypotension. . Recent history is notable for the absence of cough, fevers, chills, and sick contacts. [**Name (NI) **] denies nausea, vomiting, or diuresis in association with his CP, but does note a pleuritic quality. He does state that he has had decreased oral intake over the last few days. Past Medical History: # Severe COPD on 4 L O2 at home w/ BiPAP qhs - s/p multiple admissions and intubations for flares - [**4-/2107**]: FEV1 0.65L;FEV1/FVC 37% predicted in [**4-14**] # h/o chronic indwelling urethral catheter - has been out for >1 yr - has a h/o VRE UTI # hx of MRSA # CAD s/p NSTEMI ([**2101**]) - [**4-10**] with NL cath - TTE with preserved biventricular function in [**2103**] - uses ntg ~1x/week # Steroid induced hyperglycemia # Hypertension # Hyperlipidemia # Chronic low back pain L1-2 laminectomy from accident at work # Left shoulder pain for several months # Cataracts bilaterally - s/p surgery for both # GERD # BPH # Hx of resistant Pseduomonas PNA infxn Social History: Retired [**Company **] mechanic. Exposed to a lot of spray paint. Married with six children. Lives at home in [**Location (un) 686**] with wife. [**Name (NI) **]-son was recently removed from the house per home services given his selling drugs and guns in the house. The patient reports feeling safe currently at home. Minimally active at baseline, walks to kitchen and bathroom, but spends most of day in bed. Substances: 20 p-y smoking, quit 25 years ago. Occassional EtOH. Quit marijuana 3 years ago. Denies IVDA. Family History: Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer. Physical Exam: Per Admitting Resident: T: 97.3 BP: 118/67 P: 102 RR: 22 O2 sats: 93% on 4L NC Gen: lying in bed, NAD HEENT: teeth missing, PERRL, MMM Neck: no JVD appreciated, well healed scar from prior trach CV: tachycardic RR, very distant heart sounds, no murmur appreciated Resp: tachypnic, bilateral decreased [**Name2 (NI) 1440**] sounds, bibasilar soft rales, no wheezes Abd: +BS, soft, NTND Ext: DP 2+ symmetric, muscle atrophy Neuro: alert and oriented to person, place and date Pertinent Results: Admitting Labs: WBC-21.7* RBC-3.70* Hgb-9.5* Hct-31.4* MCV-85 MCH-25.6* MCHC-30.2* RDW-14.8 Plt Ct-327 Neuts-90.2* Lymphs-5.3* Monos-2.6 Eos-1.6 Baso-0.4 PT-11.0 PTT-28.3 INR(PT)-0.9 Glucose-115* UreaN-15 Creat-0.7 Na-133 K-4.7 Cl-92* HCO3-31 AnGap-15 Calcium-8.8 Mg-2.1 ABG Type-ART pO2-115* pCO2-63* pH-7.34* calTCO2-35* Base XS-6 Discharge Labs: WBC-12.2* RBC-3.36* Hgb-8.2* Hct-28.6* MCV-85 MCH-24.4* MCHC-28.6* RDW-15.1 Plt Ct-292 Glucose-81 UreaN-14 Creat-0.6 Na-139 K-4.1 Cl-98 HCO3-38* AnGap-7* ALT-16 AST-16 LD(LDH)-162 AlkPhos-63 TotBili-0.3 Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-2.1 Cardiac Biomarkers: [**2107-8-23**] 10:55AM CK(CPK)-41 CK-MB-NotDone cTropnT-<0.01 [**2107-8-23**] 04:16PM CK(CPK)-33* CK-MB-NotDone cTropnT-<0.01 [**2107-8-23**] 10:39PM CK(CPK)-50 CK-MB-NotDone cTropnT-<0.01 proBNP-245* Other Labs: [**2107-8-23**] 11:01AM Lactate-2.4* [**2107-8-23**] 06:33PM Lactate-5.2* [**2107-8-23**] 09:28PM Lactate-2.3* [**2107-8-24**] 04:41AM Lactate-1.4 [**2107-8-24**] 02:03PM Lactate-2.3* [**2107-8-25**] 11:19AM Lactate-2.1* Free T4-1.3 TSH-0.081* Urine Studies: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG IMAGING: CXR ([**8-23**]) - IMPRESSION: Reticular bilateral lower lobe opacities are likely secondary to fibrotic changes and bronchiectasis seen on prior CT. No focal consolidation. Probable COPD. CXR ([**8-24**]) - In comparison with study of [**8-23**], there is continued hyperexpansion of the lungs consistent with COPD. No evidence of acute pneumonia. Fibrotic and even bronchiectatic changes are seen at both bases, especially on the left. CXR ([**8-25**]) - FINDINGS: As compared to the previous radiograph, there is no relevant change. Bilateral medial subtle areas of parenchymal opacities, with a predominant peribronchial pattern, these could represent a status post aspiration or an early pneumonia. On the left, this area appears minimally denser than on the previous radiograph. No newly occurred areas of parenchymal opacity. Signs of overinflation with subsequent increasing transparency of the lung parenchyma. Unchanged size of the cardiac silhouette. CXR ([**8-26**]) - IMPRESSION: Stable appearances since the previous study with no new consolidation or pneumothorax. CT Chest/Abd/Pelvis - IMPRESSION: 1. Increased bibasilar consolidation and pleural effusions, concerning for aspiration. 2. Development of mild ascites. 3. Right shoulder joint effusion. 4. Sigmoid diverticulosis. Echo - Very poor echo windows. The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve was poorly seen. No mitral regurgitation is identified. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2103-8-20**], moderate pulmonary artery systolic hypertension is now documented (could not be quanitified on prior study). The other findings are similar. Brief Hospital Course: # Dyspnea / Chest Pain - On admission, it was unclear whether the patient's dyspnea was due to a COPD exacerbation or a pneumonia. The patient's tachycardia, hypotension, leukocytosis were suspicious for a SIRS/sepsis picture. CT of the chest showed bibasilar consolidation and pleural effusions, which was concerning for aspiration. He was started on vancomycin and zosyn on admission. He was also started on solumedrol and a 5-day course of azithromycin. He was also given albuterol and ipratropium nebs. Of note, the patient was continued on his bactrim prophylaxis and his calcium/vitamin D supplementation in the setting of chronic steroid use. ACS was ruled out with three sets of negative cardiac enzymes. His dyspnea improved throughout his time in the MICU. Prior to transfer to the floor, his vancomycin and zosyn were d/c'ed and he was started on unasyn. The patient's shortness of [**Year (4 digits) 1440**] continued to improve when he was on the floor. He denied any further episodes of chest pain while on the floor. At discharge, the patient said that his shortness of [**Year (4 digits) 1440**] was at its baseline. He was discharged home on unasyn (to complete a 10-day course) and on a steroid taper. Of note, blood and urine cultures did not grow out any organisms. # Chest Pain - The patient complained of some chest pain prior to admission. He also admitted to having some chest pains in the MICU. ACS was ruled out with three sets of negative cardiac enzymes. Of note, the patient was not on an aspirin. When asked about this, he stated that his doctor had taken him off of aspirin. Also, of note, the patient is not on a beta blocker (likely because of his COPD) or a statin. These medication changes can be made as an outpatient. The patient was free of chest pain at discharge. # Constipation - The patient was continued on his home regimen of lactulose and colace. He did not complain of any constipation while on the floor. # Lower Back Pain - The patient was continued on his fentanyl patch for his lower back pain. # HTN - The patient was continued on his home lisinopril dose. # HL - The patient was not currently on any meds for his hyperlipidemia. # GERD - The patient was continued on omeprazole for his GERD # BPH - The patient was continued on his finasteride for his BPH. Medications on Admission: Home Meds (per last d/c summary) 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days. 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) tablet PO 3X/WEEK (MO,WE,FR). 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) 15. Prednisone 10 mg Tablet Sig: Take Six (6) tablets from [**Date range (1) 19036**], take five tablet from [**Date range (1) 3563**], take 4 tablets from [**Date range (1) 19037**], take three (3) tablets from [**Date range (1) 19038**], then take your normal 20mg per day from then on Tablets PO once a day. 16. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a day. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) INH Inhalation once a day. 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) application Topical three times a day as needed. 19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for nebulization Sig: One (1) Neb Inhalation every six (6) hours as needed for sob/wheeze. Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation Inhalation twice a day. 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-[**Date range (1) 2974**]). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for Constipation. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation Inhalation once a day. 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer treatment Inhalation every six (6) hours as needed for shortness of [**Date range (1) 1440**] or wheezing. 18. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: to complete a 10-day course ending on [**9-3**]. Disp:*9 Tablet(s)* Refills:*0* 19. Prednisone 10 mg Tablet Sig: As directed Tablet PO As directed: Please take five tablets daily for 2 days, followed by four tablets daily for 3 days, followed by three tablets daily for 3 days. After that, take two tablets a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis COPD Exacerbation Possible Aspiration Pneumonia Secondary Diagnosis Coronary Artery Disease Hypertension Hyperlipidemia Chronic Low Back Pain Gastroesophageal Reflux Disease Benign Prostatic Hypertrophy Discharge Condition: Afebrile, hemodynamically stable. Discharge Instructions: You presented to the emergency department with worsening shortness of [**Hospital 1440**]. You were initially admitted to the ICU, where you were treated with IV antibiotics. Your breathing slowly improved while you were in the ICU. After you were transferred to the regular medical floor, you continued to improve and were switched to oral antibiotics to complete a 10 day course, ending on [**9-3**]. You also worked with physical therapy and showed improvement. Changes to your medications: START Amoxicillin/Clavulanic Acid (Augmentin) 875 mg twice a day, to complete a 10 day course ending on [**9-3**] START Prednisone Taper: 50 mg daily for 2 more days, then 40 mg daily for 3 days, then 30 mg daily for 3 days, then 20 mg daily permanently CHANGE Calcium Carbonate to 500 mg TID Please return to the emergency department for any worsening shortness of [**Month/Year (2) 1440**], chest pain, fevers greater than 101.5, confusion, or any other concerning symptoms. It was a pleasure taking part in your medical care. Followup Instructions: Please keep the following appointment with your PCP: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2107-9-9**] 2:45 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

13795, 13853

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277, 283

14119, 14155

3779, 4114

15233, 15534

3189, 3268

11670, 13772

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3283, 3760

14678, 15210

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15,814

102,657

16251

Discharge summary

report

Admission Date: [**2193-12-25**] Discharge Date: [**2194-1-4**] Date of Birth: [**2119-1-4**] Sex: M Service: GENERAL SURGERY/PURPLE SERVICE HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old gentleman with a history of gastric CA who presented to [**Hospital1 18**] for evaluation and management. PAST MEDICAL HISTORY: 1. Prostate CA, status post XRT. 2. Hypertension. 3. GERD. 4. Emphysema. 5. URI. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lisinopril. 2. Senna. 3. Zantac. 4. Tylenol. PAST SURGICAL HISTORY: 1. Status post appendectomy. 2. Status post left knee surgery. 3. Status post colostomy. PHYSICAL EXAMINATION ON ADMISSION: The patient was pleasant and cooperative, in no acute distress. The heart revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, nondistended. The extremities were warm and perfuse. No edema. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2193-12-25**] where exploratory laparotomy was performed. The patient had multiple metastases so gastrectomy was not performed. The patient had two omental biopsies, liver biopsy, and was transferred to the PACU in stable condition and later to the floor. However, on the floor, the patient's respiratory status had decreased. He required increasing amounts of oxygen until finally he became unresponsive and hypotensive. He was intubated. IV fluids were started and he was transferred to the SICU. He required levo for hypotension. Chest x-ray showed a right infiltrate. He was also started on Lasix for pulmonary edema. The patient did not require levo by postoperative day number two. Attempts to extubate the patient on postoperative day number two and three failed. We were not able to wean him off the ventilator. He was extubated on postoperative day number four. Over the next few days he continued to have shortness of breath. He developed tachycardia up to 120-130. His blood pressure remained stable. He was producing large amounts of mucus. His chest x-ray was unremarkable except for a suspicious opacification in the left lobe which was considered to be a possible pneumonia. The patient was started on levo. He was also started on Lopressor and then Diltiazem drip for tachycardia control. On postoperative day number six, the patient was started on a combination of oral and IV Lopresor which seemed to control his tachycardia much better. There was a suspicion of aspiration so a video swallow study was performed which showed the patient aspirates some air when using a straw, however, can drink normally from a cup without any aspiration. The patient's respiratory status has improved. He was started on chest PT which produced a large amount of mucus. His shortness of breath has improved. His heart rate and blood pressure were under control. He was transferred to the floor on postoperative day number seven. On postoperative day number eight and nine, the patient continued PT and chest PT with improving strength. His respiratory status is improving. He has a little bit less shortness of breath; however, he still requires 02. He was progressed to a general diet which he was tolerating well. He was passing gas and stool. On postoperative day number nine, the patient was afebrile. The vital signs were stable to 96-97% 02 saturation on 2 liters, producing large amounts of clear sputum (cultures were negative to date on the oropharyngeal flora). The patient was ambulating with help. No concerns. No active issues at this time. CONDITION ON DISCHARGE: Stable. DISPOSITION: The patient was discharged to rehabilitation. The patient should continue his PT to a goal of independent ambulation, chest PT with a goal of weaning off 02. Regular diet as tolerated. The patient should not drink through a straw. FOLLOW-UP: The patient should contact Dr. [**Last Name (STitle) **] for a follow-up appointment. The staples will be removed at follow-up. MEDICATIONS ON DISCHARGE: 1. Sarna lotion applied to affected area p.o. q.i.d. p.r.n. 2. Albuterol inhaler q. 4-6 hours p.r.n. 3. Ipratropium inhaler q. six hours p.r.n. 4. Beclomethasone inhaler two puffs q.i.d. 5. Lisinopril 20 mg q.d. 6. Percocet one to two tablets p.o. q. 4-6 hours p.r.n. 7. Lopressor 25 mg t.i.d. 8. Tamsulosin 0.4 mg q.d. 9. Protonix 40 mg q.d. DIAGNOSIS ON DISCHARGE: 1. Gastric CA. 2. Prostatic CA, status post exploratory laparotomy, omental biopsy, liver biopsy. 3. Hypertension. 4. Respiratory distress. 5. Pulmonary edema. 6. Hypertension. 7. Hypovolemia. 8. Gastroesophageal reflux disease. 9. Emphysema. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (STitle) 46350**] MEDQUIST36 D: [**2194-1-3**] 08:16 T: [**2194-1-3**] 20:29 JOB#: [**Job Number 46351**]

[ "197.6", "197.7", "997.1", "276.5", "157.8", "507.0", "997.3", "492.8", "553.20" ]

icd9cm

[ [ [] ] ]

[ "34.81", "53.59", "50.22", "54.4", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

4093, 4456

520, 573

1005, 3644

596, 710

4470, 5017

725, 987

353, 494

3669, 4067

29,463

192,696

46325

Discharge summary

report

Admission Date: [**2153-2-22**] Discharge Date: [**2153-2-28**] Date of Birth: [**2090-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1828**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Percutaneous Cholecystostomy History of Present Illness: SIRS SUB-I ADMIT NOTE . CC: Admit for N/V, weakness Transfer to MICU for hypotension, tachycardia Transfer to floor after stabilization for necrotic cholecystitis . HPI: 62 yo M with CAD s/p CABG, HTN, hyperlipidemia, CHF, DM1, presented to OSH with feeling weak, N/V, poor PO intake and abdominal pain since Sunday. Pt started to feel ill on Sunday after eating chinese food with abdominal cramping. No diarrhea but N/V and poor PO intake. Pt with increasing abdominal pain, feeling weak with subjective fevers at home-no temp taken. Pt denied any CP or difficulty breathing, has occasional orthopnea and PND, baseline LE edema-chronic. He continued taking his home BP meds, including an ACE-I and diuretics despite poor PO intake. He has had occasional palpitations and possible prior AF subsequent to his CABG but not recently. He was also c/o lightheadedness and dizziness. Denied cough, dysuria, no hematuria, no BRBPR, No hematochezia. . 3 weeks prior to admission family with viral illness-no abx given. However 1 week ago was dx with sinusitis infection per PCP and was treated w/10day course of an abx, pt unclear which abx he was given. No recent travel. . OSH COURSE: Pt found to be in AF w/RVR, bp 82/48-->102/47 prior to transfer, BNP & CE pending, CXR w/?PNA, received moxifloxacin 400mg IV x1 for ?PNA, Hep gtt w/bolus for new onset AF, no nodal agents given, 250cc IVF bolus x1, transferred to [**Hospital1 18**] for further evaluation. . ED COURSE [**Hospital1 18**]: Initial BP 107/68, HR 110, CXR done, 2mg morphine IV x1 for abdominal pain, 250cc IVF given. Admit for further managment and evaluation of PNA. Pt received no further antibiotics and further workup for abdominal pain. No cultures were drawn despite a WBC of 20,000. . On the floor, pt SBP 95-85 with HR 120-130. Pt was found to have abdominal pain with positive [**Doctor Last Name 515**] sign. Pt was started on Vancomycin, Ciprofloxacin and Flagyl and received one dose each. US was done and findings consistent with acute cholecystitis. The gallbladder contains small stones and sludge. Surgery was consulted and was concerned for nectrotic gallbladder. However, given poor operative candidate, percutaneous cholecystostomy was recommended. The pt received about 1.5L of NS and Diltiazem was pushed x2 with intermittent effect on the patient's HR. The patient was changed to Vanco and Zosyn for antibiotic coverage. Cultures were drawn. He is now transferred to the MICU due to hypotension and tachycardia for further management. . MICU COURSE: Percutaneous cholecystostomy tube is in place, drained ~700cc bilious fluid. The patient converted from NSR to AFIB despite Digoxin 0.25IV x1, lopressor 5mg IV x2, dilt 10mg IV x1, dig 0.125mg PO x1 today. There was a small amount of blood in the cholecystostomy drain tube, but per IR, this small blood is to be expected. Upon transfer from the MICU, BP 120s, HR 100s, 92%RA, no respiratory distress. Surgery recommended that since the patient was improving, to continue vanc/zosyn. [**Last Name (un) **] consult recommended to start lantus 6 HS, low dose HISS. Wound care consult saw patient for chronic venous stasis ulcers and recommended dressing changes. On the floor, he is comfortable, eating, and states that he wants to go home. Past Medical History: CAD s/p CABG [**2139**], stress test in [**11-25**] negative for ischemia -CHF, EF 60 % on stress test in [**11-25**] -HTN -Hyperlipidemia -IDDM -CRI, BUN 15, Crea 0.7 in [**Month (only) 1096**] -b/l leg ulcers w/chronic peripheral edema -neuropathy Social History: SOCIAL HX: Retired retail manager. Married, 3 adult children. Former smoker. Denies ETOH. . Family History: FAMILY HX: -NC . Physical Exam: PE VS: 101.0 BP 112/54 HR 117 RR 22 94% on 3L NC GEN: comfortable sitting in bed HEENT: Dry MM, anicteric sclera RESP: Diminished BS on right with bibasilar crackles, no wheezing CV: Irregularly irreg, tachcardic, nml S1, S2, no M/R/G ABD: Obese. Hypoactive BS. Soft, distended. +[**Doctor Last Name 515**] sign. +rebound tenderness. No LQ tenderness. EXT: legs wrapped to knees with 2+pitting edema up to knees, swollen feet NEURO: A&Ox3, no focal deficits, fluent speech, normal strength [**4-23**] in all 4 extremities Pertinent Results: [**2153-2-22**] 02:38PM ALT(SGPT)-19 AST(SGOT)-41* CK(CPK)-83 ALK PHOS-84 TOT BILI-0.4 [**2153-2-22**] 02:38PM ALT(SGPT)-19 AST(SGOT)-41* CK(CPK)-83 ALK PHOS-84 TOT BILI-0.4 [**2153-2-22**] 02:38PM CK-MB-NotDone cTropnT-0.11* [**2153-2-22**] 02:38PM CALCIUM-8.0* PHOSPHATE-4.1 MAGNESIUM-2.3 [**2153-2-22**] 02:38PM WBC-14.6* RBC-3.48* HGB-9.5* HCT-28.3* MCV-81* MCH-27.2 MCHC-33.4 RDW-15.8* [**2153-2-22**] 02:38PM PLT COUNT-207 [**2153-2-22**] 02:38PM PT-12.9 PTT-30.1 INR(PT)-1.1 [**2153-2-22**] 09:40AM CK(CPK)-81 [**2153-2-22**] 09:40AM CK-MB-NotDone cTropnT-0.12* [**2153-2-22**] 09:40AM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-2.4 IRON-15* [**2153-2-22**] 09:40AM calTIBC-207* FERRITIN-460* TRF-159* [**2153-2-22**] 09:40AM TSH-1.4 [**2153-2-22**] 06:31AM URINE OSMOLAL-331 [**2153-2-22**] 06:31AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 [**2153-2-22**] 06:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2153-2-22**] 06:31AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2153-2-22**] 06:31AM URINE HYALINE-15* [**2153-2-22**] 06:31AM URINE MUCOUS-RARE [**2153-2-22**] 03:55AM GLUCOSE-132* UREA N-73* CREAT-4.0* SODIUM-128* POTASSIUM-4.6 CHLORIDE-90* TOTAL CO2-23 ANION GAP-20 [**2153-2-22**] 03:55AM estGFR-Using this [**2153-2-22**] 03:55AM ALT(SGPT)-13 AST(SGOT)-19 CK(CPK)-91 ALK PHOS-85 TOT BILI-0.6 [**2153-2-22**] 03:55AM LIPASE-32 [**2153-2-22**] 03:55AM cTropnT-0.13* [**2153-2-22**] 03:55AM CK-MB-4 proBNP-7503* [**2153-2-22**] 03:55AM ALBUMIN-3.4 [**2153-2-22**] 03:55AM WBC-20.1* RBC-3.80* HGB-10.1* HCT-30.8* MCV-81* MCH-26.6* MCHC-32.8 RDW-15.8* [**2153-2-22**] 03:55AM PT-14.2* PTT-79.4* INR(PT)-1.2* . TTE: The left atrial volume is markedly increased. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. No vegetation is seen on the tricuspid valve. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mildly dilated right ventricle with preserved systolic function. Moderate-to-severe tricuspid regurgitation. Mild pulmonary hypertertension. . CT abdomen: IMPRESSION: 1. Right-sided pigtail catheter terminating within the gallbladder lumen in appropriate position. Hyperdense material within the gallbladder lumen likely represents contrast material from prior study. Correlation with history recommended. Markedly thickened gallbladder wall. 2. Extensive bibasilar atelectasis and tiny pleural effusions. Findings are slightly greater than what would be expected for simple atelectasis and aspiration pneumonia could be considered. 3. Splenic calcified cystic lesion likely post-traumatic in etiology. Splenomegaly. 4. Expanded, ill-defined kidneys consistent with ongoing renal disease as discussed on recent US examinations. 5. Numerous shotty lymph nodes, likely reactive. . Renal US: FINDINGS: The right kidney measures 15.6 cm and the left kidney measures 16.4 cm. There is preservation of the corticomedullary differentiation. There is no hydronephrosis. A small amount of perinephric fluid is noted around the right kidney. At the lower pole of the right kidney there is an anechoic focus measuring 5.5 x 4.6 x 5.4 cm consistent in appearance with a simple cyst. No renal masses are identified. A Foley balloon is noted within the bladder which is collapsed. IMPRESSION: No renal hydronephrosis. Again noted enlarged kidneys bilaterally which is unchanged compared to the previous examination. A small amount of right-sided perinephric fluid. Brief Hospital Course: 62 yo M w/CAD s/p CABG, HTN, Hyperlipidemia, IDDM, presents with necrotic cholecystitis s/p percutaneous cholecystomstomy drainage, new onset AFIB, ARF, tricuspid regurgitation. . ***PLAN***: 1. Followup with Dr. [**Last Name (STitle) **] 1 week after discharge to determine cholecystectomy date (will be 2-6 weeks after discharge). Perc chole will remain in for 2-6 weeks after discharge (to be determined by surgery). 2. Continue Ceftriaxone/Flagyl daily until surgery. 3. Followup with new primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 4427**], in 3 weeks. 4. Followup with [**Last Name (un) **] Dr. [**Last Name (STitle) 14116**] after cholecystectomy. 5. Needs ophthalmology and podiatry care for diabetes. 6. Needs followup for Bumex 4 daily for fluid overload. He needs to be followed closely for diuresis as an outpatient. # Sepsis/necrotic cholecystitis: The patient was admitted to [**Hospital1 18**] with a diagnosis of pneumonia and was sent to the floor following ED triage. He was found to have necrotic cholecystitis on RUQ US anc clinical exam, and was hypotensive and febrile. Surgery consult deemed the patient a poor surgical candidate due to sepsis and recommended percutaneous cholecystostomy, which was placed. He was transferred to the MICU for sepsis. The perc chole drained well, approximately 70-100 ml daily, for total drainage of approximately 1L dark bilious fluid and small blood (no pus) for length of stay. He was maintained on zosyn/vanc for 2 days, then was switched to Ceftriaxone IV/Flagyl PO, to be taken as an outpatient until surgery in [**1-24**] weeks from discharge. Bile cx returned Strep viridans and gm negative rods, sensitivities were requested from micro lab but were not returned by time of discharge. Surveillance blood cultures and urine cultures were negative. He has followup with Dr. [**Last Name (STitle) **] in 1 week after discharge. # Tricuspid regurgitation/fluid overload: Regarding his cardiac pump issues, [**2153-2-27**] TTE showed LVEF >55%, Mild LVH, 3+ TR, 1+ MR. [**Name13 (STitle) **] was moderately fluid overloaded on exam, and was diuresed inhouse, to be continued as an outpatient. He takes Bumex 2 daily, which has been increased to Bumex 4 daily as an outpatient. He will followup with his new PCP regarding fluid status, per our extensive conversation with the patient regarding this. His CXR showed bilateral effusions and pneumonia in his lungs, and 4+ pitting edema with venous stasis ulcers. # Paroxysmal AFIB: The patient was in AFIB with RVR on admission, attributed to infection from cholecystitis. In the MICU, he converted to NSR, then was alternately in AFIB and sinus for the remaining admission. He was rate controlled on Diltiazem and loaded with Digoxin in the MICU, which was changed to Metoprolol on the floor, and he was discharged on Toprol XL. He is on no rhythm control. He is anticoagulated on ASA (not on coumadin inhouse or on his home regimen). His coags were stable inhouse. # Cardiac ischemia: Regarding his cardiac ischemia issues, he is s/p CABG [**2139**], stress test in [**11-25**] was negative for ischemia. EKG shows AFIB 120, normal axis, normal intervals. CE x2 were negative in CK, MB, and TropT was 0.15, presumably from renal failure. He was maintained on ASA 325 daily, Lisinopril was held for renal failure, Atenolol was held for renal failure (changed to Toprol XL on discharge), and he was maintained on lipitor. # Prerenal/ATN/acute renal failure: His Cr was 4.0 on admission, and his baseline Cr is 0.7 in [**11-25**] per the patient's outpatient cardiologist. The etiology of his ARF was prerenal, and Cr improved daily from 4.0 to 1.4, at which point his clinical status stabilized sufficiently to be diuresed on the floor. His UA was negative for protein, and urine culture was negative. Renal US showed no hydronephrosis. Lisinopril and atenolol were held on admission, and lisinopril was restarted on discharge (patient has DM2 on insulin). His BP should be followed as an outpatient for titration of antihypertensives. # Pneumonia: He has bilateral pleural effusions and pneumonia. He is being treated for weeks on Ceftriaxone/Flagyl for necrotic cholecystitis. He had no shortness of breath and no coughing during this admission. # Chronic venous stasis ulcers: Wound care changed dressing daily. He has 2 mild ulcers with broken skin on his distal left leg, and 6 superficial ulcers with very small skin breakage on his distal right leg. He has no pain over his ulcers due to peripheral neuropathy (which extends to his shins on both legs and his distal arms). # Anemia: Baseline Hct was unknown, and his Hct was stable during admission. His stools were guaiac negative. Iron, B12, folate studies were unrevealing. # DM2 on insulin: His HgbA1c was 7.2 on [**2153-2-23**]. [**Last Name (un) **] was consulted inhouse and recommended 15 Lantus QHS, to be followed up by Dr. [**Last Name (STitle) 14116**] as an outpatient. We discussed the importance of followup with Dr. [**Last Name (STitle) 14116**] with the patient, since he has missed several appointments in followup. He was maintained on insulin sliding scale inhouse. # Communication: [**Name (NI) 30512**] (sister) [**Telephone/Fax (1) 98482**] cell, [**Telephone/Fax (1) 98483**] [**Name (NI) **] (Brother), Cardiologist Dr. [**Last Name (STitle) **] at LGH ([**Telephone/Fax (1) 5687**] Medications on Admission: MEDS on admission: -Atenolol 100mg daily -Bumex 2mg daily -ASA 325mg daily -Lisinopril 20mg daily -Insulin (pt reports taking novolog 80 units TID) -Lipitor 20mg daily . Medications on transfer: Insulin SC Sliding Scale Morphine Sulfate 2-4 mg IV Q4H:PRN pain Piperacillin-Tazobactam Na 2.25 g IV Q8H Aspirin 325 mg PO DAILY Simethicone 40-80 mg PO QID:PRN bloating Atorvastatin 20 mg PO DAILY Vancomycin 1000 mg IV Q48H Discharge Medications: 1. Aspirin 325 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Ceftriaxone 1 gram Recon Soln Sig: One (1) g Intravenous once a day. Disp:*1 month supply* Refills:*2* 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous with every dinner. Disp:*1 month supply* Refills:*5* 12. Bumex 2 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Necrotic cholecystitis Secondary diagnosis: DM2 on insulin, chronic venous stasis ulcers, tricuspid regurgitation Discharge Condition: VSS for several days, patient is ambulating, eating, drinking normally, no pain in abdomen, afebrile, feels very well. Discharge Instructions: Please keep your appointment with your primary care physician and other doctors. Please return to the emergency room if you experience increasing abdominal pain, fever, chills, shortness of breath, chest discomfort, other concerning symptoms. Followup Instructions: 1. New Primary care physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 4427**], [**Hospital Ward Name 23**] building, South Suite, [**Telephone/Fax (1) 2756**]. Monday, [**2153-3-26**], 2:30 PM. 2. General Surgery: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 9**], [**Street Address(2) 59351**], [**Location (un) **], MA, [**Location (un) **]. Thursday, [**2153-3-8**], 9:00 AM. 3. Endocrinologist: Please make an appointment to see Dr. [**Last Name (STitle) 14116**] at [**Last Name (un) **] diabetes clinic at [**Telephone/Fax (1) 21119**] for your diabetes care. It is extremely important that you keep your appointments in the future. You will need to see an ophthalmologist and podiatrist concerning diabetes care. *** Needs colonoscopy as outpatient. BRBPR in hospital with h/o hemorrhoids. *** *** Patient would like to switch from O2 condenser to O2 tank on discharge because of utility costs. *** Completed by:[**2153-2-28**]

[ "357.2", "428.0", "V45.81", "585.9", "414.01", "995.91", "574.00", "V58.67", "285.21", "427.31", "584.5", "403.90", "511.9", "459.81", "486", "428.32", "397.0", "272.4", "038.0", "250.60", "707.12", "276.1" ]

icd9cm

[ [ [] ] ]

[ "51.03", "38.93" ]

icd9pcs

[ [ [] ] ]

16324, 16382

9044, 14512

330, 360

16559, 16680

4638, 9021

16972, 17979

4061, 4080

14984, 16301

16403, 16403

14538, 14543

16704, 16949

4095, 4619

276, 292

388, 3661

16466, 16538

16422, 16445

14557, 14708

14733, 14961

3683, 3935

3951, 4045

50,479

118,654

54402

Discharge summary

report

Admission Date: [**2196-12-20**] Discharge Date: [**2196-12-25**] Date of Birth: [**2141-3-12**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x4(LIMA-LAD,SVG-OM,SVG-diag,SVG-PDA) History of Present Illness: This 55 year old white male has suffered a myocardial infarction in [**2182**] treated with RCA angioplasty and stenting. He again infarcted in [**2188**].He has now a year of intermittent exertional angina and found to have triple vessel disease at ctahterization. He was now admitted for revascularization. Past Medical History: Hyperlipidemia Hypertension CAD s/p MI in [**2182**] and [**2188**], s/p RCA stenting Diabetes Type 2 Asthma (inactive since quitting smoking) Gout Hx of gastritis/duodenitis Obesity Colon polyps s/p resection Prior heavy ETOH s/p Left shoulder fracture Social History: Race:Caucasian Last Dental Exam:in the last month Lives with:wife Contact:[**Name (NI) **] [**Name (NI) 111365**] (wife): [**Telephone/Fax (1) 111366**] Occupation:Works as a grave digger Cigarettes: Smoked no [] yes [x] Hx:smoked 2-3 packs a day for approximately 15-20 years, quit 10-15 years ago Other Tobacco use:denies ETOH: history of ETOH and none in 30 years Illicit drug use: denies Family History: Family History:Premature coronary artery disease- Mother with diabetes and a prior MI, dying at age 69 from cancer. [**Name (NI) **] brother recently had an MI at the age of 51. Father with diabetes and congestive heart failure Physical Exam: Pulse:64 Resp:18 O2 sat:100/RA B/P Left: 166/80 Height:6' Weight:233 lbs General: Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [] Neuro: Grossly intact [x] 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 Right: not present Left: not present Pertinent Results: [**2196-12-23**] 04:32AM BLOOD WBC-10.4 RBC-3.30* Hgb-10.3* Hct-30.3* MCV-92 MCH-31.2 MCHC-34.0 RDW-13.0 Plt Ct-155 [**2196-12-20**] 02:55PM BLOOD WBC-14.9*# RBC-3.46*# Hgb-10.8*# Hct-32.1* MCV-93 MCH-31.3 MCHC-33.7 RDW-12.9 Plt Ct-153 [**2196-12-20**] 04:01PM BLOOD PT-12.3 PTT-27.6 INR(PT)-1.1 [**2196-12-24**] 10:10AM BLOOD UreaN-20 Creat-1.0 Na-139 K-4.2 Cl-95* [**2196-12-20**] 04:01PM BLOOD UreaN-17 Creat-1.0 Na-130* K-4.0 Cl-99 HCO3-25 AnGap-10 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 111367**] (Complete) Done [**2196-12-20**] at 1:43:36 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2141-3-12**] Age (years): 55 M Hgt (in): 72 BP (mm Hg): 134/67 Wgt (lb): 240 HR (bpm): 67 BSA (m2): 2.30 m2 Indication: Coronary artery disease. Intraoperative TEE for CABG. Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. Right ventricular function. ICD-9 Codes: 786.51, 424.0 Test Information Date/Time: [**2196-12-20**] at 13:43 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Limited Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2011AW03-: Machine: U/S 1 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% >= 55% Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The patient was under general anesthesia throughout the procedure. No TEE related complications. Image quality was suboptimald - poor esophageal contact. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. 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. Mild mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2196-12-20**] at 1230pm. Poor transgastric views. Prebypass study performed by Dr [**Last Name (STitle) 3893**]. POST-BYPASS: Patient is AV paced and receiving an infusion of phenylephrine. LVEF=50%. Aorta is intact post decannulation. Trace to mild mitral regurgitation present. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-12-22**] 11:42 ?????? [**2188**] CareGroup IS. All rights reserved. Brief Hospital Course: Following admission he went to the Operating Room where coronary revascularization x4 (left internal mammary artery grafted to left anterior descending artery/saphenous vein grafted to Diag/Obtuse Marginal/and Posterior descending artery)with Dr.[**Last Name (STitle) **]. Cardiopulmonary Bypass time=71 minutes. Cross Clamp time=56 minutes. Please refer to operative report for further details. He weaned from bypass on Neo Synephrine,Insulin and Propofol.He tolerated the procedure well and was transferred to the CVICU intubated and sedated. He remained stable, awoke intact and weaned from the ventilator and was extubated. The pressor weaned off and beta blockade and diuresis begun. CTs were retained on POD 1 as there continued to be serosanguinous drainage, too voluminous to remove them. Pain was controlled with Dilaudid and oral diabetic agents and glargine insulin coverage to wean the insulin infusion off. He was transferred to the floor on POD 1 where Physical Therapy was consulted for evaluation of strength and mobility. Pacing wires were removed per protocol and he progressed satisfactorily. He failed to void and the foley catheter was replaced. Flomax was initiated. Prior to his discharge a second void trial was successful. He was ready for discharge to home on POD#5. Follow up appointments were advised. Medications on Admission: FOLIC ACID 1 mg daily GLIPIZIDE 10 mg daily LISINOPRIL 40 mg daily METFORMIN 1,000 mg [**Hospital1 **] METOPROLOL TARTRATE 50 mg [**Hospital1 **] NITROGLYCERIN 0.4 mg Tablet, Sublingual - 1 Tablet sublingually every five minutes for chest discomfort. Call 911 if pain persists longer than 15 minutes ROSUVASTATIN [CRESTOR] 20 mg daily ASPIRIN 81 mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever or pain. 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*1* 8. 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* 9. glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*1* 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* 19. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP <100 or HR <60. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass hyperlipidemia hypertension noninsulin dependent diabetes mellitus obesity s/p stenting right coronary artery s/p colonic polypectomy h/o gastritis prior alcohol abuse h/o gout Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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: Cardiac Surgery Office [**Hospital **] medical building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Wound check: Thrusday [**12-29**] at 10:45 am Surgeon:Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2196-1-26**] at 1:15pm Cardiologist:Dr. [**First Name (STitle) **] [**Name (STitle) **] office will call with appointment Please call to schedule appointments with: Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28549**] in [**4-12**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2196-12-25**]

[ "788.20", "V17.3", "272.4", "305.03", "250.00", "413.9", "278.00", "V45.82", "414.01", "401.9", "V85.35", "V15.82", "V15.51", "458.29", "412" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10785, 10834

6836, 8173

336, 405

11106, 11332

2365, 6813

12172, 12921

1462, 1677

8580, 10762

10855, 11085

8199, 8557

11356, 12149

1692, 2346

273, 298

433, 743

765, 1021

1037, 1431

51,615

136,723

48213

Discharge summary

report

Admission Date: [**2106-4-19**] Discharge Date: [**2106-4-21**] Date of Birth: [**2034-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 20128**] Chief Complaint: L-sided chest pain Major Surgical or Invasive Procedure: Right IJ placement [**2106-4-18**] History of Present Illness: Mr. [**Known lastname **] is a 72 year old man with history of hypertension, hyperlipidemia, and BPH who presents from home with chief complaint of left-sided chest pain. Pt had been feeling in his usual state of health earlier yesterday. Went out to dinner with his family. When lying in bed last night around 7:30pm, developed L breast pain. No radiation to shoulder, arm, neck, or back. No associated nausea, lightheadedenss, diaphoresis, or SOB. +chills, no fever. No vomiting or diarrhea. No dysuria. No sick contacts. Only recent travel was trip to [**First Name4 (NamePattern1) 28893**] [**Last Name (NamePattern1) 430**], North [**Doctor First Name **] 2 months ago. Never had chest pain like this before, though has been having bilateral nipple discomfort for the past few months, felt to be secondary to one of his medications (?spironolactone). Pt came to ED for further evaluation. . Of note, pt had been complaining of HA and congestion for several weeks. Seen in [**Hospital1 18**] ED on [**4-12**] and diagnosed with sinusitis. He saw an ENT doctor [**First Name (Titles) **] [**Last Name (Titles) 25896**] and was started on a 3 week course of [**Last Name (Titles) 101619**] and flonase within the last week. He reports resolution of his HA with this treatment. Also notes overall malaise for past few months. . In the ED, initial vs were: T 98.0, P 116, BP 106/57, R 15, O2 sat 96% on RA. Chest pain had resolved by arrival to the ED. Initial EKG was concerning for inferolateral ST depressions, however these quickly resolved. Received aspirin. CE negative x 2. Bedside ultrasound performed by ED resident did not show any obvious cardiac abnormalities. Initial plan was to admit to cardiology for ROMI, however pt then became hypotensive to 80s. Somewhat fluid responsive, however after each bolus, BP would drop again to 80s. CXR clear. UA negative. R IJ was placed and initial CVP was 3. Received total 3L NS. . On arrival to the MICU, pt reports that chest discomfort has resolved. He complains of dry mouth and overall malaise. Denies lightheadedness, nausea, SOB. Past Medical History: HTN Hyperlipidemia Gout BPH on meds h/o nasal polyp FHx of CAD fall 5 months ago onto R side (mechanical) Social History: SOCIAL HISTORY: The patient is married, three children, is partially retired. Does real estate. Smoking: Negative. ETOH: Rare. ecreational drugs: Negative. Diet: Balanced. Exercise: Deceased. The patient is originally from the area. Seatbelt use: Positive. He states he had a colonoscopy within the last year who was told he did not need to come back for 10 years. Family History: FHX: Father died of MI at age 58. Mother deceased age 49 of Bright disease. No siblings. Physical Exam: Vitals: T: 99.6, BP: 122/57, P: 112, R: 22, O2: 95% on RA General: fatigued, alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs [**2106-4-18**] 10:40PM BLOOD WBC-7.6# RBC-4.45* Hgb-13.6* Hct-38.5* MCV-86 MCH-30.6 MCHC-35.4* RDW-12.4 Plt Ct-198# [**2106-4-18**] 10:40PM BLOOD Neuts-86* Bands-6* Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2106-4-18**] 11:04PM BLOOD PT-12.6 PTT-22.8 INR(PT)-1.1 [**2106-4-18**] 10:40PM BLOOD Glucose-144* UreaN-38* Creat-1.6* Na-139 K-3.5 Cl-102 HCO3-23 AnGap-18 [**2106-4-19**] 05:14PM BLOOD Calcium-7.8* Phos-1.5* Mg-1.6 . Discharge labs [**2106-4-21**] 06:45AM BLOOD WBC-6.8 RBC-3.67* Hgb-11.3* Hct-32.2* MCV-88 MCH-30.8 MCHC-35.1* RDW-12.6 Plt Ct-155 [**2106-4-21**] 06:45AM BLOOD Glucose-125* UreaN-15 Creat-1.3* Na-139 K-4.2 Cl-106 HCO3-24 AnGap-13 [**2106-4-21**] 06:45AM BLOOD Albumin-3.5 Calcium-9.0 Phos-2.0* Mg-2.3 . [**2106-4-18**] 10:40PM BLOOD CK(CPK)-36* CK-MB-NotDone cTropnT-<0.01 [**2106-4-19**] 02:55AM BLOOD CK(CPK)-40 CK-MB-NotDone cTropnT-0.01 [**2106-4-19**] 09:49AM BLOOD CK(CPK)-130 CK-MB-3 cTropnT-<0.01 [**2106-4-19**] 07:35AM BLOOD Lactate-1.6 [**2106-4-19**] 09:49AM BLOOD Cortsol-21.3* [**2106-4-21**] 06:45AM BLOOD TSH-PND . [**2106-4-21**] 06:45AM BLOOD Ret Aut-2.1 [**2106-4-21**] 06:45AM BLOOD VitB12-PND Folate-PND Iron-PND Ferritn-PND TRF-PND . [**2106-4-19**] 02:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR [**2106-4-19**] 02:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2106-4-19**] 02:15AM URINE RBC-0-2 WBC-[**2-11**] Bacteri-FEW Yeast-NONE Epi-0 [**2106-4-19**] URINE CULTURE (Final [**2106-4-20**]): NO GROWTH. [**2106-4-19**] Blood culture: pending x 2 [**2106-4-19**] Urine legionella Ag: neg [**2106-4-19**] Influenza DFA: Neg . EKG #1 (10:28pm): sinus tach at 108 bpm, nl axis, nl intervals, wavy baseline, <1mm STD in II, III, aVF, upsloping STD in V4-V6 (changed from prior) . EKG #2 (11:21pm): NSR, ST changes resolved . [**2106-4-20**] TTE: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. 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) are mildly thickened. The mitral valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . [**2106-4-19**] CXR: No evidence of pneumonia. . [**2106-4-19**] CT head: Essentially unremarkable unenhanced head CT. . [**2106-4-19**] CT torso: 1. No findings in the chest, abdomen, or pelvis to explain symptoms. No pneumonia or abscess. 2. Stable right renal angiomyolipoma. 3. Few scattered, non-enlarged mesenteric lymph nodes, nonspecific. . [**2106-4-12**] CT sinus: Chronic-appearing paranasal sinus inflammatory disease, with anatomic abnormalities, as above. . [**2106-4-19**] Renal US: No hydronephrosis. No change since [**2106-4-5**]. Brief Hospital Course: 72 year-old man with h/o HTN presents with left sided chest pain, hypotension, and leukocytosis. . # Hypotension: Antihypertensives were held except for [**Month/Day/Year 101619**] with resolution of hypotension overnight in MICU. Unclear etiology but initial concern for sepsis given leukocytosis with bandemia and fevers, which have now resolved. Pt has remained hemodynamically stable and afebrile on [**Month/Day/Year 101619**] alone for sinusitis. [**Month (only) 116**] have had component of dehydration responsive eventually to fluid resuscitation. No evidence of cardiogenic etiology given neg cardiac enzymes and TTE. AM cortisol nl. TSH checked 1 year ago nl; in any case, unlikely to cause transient hypotension. Pt restarted gradually on atenolol and doxazosin. Holding lisinopril for now, but to be restart as tolerated by PCP on close [**Name9 (PRE) 702**]. Would discontinue aldactizide due to [**1-11**] nipple tenderness (could continue HCTZ component). Will discharge on [**Month/Day (2) **]; pt reports that he was prescribed 3-week [**Month/Day (2) 101619**] course by Dr. [**First Name (STitle) **] (ENT) and will f/u in [**2106-5-10**]. Will need f/u of pending micro data (blood and urine cultures) by PCP. . # Leukocytosis: Increasing WBC with bandemia and low grade temps, which have resolved on the floor. No localizing signs of infection found. UA negative. CXR clear. Pan-scan negative. Initial concern for meningitis given history of HA, though no signs of meningismus on exam. No prostate tenderness to suggest prostatitis. Blood and urine cultures negative to date, should be followed. Will discharge to complete [**Year (4 digits) 101619**] course for sinusitis; pt reports that he was prescribed 3-week [**Year (4 digits) 101619**] course by Dr. [**First Name (STitle) **]. . # Chest discomfort: Chest/breast pain resolved on presentation to ED. EKG with transient ST depressions but neg serial cardiac enzymes and TTE without gross wall motion abnormality. Nipple tenderness likely [**1-11**] spironolactone; resolved with discontinuation of aldactizide. . # Acute on chronic renal failure: Cr in past year 1.4-1.9. Now improved to 1.4. Decreased po intake recently but FENa of 1.3 suggests likely not solely prerenal etiology. No evidence of post-renal etiology on renal ultrasound. Question of possible med effect from diuretic or ACE-I. Pt encouraged to increase po fluid intake. Holding ACE I and HCTZ now [**1-11**] hypotension on presentation. Given improving Cr, can be restarted as tolerated by PCP. . # Anemia: Hct dropped from 38.5 to 31.7 in the setting of volume resuscitation. [**Month (only) 116**] be secondary to hemodilution or in setting of acute illness. Initial concern for blood loss in setting of hypovolemia but no obvious source for blood loss; no bleed on CT, guaiac neg stools. Low concern for hemolysis given nl total bili. Calculated RPI 0.75 suggests inadequate marrow response. Labs for Fe, B12, folate pending and should be followed with PCP. [**Name10 (NameIs) **] would also include anemia due to chronic renal failure. . # Headache: Constant frontal pressure most consistent with sinusitis. No evidence of temporal arteritis. CT head unremarkable. Pt to continue course of [**Name10 (NameIs) 101619**] for sinusitis and ENT f/u as above. Suggested repeat sinus imaging or ENT eval if no improvement. . # Malaise: [**Month (only) 116**] have been in setting of acute infection, possible component of dehydration with anorexia. No notable weight loss and up to date on cancer screening per pt (colonoscopy, PSA, recent SPEP); albumin nl. Labs notable for anemia with pending w/u. TSH level also pending and will need f/u by PCP. . # Hyperlipidemia: Statin resumed, continue at home. . # BPH: Doxazosin resumed, continue at home. . # Code: Full code . # Communication: With patient. HCP is wife [**Name (NI) 101620**] [**Telephone/Fax (1) 101621**]. Medications on Admission: ASA 325 Zocor 10 Atenolol 25 Aldactazide 25/25 Doxazosin 4mg [**Hospital1 **] Lisinopril 40mg [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for heartburn. 3. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - Hypotension - Atypical chest pain - Sinusitis Secondary diagnoses: - Acute on chronic renal failure - Anemia - Hypertension - Hyperlipidemia - BPH Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: You were admitted for evaluation of chest pain and low blood pressure. Your chest pain resolved. There was no evidence you had a heart attack, and your echocardiogram showed normal heart function. Your breast tenderness was thought to be due to one of the components of your medication Aldactizide. It is possible that your blood pressure dropped in the setting of infection, but it resolved with IV fluids. Your blood pressures have remained stable, and you will need to complete a 10-day course of your antibiotics for sinusitis. We are restarting you slowly on your blood pressure medications, but you will need close follow-up with your primary care provider. The following changes were made to your medications: - Aldactizide discontinued - Holding lisinopril until you speak with your primary care provider [**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name Initial (NameIs) **] 3 more days Please continue to take all other medications as prescribed. Please seek immediate medical attention if you develop chest pain, difficulty breathing, dizziness, worsening headache, vision changes, one-sided weakness or numbness, or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2204**] within 1 week for follow-up and to discuss your medications. His office will contact you with an appointment time. If you have any questions, please call his office at [**Telephone/Fax (1) 2205**]. Other previously scheduled appointment. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2106-8-11**] 10:00 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11366, 11372

6754, 10672

335, 372

11584, 11619

3661, 6246

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11393, 11460

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4,615

160,738

9820

Discharge summary

report

Admission Date: [**2200-6-25**] Discharge Date: [**2200-6-29**] Date of Birth: [**2126-9-17**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 73 year old male with a history of coronary artery disease and aortic stenosis who has had a jaw tightness with walking short distances. He has been followed by his cardiologist given his history of coronary artery disease and was discovered to have aortic stenosis. This aortic stenosis is followed by echocardiogram. The patient's coronary history is significant for percutaneous transluminal coronary angioplasty with stent to obtuse marginal one. This percutaneous transluminal coronary angioplasty was complicated by formation of a right femoral AV fistula and pseudoaneurysm which eventually required surgical repair. Cardiac catheterization in [**2196-12-7**], showed 80 percent in-stent restenosis of the obtuse marginal one which was treated with roto. Cardiac catheterization in [**2198-1-6**], showed 30 percent in-stent restenosis of obtuse marginal one. Also at that time, the patient was discovered to have a moderate to severe aortic stenosis with a mean gradient of 26 mmHg. Ejection fraction was 61 percent at the time. The patient was followed by echocardiogram and echocardiogram in [**2199-11-6**], showed progression of the aortic stenosis with a mean gradient at 64 mmHg. The aortic valve area was calculated to be 0.9 with preserved left ventricular function. Cardiac catheterization done [**2200-6-18**], showed a worsening of the aortic stenosis. Although the mean gradient was calculated to be 48 mmHg, the calculated valve area was 0.8 centimeter square. At this time, the coronary angiography showed the left main to be normal. The left anterior descending coronary artery showed mildly diffuse disease with discrete 40 to 50 percent midstenosis. The left circumflex had mild diffuse disease at 40 percent in-stent stenosis and right coronary artery had no angiographically significant obstruction. Left ventricular function was preserved at 65 percent with no regional wall motion abnormality. Given these findings, the patient was seen by cardiac surgery for surgical intervention. Based on the findings, the patient agreed to undergo aortic valve replacement and coronary artery bypass graft at the same time. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post percutaneous transluminal coronary angioplasty with multiple in-stent restenoses complicated by right femoral pseudoaneurysm requiring surgical repair, worsening aortic stenosis. 2. History of hypertension. 3. History of diabetes mellitus. 4. History of hypercholesterolemia. ALLERGIES: The patient denies any allergies to medications. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. once daily. 2. Lipitor 10 mg p.o. once daily. 3. Lisinopril 40 mg p.o. once daily. 4. Atenolol 50 mg p.o. once daily. 5. Glipizide 10 mg p.o. once daily. SOCIAL HISTORY: The patient denies any smoking and reports occasional alcohol use. REVIEW OF SYMPTOMS: Otherwise, review of systems is unremarkable. PHYSICAL EXAMINATION: The patient was afebrile with stable vital signs and not in apparent distress, awake, alert and oriented times three. The head examination was normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. Extraocular movements were intact. The neck was supple with evidence of cervical lymphadenopathy. There was no thyromegaly. There was thought to be carotid bruit appreciated. The lungs are clear to auscultation bilaterally . Cardiac examination showed regular rate and rhythm, S1 and S2, grade III/VI systolic ejection murmur appreciated. The abdomen was with bowel sounds, soft, nontender, nondistended, without hepatosplenomegaly. The extremities were without cyanosis, clubbing or edema. The pulses were two plus bilaterally at dorsalis pedis. LABORATORY DATA: Preoperative workup included carotid ultrasound which was consistent with a right sided 70 to 79 percent internal carotid artery stenosis with decreased velocity in the right vertebral artery. The left internal carotid artery showed less than 40 percent stenosis. HOSPITAL COURSE: The patient presented to the operating room on [**2200-6-25**], for aortic valve replacement with number 21 CE tissue and coronary artery bypass graft times one, left internal mammary artery to left anterior descending coronary artery. The patient underwent this surgery without any immediate complication. Please see the operative report for further details. The patient's postoperative course was rather uncomplicated. The patient was easily extubated on postoperative day zero. The patient was also to start on p.o. Lopressor by postoperative day one and by postoperative day number two, the patient was on the floor without any evidence of arrhythmia. The patient's chest tube and epicardial pacing wires were discontinued on postoperative day number two. The patient's p.o. Lopressor was increased until good heart rate control and blood pressure control was achieved. The patient's fingerstick levels were poorly controlled on preoperative Glucotrol doses and [**Last Name (un) **] consultation was called. The patient was evaluated by [**Last Name (un) **] team and was started on 20 units of Lantus at nighttime with coverage with sliding scale. The patient was also advised to take his Glucotrol 5 mg twice a day. On the day of discharge, the patient was afebrile with stable vital signs. The patient was awake, alert and oriented times three and not in apparent distress with supple neck. Cardiac examination revealed regular rate and rhythm, S1 and S2, systolic ejection grade II/VI. The lungs were clear to auscultation bilaterally . The abdomen was soft, nontender, nondistended. The sternum was clean, dry and intact and stable. The patient had bilateral lower extremity edema, mildly pitting to midtibial levels, and decreasing. A chest x-ray three days prior to discharge showed clear lung fields with no pleural effusion and no vascular congestion or pneumothorax. DISCHARGE STATUS: The patient was discharged home. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Severe aortic stenosis, status post aortic valve replacement with number 21 CE tissue and coronary artery bypass graft times one, left internal mammary artery to left anterior descending coronary artery. 3. Hypertension. 4. Hypercholesterolemia. 5. Diabetes mellitus type 2. MEDICATIONS ON DISCHARGE: 1. Lopressor 100 mg p.o. twice a day. 2. Aspirin enteric coated 325 mg p.o. once daily. 3. Lipitor 10 mg p.o. once daily. 4. Vicodin 500 mg p.o. q6hours p.r.n. pain. 5. Colace 100 mg p.o. twice a day. 6. Ibuprofen 600 mg p.o. q6hours. 7. Milk of Magnesia. 8. Lasix 20 mg p.o. twice a day for seven days. 9. Potassium Chloride 30 mEq p.o. twice a day for seven days. 10. Glipizide 5 mg p.o. twice a day. 11. Lantus 20 units q.h.s. 12. Humalog sliding scale as per directions. FOLLOW UP: The patient is to follow-up with Dr. [**Last Name (STitle) 3497**] (cardiology) in approximately two weeks and is to follow-up with Dr. [**Last Name (STitle) 70**] in approximately six weeks. The patient is to follow-up with [**Hospital **] Clinic as scheduled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) 12164**] MEDQUIST36 D: [**2200-6-29**] 10:41:28 T: [**2200-6-29**] 11:52:01 Job#: [**Job Number 33041**]

[ "401.9", "433.10", "V45.82", "250.82", "424.1", "414.01", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.72", "36.15", "36.11", "35.21" ]

icd9pcs

[ [ [] ] ]

6238, 6555

6581, 7073

2777, 2955

4233, 6185

7085, 7623

3131, 4215

165, 2340

2362, 2751

2972, 3108

6210, 6217

29,532

114,203

33826

Discharge summary

report

Admission Date: [**2199-3-5**] Discharge Date: [**2199-3-5**] Service: MEDICINE Allergies: Heparin Sodium Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old woman with hx of CAD s/p stenting, COPD (02 dependent), PAfib, recent DVT and multiple admissions for pneumonia since [**2198-11-27**] for shortness of breath presenting from nursing home with hypoxia. The patient was recently discharged from [**Hospital1 2025**] on [**2199-3-1**] following being admitted on [**2199-2-13**] for pneumonia. Prior to that she had been discharged to rehab on [**2199-2-6**] to complete a course of abx (which completed on [**2199-2-11**]). During that admission she was found to have a DVT. She was re-admitted to [**Hospital1 2025**] on [**2199-2-13**] with shortness of breath, weakness, and poor PO intake. She was found a low grade temp and had a chest xray that showed atelectasis and residual pneumonia. Her course was complicated by acute on chronic renal failure with Cr upto 2.5. A right PICC line was placed for access. On the evening of [**2199-3-4**] she was noted to be moaning. Vital signs at that thime were notable for T(tympanic) 99.3 HR 87 143/40 88%2L NC. She received nebs, tylenol, KCl (for hypokalemia), ativan, metoprolol, and isordil prior to transfer to the ED. Per the patient's daughter, the patient had not been coughing or choking on food recently but did have temporary swallowing difficulties during her most recent admission at [**Hospital1 2025**]. Also of note, the In the ED she was 100.3 96 116/41 22 95%NRB. She had a CXR that showed RLL infiltrate and RML collapse. She received vanc/zosyn. Per discussion with the patient she reversed her DNR/DNI status. She was admitted to the ICU. ROS: no weight loss. no pain. no chest pain. no abd pain. no dysuria. Constitutional: No(t) Weight loss Eyes: No(t) Blurry vision, No(t) Conjunctival edema Ear, Nose, Throat: No(t) Dry mouth, Epistaxis, No(t) OG / NG tube Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Orthopnea Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral nutrition Respiratory: No(t) Cough, No(t) Wheeze Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis, No(t) Diarrhea Genitourinary: No(t) Dysuria, No(t) Dialysis Musculoskeletal: No(t) Joint pain, No(t) Myalgias Integumentary (skin): No(t) Jaundice, No(t) Rash Heme / Lymph: No(t) Lymphadenopathy Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious, No(t) Daytime somnolence Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine Signs or concerns for abuse : No Pain: No pain / appears comfortable Past Medical History: COPD O2 dependent CAD s/p stenting x3 ~3 years ago Depression CHF with apical ballooning Hypothyroidism Chronic kidney disease (Cr baseline 1.5-2) Atrial fibrillation (PAF) Hx of GI bleeding DVT (found in early [**2199-1-26**]) Social History: Occupation: retired Drugs: unknown Tobacco: unknown Alcohol: unknown Other: per daughter has been in an out of hospitals and rehabs ever since [**2198-11-27**] with only a few days at home each time before being re-admitted Family History: unknown Physical Exam: Tmax: 37.7 ??????C (99.8 ??????F) Tcurrent: 37.7 ??????C (99.8 ??????F) HR: 83 (83 - 83) bpm BP: 133/47(69) {133/47(69) - 133/47(69)} mmHg RR: 17 (17 - 17) insp/min SpO2: 99% Heart rhythm: SR (Sinus Rhythm) General Appearance: No(t) No acute distress, No(t) Thin, No(t) Anxious, No(t) Diaphoretic Eyes / Conjunctiva: No(t) Pupils dilated, No(t) Sclera edema Head, Ears, Nose, Throat: No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube Lymphatic: No(t) Cervical adenopathy Cardiovascular: (S2: No(t) Distant, No(t) Loud, No(t) Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished). blue right [**11-29**] toe tips Respiratory / Chest: (Expansion: No(t) Paradoxical), (Percussion: No(t) Hyperresonant: , No(t) Dullness : ), (Breath Sounds: No(t) Clear : , Crackles : bibasilar, No(t) Bronchial: , No(t) Wheezes : , Diminished: right base, No(t) Absent : , No(t) Rhonchorous: ) Abdominal: No(t) Distended, No(t) Tender: Extremities: Right: 1+, Left: 1+, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand Skin: Warm, No(t) Rash: , No(t) Jaundice, sacral pressure ulcer Neurologic: Responds to: Not assessed, Oriented (to): self, hospital, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not assessed Pertinent Results: [**2199-3-4**] 10:45PM WBC-19.6* RBC-3.87* HGB-11.8* HCT-33.9* MCV-87 MCH-30.6 MCHC-35.0 RDW-15.4 [**2199-3-4**] 10:45PM PLT COUNT-155 [**2199-3-4**] 10:45PM PT-29.5* PTT-33.2 INR(PT)-3.0* [**2199-3-4**] 10:45PM GLUCOSE-151* UREA N-71* CREAT-2.0* SODIUM-134 POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-29 ANION GAP-18 [**2199-3-4**] 10:45PM ALT(SGPT)-29 AST(SGOT)-30 LD(LDH)-368* ALK PHOS-69 TOT BILI-1.1 CXR: [**2199-3-5**] 7am CXR - The study is markedly limited by patient rotation. The cardiac and mediastinal silhouettes are difficult to evaluate. The right mid and lower lung are somewhat obscured by overlying mediastinal structures due to rotation; there is right lower lobe atelectasis. In the visualized right upper lung and left lung, no consolidation is appreciated. There may be bilateral costophrenic angle blunting. A right-sided PICC line tip is not well visualized, but at least extends to the SVC. CHEST (PORTABLE AP) [**2199-3-5**] 2:37 PM Reason: eval for [**Hospital 78194**] [**Hospital 93**] MEDICAL CONDITION: 84 year old woman with pneumonia and probable RML collapse REASON FOR THIS EXAMINATION: eval for re-expansion TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: History of pneumonia and probably right middle lobe collapse. Evaluate for re-expansion. FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position and analysis is performed in direct comparison with a preceding similar study obtained approximately ten hours earlier. The on previous examinations ([**3-4**] and [**3-5**]) identified PICC line appears in unchanged position and terminates overlying the SVC at the level 1 cm below the carina. No pneumothorax or any other placement-related complication is noted. The accessible pulmonary vasculature does not show any congestive pattern. The previously described right-sided basal density terminating rather straight and probably related to the slightly downwards placed minor fissure, is unchanged and consistent with right middle lobe and probably also right lower lobe atelectasis. As on previous examinations, there is some suggestion of mild right-sided mediastinal shift in support of this diagnosis. There is a plate thin atelectasis on the left base but no evidence of pleural effusion. IMPRESSION: Persistent findings compatible with right lower lobe and middle lobe atelectasis. Cause unknown. Chest followup examination after airway exploration is recommended. Alternatively, a CT chest examination may clarify the cause of the abnormality. Telephone call delivered to referring physician. GENERAL URINE INFORMATION [**2199-3-5**] 02:00AM Type Color Appear Sp [**Last Name (un) **] Amber1 Clear 1.009 1 ABN COLOR [**Month (only) **] AFFECT DIPSTICK DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks NEG POS TR NEG NEG SM NEG 5.0 NEG MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp 0 0-2 OCC NONE 0 Brief Hospital Course: 84 year old woman with MMP including CAD s/p PCI, CHF, COPD, DVT, and multiple recent admissions for pneumonia presenting with worsening hypoxia and leukocytosis. 1) Hypoxia: Most likely related to pneumonia potentially from aspiration and complicated by lobar collapse. Have no comparison with prior imaging but likely current infitrates are not new but lobar collapse may be. Other possibilities are CHF, COPD exacerbation but these are less likely in the setting of low grade fever and elevated WBC#. Low probability for ACS presenting in this manner. Also with therapeutic anti-coagulation PE would be unlikely. Rapid improvement in oxygenation upon arrival to ICU would suggest plugging or fluid shifts present. - repeat CXR essentially unchanged - sputum culture, blood culture, urine legionella Ag - abx: vancomycin/ zosyn with azithromycin until legionella Ag negative - hold on steroids - continue home COPD treatments (nebs, spiriva) - chest PT - wean O2 as able - OOB as tolerated 2) CAD: low probability for ACS. - will continue beta-blocker, aspirin, statin 3) Atrial fibrillation: currently in sinus rhythm with normal rate and INR at goal. - hold coumadin dose tonight - continue metroprolol - for now switch diltazem to short acting 4) DVT- continue coumadin. Hold tonight??????s dose 5) Anemia ?????? given recent Hct was 38.6 now down to ~31% in the setting of prior GI bleeds and active anti-coagulation would be most concerned for acute blood loss. Currently not showing any sign of hemodynamic compromise. No RDW expansion or elevated bili to suggest hemolysis although LDH is elevated. - check Hct [**Hospital1 **] for now - guaiac all stools for now 6) Acute on Chronic renal failure: baseline Cr range from 1.5-2. likely etiology pre-renal from combination of CHF, fever, poor PO intake. No clear meds prior to admission to blame. Relatively low sp [**Last Name (un) **] on UA could suggest concentrating defect (i.e. tubular damage) - UA lytes, Uosm - Dose meds for GFR~20 - IVF - Aluminum hydroxide x3 days for phos management ICU Care Nutrition: NPO for now Glycemic Control: adequate for now Lines: right PICC and PIV Prophylaxis: DVT: anti-coagulated, pneumoboots Stress ulcer: continue home PPI Communication: Comments: daughter/HCP : [**Name (NI) 11705**] [**Name (NI) 4135**] (c) [**Telephone/Fax (1) 78195**] Code status: DNR/DNI confirmed with HCP Disposition: requested transfer to [**Hospital1 2025**] in process Medications on Admission: Torsemide 60 mg daily MVI with minerals daily Hydralazine 25 mg QID Metoprolol 37.5mg TID Diltizem CD 360 mg daily Cholecalciferol 800 units daily Colace 100 mg TID Fluticasone 220 mcg 2 puffs [**Hospital1 **] Atrovent Neb q6hours Levothyroxine 75 mcg daily Singulair 10 mg daily Prilosec 20 mg daily Miralax 17 g daily Salmeterol diskus 50 mcg [**Hospital1 **] Senna 8.6 mg 2 tabs daily Sertraline 25 mg daily Spiriva 1 cap daily Atorvastatin 10 mg daily Calcium Carbonate 1250 mg [**Hospital1 **] Albuterol NEB q4hrs PRN Coumadin 3 mg daily (goal INR 2.5-3.5) Roxanol 20 mg/mL 5 mg SL q8H: prn Nitroglycerin sL q5min x3 PRN Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Five (5) ML PO TID (3 times a day) for 3 days. 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. 17. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 18. Vancomycin 1000 mg IV Q48H HAP 19. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) as needed for HAP. Discharge Disposition: Extended Care Discharge Diagnosis: Pneumonia Discharge Condition: Fair Discharge Instructions: You were admitted with shortness of breath and findings on chest xray consistent with pneumonia. You were not found to have any evidence of heart attack. You were treated with antibiotics and at your request transferred to [**Hospital1 2025**]. Followup Instructions: Follow up with your primary care physician after hospital discharge

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12882, 12897

7900, 10575

235, 242

12951, 12958

4855, 5858

13253, 13324

3361, 3370

11253, 12859

5895, 5954

12918, 12930

10601, 11230

12982, 13230

3385, 4836

188, 197

5983, 7877

270, 2847

2869, 3099

3115, 3345

30,992

166,246

52831

Discharge summary

report

Admission Date: [**2164-5-14**] Discharge Date: [**2164-5-22**] Date of Birth: [**2102-12-13**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 562**] Chief Complaint: fall Major Surgical or Invasive Procedure: Trachestomy Endotracheal intubation and removal Dobhoff placement Central line placement and removal PICC line placement History of Present Illness: HPI: This is a 61 yo M with h/o alcoholic cardiomyopathy (EF 15%), EtOH abuse, CKD, DM II, and afib not on anticoagulation [**12-31**] falls who presents s/p fall with AMS, hypoxia, and hypotension requiring intubation and pressors. Per ED report, the pt fell on [**5-12**] with head trauma and ? LOC. He then called EMS on [**5-14**] as he felt "unwell" and was found in bed. HOSPITAL COURSE: He was brought to the ED, he was hypotensive and a femoral CVL was placed. Pressors were started and he was transferred to the MICU. He was started on Abx to cover aspiration PNA on [**5-14**]. He was found to have a C2 dens fracture in the ED and was placed in a C-collar. Ortho spine was consulted who recommended placement of a HALO. He was intubated on [**5-15**] for hypoxemic respiratory failure and subsequently had a trach placed on [**5-17**] due to his dens fracture and need for long-term ventilation with the HALO in place. Pressors were weaned off on [**5-16**]. He was continued on CTX/Levaquin/Flagyl to cover aspiration PNA. CTX was discontined on [**5-19**] and he was continued on [**Last Name (un) **]/Flagyl for coverage. His oxygen requirement decreased and he was placed on transtracheal oxygen on [**5-19**]. He was called out to the medical floor on [**5-21**]. On questioning, pt denies any pain. He is unable to speak due to trach in place, but is able to mouth words. Past Medical History: 1)EtoH abuse - no h/o variceal bleeds, no h/o cirrhosis - no h/o DTs or withdrawal seizures - does admit to hallucinations during withdrawal in past 2)hypothyroidism 3) cardiomyopathy - CHF EF 15% by [**7-1**] TTE - not on anticoagulation [**12-31**] falls 4)DM type II - not on meds 5)CRI 6)OA 7)hyperlipidemia 8)depression 9)gout 10)afib 11)hypospadias 12)h/o DVT [**2142**] - behind R knee, was on coumadin for a while 13)s/p laminectomy 14)h/o syncopal episodes in the past w/ neg holter monitor eval 15)? h/o amaurosis fugax 16)cholelithaisis w/o cholecystitis 17)anemia 18)atopic dermatitis Social History: Pt lives alone in an apartment in [**Location (un) 86**]. He has no close family or friends nearby. [**Name2 (NI) **] is a retired assistant for food and beverages at [**First Name9 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He worked there for 10-11 years but then retired and worked part time. He eventually left that when his cardiomyopathy became more symptomatic and he is currently on SSDI for this. He has a long smoking history (>30 pack years) but does not smoke now. He drinks 4 drinks (unable to quantify how much in each drink) about 4 times per week. This is the most that he states he has ever drunk. He denies any history of DTs, seizures, or withdrawal but does mention a history of hallucinations during withdrawal in the past. No other drug use. Family History: F died of Parkinson's and pneumonia in his 80s. M died of Alzheimer's and CAD in her 80s. Mother and MGM both had a history of breast cancer. PGM had a history of cervical cancer. He has one sister who was killed by a gunshot and he does not want to further elaborate on this. He denies having a wife or children. Physical Exam: VS: T98.0 BP98-119/69-81 HR60-70 RR 16 o2sat: 99-100% 40% Fi02 transtracheal 02 Gen: Suspended in HALO. NAD, comfortable. Not able to speak due to trach in place, but appears comfortable. HEENT: HALO in place. Pupils reactive. Dobhoff in place Neck: Unable to palpate. Lungs: +anterior rhonchi Heart: RRR. No m/r/g Abd: Soft. NTND. +BS. Extrem: No peripheral edema. Pertinent Results: [**2164-5-21**] 03:48AM BLOOD WBC-4.3 RBC-2.81* Hgb-9.0* Hct-29.1* MCV-104* MCH-32.2* MCHC-31.0 RDW-19.2* Plt Ct-99* [**2164-5-21**] 03:48AM BLOOD Glucose-98 UreaN-32* Creat-1.2 Na-138 K-4.8 Cl-112* HCO3-19* AnGap-12 [**2164-5-16**] 04:30AM BLOOD ALT-82* AST-277* LD(LDH)-263* AlkPhos-174* TotBili-0.7 Imaging: CXR [**5-19**]: Feeding tube terminates below the diaphragm with the tip not included on the radiograph. A left PICC line has changed in position, with the tip now directed cephalad at level of the azygos vein contour. This may either be entering the azygous vein or it may be directed superiorly within the right brachiocephalic vein. This finding has been communicated by telephone to Dr. [**Last Name (STitle) 108957**] on [**2164-5-19**]. The exam is otherwise remarkable for slight worsening of pulmonary edema with otherwise no substantial change since the recent study. TTE [**5-15**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1914**]. RA mod dilated. LV EF 20%. Sig dyssynchrony present (inf wall >230msec after ant wall). Consider resychonrization therapy. RV size nml. AV nml. 2+ MR. 2+ TR. Mod PA sHTN. CT C-Spine [**5-14**]: 1. Acute Type II odontoid fracture with 3-4 mm of apicoposterior distraction of the dental fracture fragment, relative to the [**Name (NI) 12952**] body. No visible impingement on the thecal sac at this level. Extensive prevertebral soft tissue swelling. This fracture is unstable. 2. Stable bony fusion at C5-C7, with unchanged disc herniation. CT Torso [**5-14**]: 1. Pulmonary edema, with large right and small left pleural effusions and associated atelectasis due to heart failure. 2. Diffuse anasarca, perihepatic ascites, periportal edema, gallbladder wall and bowel wall thickening, all likely secondary to right heart failure and/or chronic liver disease, which should be correlated with clinical data. 3. No acute fractures. Old fracture of posterior right 11th rib. Severe degenerative changes in the lower lumbar spine. 4. No evidence of trauma to the chest, abdomen, or pelvis. Brief Hospital Course: ASSESSMENT AND PLAN: 61 yo M with h/o EtOh abuse, alcoholic cardiomyopathy (EF 15%), DM II, CRI, admitted to the MICU s/p fall with C2 dens fracture s/p HALO placement, aspiration PNA and respiratory failure s/p intubation converted to tracheostomy, now awaiting rehab placement. 1) Respiratory Failure now improved Admitted with severe aspiration PNA s/p intubation. Converted to tracheostomy [**5-17**] given dens fracture and concern for ventilation. On Levaquin/Flagyl day [**7-12**] for treatment. Sputum growing non-fermenter GNR, likely Acinetobacter. Needs to complete 14 day course of Abx - 1 week of Abx remains on day of discharge. Please continue to wean down oxygen as needed and cap trach as tolerated. Please provide Passy-Muir valve when no longer requires o2 prior to removal of trach. 2. Dens fracture: HALO placed by Ortho [**5-15**]. Patient will need repeat surgery in future for definitive treatment of dens fracture. Per ortho, requires several months of attempt at HALO-vest to heal fracture given his high surgical risk. Please contact Dr. [**Last Name (STitle) 363**] at ([**Telephone/Fax (1) 11061**] to schedule a follow up appointment. Her HALO must be maintained at all times. Please move to chair as tolerated and rehab as necessary. Please continue pain medication as needed. 3. ARF - Improved with IVF. Likely prerenal azotemia. Resolved on discharge. 4. Transaminitis Due to alcoholic liver disease. No need for further w/u 5. EtOH CM EF with 15-20%. Currently euvolemic. Diuretics held during ICU stay given hypotension. ACE restarted and tolerating well. 6. Afib Not anti-coagulated due to hx of recurrent falls and recent dens fracture. Cont amiodarone and digoxin for rate control. No anticoagulation given recent dens fracture. 7) H/o EtOH abuse No clear h/o DTs, but has been admitted in the past for EtOH withdrawal. Unclear when last drink was. Cont thiamine, folate, MVI. 8) DM II - HgbA1c 4.8 in [**5-6**]. Not on oral hypoglycemics or insulin. Monitor FS as needed. 9) Thrombocytopenia Stable. Likely due to baseline liver disease 10) Anemia Stable with baseline Hct at 29-32. # FEN: Dobhoff placed in ICU. Cont TFs - currently on Probalance Full Strength at goal 60ml/hr with residual check q4h. Flush w/ 150 mL water q6h. # Ppx - H2 blocker, Hep SC tid, bowel regimen # Access: PIV # Code - presumed full # Communication - next of [**Doctor First Name **] is [**Name (NI) 547**] [**Name (NI) **] (niece) [**Telephone/Fax (1) 108958**] (after 4pm), cell [**Telephone/Fax (1) 108959**], work [**Telephone/Fax (2) 108960**]. # Dispo - call out to medical floor; begin process for rehab placement Medications on Admission: Folic Acid 1 mg daily Thiamine 100 mg dialy Lisinopril 10 mg daily Amiodarone 200 gm daily Digoxin 0.125 mcg qod Levothyroxine 250 mcg daily Fluoxetine 10 mg daily Allopurinol 200 mg daily Colchicine 0.6 mg daily MVI daily MgOxide 400 mg daily Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: C2 Dens Fracture s/p HALO Aspiration PNA s/p intubation and tracheostomy Acute renal failure now improved Transaminitis Secondary Diagnosis: Alcoholic Cardiomyopathy EF 15% Atrial Fibrillation Diabetes Thrombocytopenia Anemia Discharge Condition: Stable for discharge to rehab Discharge Instructions: You were admitted after a fall and found to have a C2 dens fracture for which you were placed in a HALO. You had a tracheostomy placed given your severe aspiration pneumonia and the difficulty intubating your airway. You were started on a course of antibiotics to treat your aspiration pneumonia. Please take medications as instructed below. If you develop worsening shortness of breath, chest pain, fever >101, please contact your rehab doctor or report to the nearest ER. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 9625**] after you are discharged from rehab - call ([**Telephone/Fax (1) 14902**]. Please call Dr.[**Name (NI) 12040**] office at ([**Telephone/Fax (1) 11061**] to schedule Completed by:[**2164-5-23**]

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icd9cm

[ [ [] ] ]

[ "31.1", "96.55", "96.04", "38.93", "96.6", "88.72", "96.72", "02.94", "33.23" ]

icd9pcs

[ [ [] ] ]

9039, 9105

6077, 8744

273, 395

9395, 9427

3996, 6054

9953, 10206

3278, 3593

9126, 9126

8770, 9016

818, 1815

9451, 9930

3609, 3977

229, 235

423, 801

9287, 9374

9145, 9266

1837, 2437

2453, 3262

62,650

131,608

30444

Discharge summary

report

Admission Date: [**2124-8-24**] Discharge Date: [**2124-9-8**] Date of Birth: [**2048-12-10**] Sex: M Service: MEDICINE Allergies: Aspirin / Zantac / Ciprofloxacin / Taxol / Oxycodone Attending:[**First Name3 (LF) 4616**] Chief Complaint: T4-5 Lesion Major Surgical or Invasive Procedure: T4-T5 corpectomy/cage, T3-6 lami,post instrumented fusion T2-T7, iliac crest bone harvest History of Present Illness: Patient is a 75M electively admitted on [**8-24**] for planned thoracic fusion and resection of vertebral body lesion. Patient has stage IV NSLC with brain and spinal mets underwent T4-T5 corpectomy/cage, T3-6 laminectomy, post instrumentation and fusion T2-T7 on [**2124-8-24**]. Post procedure course was complicated by AFRVR and transient hypotension. Patient was called out of the SICU on [**2124-8-30**] to step down unit. . He continued to be in atrial fibrillation. He was treated initially with Zosyn which was switched to cefepime per ID recs for a hospital acquired pneumonia. The patient was then found to be diaphoretic and unresponsive at 2 AM. His FS was found to 24. He had received glyburide while NPO peri-procedure. His BP was 124/62, HR 85, T 92.7. He recieved [**2-18**] amp of Dextrose and his BS increased to 175. Patient was also placed on a bear hugger. His temp eventually recovered early morning and has been normal since. Patient currently denies chest pain, shortness of breath, abdominal pain, N/V/D, dysuria, [**Month/Day (2) **], chills, nightsweats, headache, focal weakness, numbness, change in vision or hearing. His wife was present during the presentation and helped with history as the patient was delerious. She states that patient has had similar confusion symptoms during past hospitalization which resolves with discharge and going back home. Past Medical History: Atrial fibrillation Hypertension Prostate cancer in [**2120**] treated with resection and radiation Benign parotid tumor resected in [**2115**] Bladder diverticula requiring resection Nasal polyps Inguinal hernia Social History: Heavy smoking until quit in [**2097**], occasional alcohol, no drug use. Good family support-wife. [**Name (NI) **] children. Family History: Both parents with lung cancer, father with brain tumor as well. Physical Exam: VS: T 97.4 HR 90 Afib 91 BP 120/62 RR 20 100% on 6LNC Gen: NAD. Pleasant gentleman, delerious. Oriented to only self. Able to follow commands. HEENT: NCAT. Sclera anicteric. PERRL. OP clear, no exudates or ulceration. Neck: Supple, JVP difficult to assess. CV: S1S2 irreg irreg, II/VI mid peaking systolic murmur at best at b/l sternal border Chest: Resp were unlabored, no accessory muscle use. diminished BS in b/l bases (anteriorly) Abd: Soft, NTND. Ext: No c/c/edema. Neuro: CN III-[**Doctor First Name 81**] intact, strength 5/5 b/l Pertinent Results: Labs on Admission: [**2124-8-24**] 09:20PM BLOOD WBC-11.9* RBC-3.91* Hgb-11.2* Hct-33.9* MCV-87 MCH-28.5 MCHC-32.9 RDW-15.8* Plt Ct-307 [**2124-8-24**] 07:00PM BLOOD PT-14.5* PTT-26.9 INR(PT)-1.3* [**2124-8-24**] 07:00PM BLOOD Fibrino-416* [**2124-8-24**] 09:20PM BLOOD Glucose-192* UreaN-19 Creat-0.8 Na-137 K-5.1 Cl-104 HCO3-24 AnGap-14 [**2124-8-24**] 09:20PM BLOOD Calcium-8.4 Phos-3.3 Mg-1.6 Imaging: CT T-Spine [**8-24**]: FINDINGS: Again seen is a compression fracture of the T5 vertebral body. Again seen is a small amount of retropulsed bone that encroaches on the spinal canal and indents the spinal cord. The posterior margin of the vertebral body is fractured, and this fracture extends into the pedicles bilaterally. The facet joints appear intact. There is a small vacuum phenomenon anteriorly in the vertebral body, and tiny vacuum phenomenon in the T4-5 and T5-6 intervertebral discs. Images of the remaining vertebral bodies included in this study demonstrate osteoporosis, but no evidence of fracture. CONCLUSION: T5 compression fracture with kyphotic angulation and bone retropulsed into the spinal canal compressing the spinal cord. CT T-spine [**8-24**]: FINDINGS: The patient is status post recent posterior fusion of T2 to T7 with placement of posterior fusion construct and bony fusion material, and intervertebral cage placement at T4-T5, and extensive post-surgical changes in the region. There is marked metallic streak artifact, significantly limiting the evaluation of the spinal canal. There is subcutaneous emphysema, post- surgical. At T2 level, there is tiny hyperdense focus within the spinal canal (2:[**12-28**]), which could relate to the streak artifact; however, hemorrhage cannot be excluded. There are NG and ET tubes in situ. Right lower lobe consolidation and effusion, incompletely imaged, and underlying emphysema are similar in overall appearance to the recent study. IMPRESSION: Immediately status post posterior fusion, from the T2 to T7 level, with T4-T5 partial corpectomy and intervertebral cage placement, and significant streak artifact limiting evaluation for epidural hemorrhage, with: 1. Focal hyperdensity in the right posterolateral aspect of the spinal canal, at about the level of T2, likely relates to the streak artifact; however, hemorrhage is difficult to exclude entirely. 2. No residual retropulsed bony fragment in the spinal canal. 3. Other than expected surgical result, no acute change in alignment. 4. The tips of the right-sided transpediculate screws, at the T3 and T6 levels transgress the anterior vertebral cortex. LENIS [**8-29**]: FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] were performed of the bilateral common femoral, superficial femoral, and popliteal veins. These demonstrate normal flow, compressibility and augmentation. IMPRESSION: No evidence of DVT. CTA of Chest [**8-29**]: CT OF THE CHEST WITH IV CONTRAST: There are no filling defects within the pulmonary arterial vasculature. There is evidence of prior right lower lobe lobectomy including shift of the mediastinal structures to the right with right lung volume loss and right upper lobe expansion. There is less than expected enhancement of the inferior right upper lobe concerning for consolidation (3:74). A moderate right pleural effusion has increased in size compared to the [**2124-7-25**] PET CT. Circumferential thickening of the pleural surface, particularly at the right lung base, likely reflects chronic pleural effusion. There is evidence of advanced metastatic disease including an irregular area of nodular pleural thickening seen at the right lung apex posteriorly abutting lytic destruction of an adjacent thoracic vertebral body status post posterior fixation (3:32). Multiple abnormal lymph nodes evident within the lower posterior mediastinum with the largest measuring 1.9 x 1.87 mm (3:100). There are a few solid-appearing mediastinal lymph nodes, however, none meet criteria for pathology by CT. Extensive emphysematous changes, most evident in the hyperexpanded right upper lobe and right middle lobe are evident. Multiple soft tissue metastatic nodules within the left upper and lower lobes have increased in size compared to the PET CT of [**2124-7-25**] concerning for disease progression. For example, soft tissue nodule abutting the major fissure measures 1.5 x 1.5 cm, previously 1.1 x 1.1 cm (3:58). There is a small left pleural effusion with associated atelectasis. The imaged portions of the upper abdomen demonstrate prominence of both adrenal glands better assessed by recent PET CT. Patient is status post posterior fusion of multiple upper thoracic vertebral bodies and introduction of inner body spacers. There is no CT evidence of hardware loosening. No new lytic osseous metastases are present. IMPRESSION: 1. No pulmonary embolism. 2. Right upper lobe pneumonia, most evident at the right lung base. 3. Worsening widespread thoracic metastatic disease compared to the PET CT of [**2124-7-25**]. 4. Chronic moderate right pleural effusion with smaller left pleural effusion, increased in size compared to the PET CT. Surface Echo [**8-30**]: The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2122-12-4**], the estimated pulmonary artery systolic pressure is higher and the severity of aortic stenosis has progressed. Biventricular systolic function is similar. CLINICAL IMPLICATIONS: The patient has moderate aortic stenosis. Based on [**2121**] ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, a follow-up echocardiogram is suggested in [**2-18**] years. MICROBIOLOGY: [**2124-9-2**] 12:11 pm SWAB Source: left upper back lesion. **FINAL REPORT [**2124-9-6**]** GRAM STAIN (Final [**2124-9-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2124-9-6**]): 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.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2124-9-6**]): NO ANAEROBES ISOLATED. [**2124-9-1**] 3:00 am BLOOD CULTURE **FINAL REPORT [**2124-9-7**]** Blood Culture, Routine (Final [**2124-9-7**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2124-9-2**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 4322**] @ 1440, [**2124-9-2**]. GRAM POSITIVE COCCI IN CLUSTERS. LABS DAY PRIOR TO DISCHARGE: 140 99 17 ===========< 132 3.7 33 1.0 Ca: 8.5 Mg: 2.2 P: 3.1 12.3 > 8.3 / 26.8 < 520 PT: 14.2 PTT: 28.4 INR: 1.2 Brief Hospital Course: 1. Metestatic NSCL: Patient underwent T4-T5 corpectomy/cage, T3-6 laminectomy, post instrumentation and fusion T2-T7 on [**2124-8-24**]. Post procedure course was complicated by AFRVR and transient hypotension, severe hypoglycemic course and RUL PNA on cefepime. Details of the post-op course are provided below. The patient needs PT/OT and ultimately rehab when stable clinically. He has staples/sutures in place which may be removed in follow up with neurosurgery shortly after discharge. He may bear weight but must not lift more than 10 pounds. 2. Altered Mental Status: after transfer to the floor patient developed an altered mental status with concern for seizures, brain mets, hypercapnia. At transfer he was only oriented to person which apparently wasn't far from baseline. Wife did not routine check his oreintation at home but confirmed that he was often confused and usually can't remember things from earlier in the day. At transfer he was pleasant and conversant but had no idea where he was or what month it was, and was at the same level of orientation on Sunday morning. If mental status declines would consider hypoglycemia, infection, medications, brain mets, and delirum as likely causes. B12 high, Folate and TSH both WNL. Wife confirms significantly different from baseline. Concern for myoclonus (right arm), NPH. Head MRI [**9-6**] showed vasogenic edema, slightly worse, but no new mets. It was agreed not to start to Keprra at this time. Thiamine was started. An EEG was performed, the results of which were pending at the time of discharge. 3. Dyspnea/Pulmonary/Hypercapnia: Patient had a new increased oxygen requirement after surgery, which was most likely secondary to a RUL pneumonia on top of progressive metastatic lung disease. He required 6L O2 at first, which gradually decreased to 3L. Prior to admission he was 95% on room air. No evidence of PE on CTA [**2124-8-29**], and repeated CXRs showed an evolving PNA on top of underlying neoplastic disease. The patient remained afebrile. For his pneumonia he was started on broad coverage with Cefepime, Vancomycin with concern for hospital acquired pneumonia. Towards the end of his hospitalization there was some concern over hypercapnia given the patient's mental status changes. Blood gases showed CO2 retention with a mixed acid-base disorder. Pulmonary was consulted and the patient was started on NPPV to improve ventilation (BiPAP 12/5) a 3-day course of acetazolamide and albuterol/atrovent nebs. The patient did not tolerate biPAP well, however his HCO3 consistently trended downwards in the final days of his hospitalization. 4. Bacteremia: two weeks into his admission the patient developed acute mental status changes and hypotension concerning for sepsis. He was started on broad coverage including Cefepime and Vancomycin with concern for pneumonia. Blood cultures from [**9-1**] eventually grew out coagulase negative staphylococcus in [**3-22**] bottles, likely a contaminant. Coverage was eventually narrowed to Cefepime for coverage of pneumonia, which was changed to Cefpodoxime upon discharge, for a total of 10 days of antibiotics. 5. DMII: Patient had a hypoglycemic episode shortly after surgery. Endocrinology was consulted for assistance with management of the patient's blood sugar control including the use of insulin and hypoglycemic medications. He was discharged on 5mg glyburide every morning and 2.5mg glyburide every evening. 6. Anemia: The patient has had chronic anemia. During his admission he had a brief episode of frank hematuria after attempting to remove his own catheter. Urology was consulted and a 2-way catheter was placed. A total of approximately 500cc of blood was lost. The patient's hematocrit remained stable but anemic, in the range of 25-28%. Prior to discharge he was given 1 unit PCBCs. 7. Atrial Fibrillation: Patient has a history of chronic AF rate controlled on Metoprolol and Verapamil. Shortly after surgery the patient went into AF with RVR and susequently became tachypnic, likely multifactorial in etiology, including post-operative state, metastatic NSLC and possible PNA. Anticoagulation was originally held due to brain metasteses but was restarted on Lovenox after surgery. Discharge Lovenox dose is 80mg every 24 fhours. Medications on Admission: DOXAZOSIN 4 mg',ENOXAPARIN,FLOVENT 2puffs',GLYBURIDE'',METOPROLOL 50'', Percocet,VERAPAMIL 120',Colace',senna',MVI' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for [**Date Range **], pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Glyburide 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 11. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation Q4H (every 4 hours). 14. Verapamil 40 mg Tablet Sig: 2.5 Tablets PO Q8H (every 8 hours). 15. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 16. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 19. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 20. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-18**] puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 22. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: PRIMARY: 1. NSCLC with brain/spine mets 2. PNA 3. Bacteremia 4. OSA SECONDARY: 1. DM-II 2. HTN 3. Atrial Fibrillation Discharge Condition: Neurologically Stable, stable Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? [**Location (un) **] greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in [**8-25**] days (from date of surgery) for removal of your staples/sutures and a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 6 weeks. ??????You will not need x-rays/CT-scan prior to your appointment, as this was done during your acute hospitalization.

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icd9cm

[ [ [] ] ]

[ "81.05", "57.94", "81.63", "03.53", "57.32", "77.79", "99.04", "84.51", "80.99" ]

icd9pcs

[ [ [] ] ]

17013, 17085

10535, 11096

325, 417

17248, 17280

2870, 2875

18781, 19430

2230, 2296

14984, 16990

17106, 17227

14844, 14961

17304, 18758

2311, 2851

9000, 10512

274, 287

445, 1832

2889, 8977

11111, 14818

1854, 2069

2085, 2214

885

197,189

1900

Discharge summary

report

Admission Date: [**2162-12-5**] Discharge Date: [**2162-12-8**] Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 425**] Chief Complaint: tachycardia Major Surgical or Invasive Procedure: cardioversion History of Present Illness: 84 year old female with history of atrial flutter, CAD s/p CABG [**2159**], HTN presents with asymptomatic tachycardia. Patient was previously discharged from hospital on [**2162-12-1**] after being admitted on [**11-29**] for asymptomatic tachycardia. Patient was noted to be in atrial flutter on previous admission that converted back to sinus with fluid administration alone. During her previous admission, patient was seen and evaluted by EP who reccomending continuing current management without change in medications. Please see previous discharge summary for furthur discharge info. It appears that 2 days after discharge patient was back in atrial flutter (ie since [**Month/Day (1) 2974**]) looking at ob/gyn note in OMR with HRs in 140s. Patient has regular VNA services at home, and this morning VNA thought that the patient was in afib with heart rate in the 140s. At that time patient with stable BP 112/70. As per VNA patient is patient was completely asymptomatic, afebrile, without chest pain or shortness of breath. Non specific ECG changes. . Patient was transported to our ED for further eval. On arrival to ED her vitals were T 97.1 BP 129/70 HR 143 RR 18 98% RA. Patient was in atrial flutter. Cardiology was consulted. Patient was given IV diltiazem 10 mg x 2 and IV metoprolol 5 mg x 2 per verbal ED signout. Patient then dropped her pressures to 88/46 with no change in heart rate and was given total of 3 liters of NS boluses per ED verbal signout. . On arrival to MICU her symptoms were T 96.9 HR 140s BP 109/73 RR 15 99% RA. Patient denies any fever, chills, nightsweats, cough, cold, chest pain, shortness of breath, PND, orhtopnea, abdominal pain, dysuria, hematuria, blood in stool or urine, weakness, numbness. Her diarrhea has resolved. Stable chronic back pain. No other complaints. Past Medical History: atrial flutter s/p DC cardioversion in [**6-/2162**], flutter ablation CAD s/p CABG x 4 [**2162-7-25**] (LIMA->LAD, SVG->DM2, SVG->OM1, SVG->PDA) CAD, s/p prior MI Hypertension Hyperlipidemia DJD, right knee PUD (healing pre-pyloric ulcer on EGD [**2161-12-1**]) sigmoid diverticulosis Anemia Peripheral neuropathy Chronic lower back pain Cystocele complicated by mixed incontinence Thallasemia Chronic venous insuffiency DUB DJD, right knee. s/p cataract surgery left eye s/p excision of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst, right knee Social History: Widowed. Has 2 children living nearby. Previous smoker, but quit many years ago. Occasional alcohol. Family History: Positive for diabetes in her sister and CAD in her brother. Physical Exam: VITAL SIGNS: T 96.9 HR 140s BP 109/73 RR 15 99% RA. GENERAL APPEARANCE: Elderly woman in no distress. Pleasant, following commands, able to give history. HEENT: MMM NECK: JVP 8 cm. LUNGS: fine crackles at right > left lung bases. HEART: irregularly irregular, normal S1 and S2, tachycardic ABDOMEN: +BS, Soft, NTND. EXTREMITIES: trace edema in BLE. Pertinent Results: LABS ON ADMISSION: . HEMATOLOGY: [**2162-12-5**] 02:30PM BLOOD WBC-8.4 RBC-5.41* Hgb-10.9* Hct-35.4* MCV-65* MCH-20.1* MCHC-30.7* RDW-16.2* Plt Ct-283 [**2162-12-5**] 02:30PM BLOOD Neuts-59.3 Lymphs-29.2 Monos-7.3 Eos-3.9 Baso-0.4 [**2162-12-5**] 02:30PM BLOOD PT-22.0* PTT-26.1 INR(PT)-2.1* . CHEMISTRY: [**2162-12-5**] 02:30PM BLOOD Glucose-120* UreaN-23* Creat-1.2* Na-141 K-4.4 Cl-101 HCO3-29 AnGap-15 [**2162-12-6**] 06:19AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0 [**2162-12-5**] 02:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2162-12-5**] 02:30PM BLOOD CK(CPK)-74 . EKG [**2162-12-5**] Narrow complex supraventricular tachycardia, most likely A-V nodal re-entrant tachycardia. Compared to the previous tracing of [**2162-12-1**] supraventricular tachycardia is new. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 143 0 76 326/471 0 16 128 . [**2162-12-7**] CXR Since [**2162-12-5**], mild interstitial edema is new. Prior sternotomy for CABG was performed. There is no significant pleural effusion. Heart size is top normal. The aorta is tortuous and calcified. There is no focal area of consolidation. Minimal indentation on the right tracheal wall could be due to a thyroid nodule, should be evaluated by [**Year (4 digits) 950**] if not already known. . [**2162-12-5**] CXR PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The patient is rotated to the left which limits evaluation of the heart size. The aorta is tortuous and calcified. The hilar contours are unremarkable. There are low lung volumes bilaterally. Small amount of left pleural effusion is noted. IMPRESSION: Limited study, but no acute intrathoracic pathology. Brief Hospital Course: 84F w CAD (s/p CABG), a-fib and a-flutter (s/p DCCV and cavotrunkal isthmus ablation), admitted with asymptomatic tachycardia after discharge on [**2162-12-1**] for same issue. . # RHYTHM - Patient with a history of atrial flutter s/p DC cardioversion in [**6-/2162**], and subsequent empirical CTI ablation in the setting of noninducible SVT. She was in atrial flutter with HR 140s on admission, therapeutically anticoagulated. Coumadin was held and heparin gtt started. EP saw her and recommended cardioversion. She had been therapeutic on her Coumadin for the past 8 weeks. Cardioversion was successful after one 200 J shock. She was subsequently hemodynamically stable with wandering atrial pacemaker in the 80s. Amiodarone was started at 200mg TID, and Coumadin was restarted at 1mg (half home dose because of known interaction with amiodarone). She will need outpatient PFTs for baseline on amiodarone as well as regular INR checks / Coumadin dose adjustments. Her amiodarone will be TID for 5 days, then [**Hospital1 **] for 14 days, then once a day. . # CORONARIES - patient with a history of CAD s/p CABGx4 in [**2159**]. No acute issues. Pt discharged on aspirin 81mg daily, ToprolXL 150mg daily. Enalapril reduced to 5mg PO daily due to increased creatinine. Simvastatin switched to pravastatin 80mg daily due to interaction with amiodarone. . # PUMP ?????? She had chronic systolic congestive heart failure (LVEF=30-35% on TTE in 8/[**2161**]). She initially appeared euvolemic. After receiving 3 L of fluid in the ED, she developed acute respiratory distress several hours after her cardioversion. BP was elevated to 200/120, she was transferred back to the CCU overnight. Shortness of breath improved with IV Lasix, and she was thought to have had flash pulmonary edema. Pt's symptoms resolved and she was restarted on home medications and sent back to the regular cardiology floor. . # ACUTE RENAL FAILURE - Cr on admission was 1.2, up from baseline of 0.9-1.0, likely pre-renal from recent diarrhea and poor forward flow from heart failure. ACE inhibitor was held, then restarted on a lower dose (enalapril 5mg daily). . # Thalassemia - Low MCV and normal serum iron level were consistent with a known diagnosis of thalassemia. Hematocrit on admission was 35 which is relatively stable. . # Hyperlipidemia - Discharged on pravastatin. . # Thyroid nodule- seen on CXR, needs follow up [**Year (4 digits) 950**] as out pt. TSH was 1.7 at baseline before starting amiodarone. . Pt will be discharged home with VNA. Cardiology and PCP follow up are planned, as well as a thyroid [**Year (4 digits) 950**] and PFTs. Her PCP will be following her INR. Medications on Admission: Warfarin 2 mg daily Aspirin 81 mg Tablet daily Metoprolol Succinate 150 mg daily Enalapril Maleate 10 mg Tablet daily Simvastatin 80 mg daily Furosemide 40 mg daily Gabapentin 300 mg daily Lidocaine 5 %(700 mg/patch) [**11-26**] patch daily Omeprazole EC 20 mg Capsule daily Nitroglycerin 0.3 mg SL prn Lorazepam 0.5 mg qhs prn for insomnia Calcium-Cholecalciferol (D3) 500 (1,250)-200 mg-unit [**Hospital1 **] Estradiol 0.01 % (0.1 mg/g) Cream Vaginal Multivitamin daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 5. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO as directed: take one pill three times a day through [**2161-12-9**], then take one pill twice a day for 2 weeks, then take one pill once a day. Disp:*51 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**11-26**] Adhesive Patch, Medicateds Topical DAILY (Daily). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: atrial flutter . coronary artery disease hypertension hyperlipidemia Discharge Condition: hemodynamically stable Discharge Instructions: You were admitted to the hospital with asymptomatic tachycardia (heart rate into 140's). You were found to have an arrhythmia called atrial flutter. You were treated with cardioversion. . You should follow up with your physicians as detailed below. You should have your INR checked regularly. You should have your lung function tested and have your thyroid function followed while on amiodarone. . We changed your medications as follows: 1. started amiodarone, the dose will be three times a day through [**2161-12-9**], then twice a day for 2 weeks, then once a day there after 2. changed simvastatin 80mg daily to pravastatin 80mg daily due to interactions w amiodarone 3. decreased your warfarin to 1mg po daily . If you have chest pain, shortness of breath, lightheadedness, dizziness or any other concerns, please call your physician [**Name Initial (PRE) 2227**]. Followup Instructions: You will be contact[**Name (NI) **] for outpatient pulmonary function tests for baseline levels on amiodarone therapy. . Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-12-22**] 1:45 Thyroid [**Month/Day/Year 950**] to eval for nodule. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2162-12-10**] 11:15 . Provider: [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern4) 10591**], MD Phone:[**Telephone/Fax (1) 10590**] Date/Time:[**2162-12-21**] 11:30 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD Phone:[**Telephone/Fax (1) 5068**] Date/Time:[**2162-12-23**] 3:30 @ [**Location (un) **] Completed by:[**2162-12-8**]

[ "459.81", "427.31", "272.4", "356.9", "401.9", "427.32", "428.0", "584.9", "V45.81", "282.49", "428.23" ]

icd9cm

[ [ [] ] ]

[ "99.62" ]

icd9pcs

[ [ [] ] ]

9582, 9639

5021, 7690

226, 242

9752, 9777

3265, 3270

10695, 11495

2819, 2880

8213, 9559

9660, 9731

7716, 8190

9801, 10672

2895, 3246

175, 188

270, 2088

3284, 4998

2110, 2684

2700, 2803

26,274

177,253

43139

Discharge summary

report

Admission Date: [**2135-1-18**] Discharge Date: [**2135-1-24**] Date of Birth: [**2083-1-21**] Sex: F Service: MEDICINE Allergies: Betadine / Nitroglycerin Transdermal / Gabapentin / Cilostazol / Colestipol Attending:[**First Name3 (LF) 3624**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: TUNNELED LEFT FEMORAL LINE PLACEMENT History of Present Illness: 51 year old female with history of Insulin dependent DM s/p Kidney Transplant x3, Pancreas transplant x2, orthostatic hypotension, CIDP on IVIG, severe PVD with tunneled femoral line presented via EMS after calling out for help to the janitor in her building who then called 911. The patient had been in her usual state of health (per the husband) although complained of some sinus congestion over the past few weeks. She does not remember the events today other then calling for help. When EMS arrived she was mentating fine but hypotensive to 90s, HR 150s and fever 100.3. On arrival to ED has had normal mental status but moaning, rigoring and uncomfortable. Vitals on admission to ED were T100.3 HR 136 BP 127/85 RR 21 98%RA. Labs notable for WBC 3.6, Lactate 3.0 CK 18. She received 3L IVF, Imipenem; and 125mg Methylprednisolone. CT abdomen/pelvis negative, CT Head/neck notable for maxillary sinusitis, renal transplant ultrasound neg, U/A negative, blood cultures were sent. . After fluid rescucitation pts BP improved initially to SBP 130s but drifted back to 110s; HR improved from 150->109 O2 sat 97%RA. She was subsequently admitted to the MICU for further management. . Currently, the patient [**First Name3 (LF) **] any pain. She does not remember any of the events that occured today. She [**First Name3 (LF) **] any lightheadedness, palpitations prior to the event. She does report sinus congestion which has required use of nasal steroids over past few days. She reports purulent drainage from ostomy that has been seen by her ostomy nurse. [**First Name (Titles) 4273**] [**Last Name (Titles) 5162**]/chills. She [**Last Name (Titles) **] any CP, SOB, abdominal pain, urinary frequency, does report large volume stools unchanged from the past few months. Reports normal appetite. Past Medical History: PMH: DM1 w triopathy ESRD legally Blind HTN hyperlipdemia CAD asthma VRE left hip fx [**12-30**], s/p closed reduction hx of herpes zoster - treated b/l dysplastic knee hx of pneumonia hx of toxic megacolon chronic inflammatory demylinating polyneuropathy seizures [**2132-8-5**] on Keppra osteoporosis PSH: s/p angioplasty of her below-knee popliteal artery and posterior tibial artery on [**2133-8-28**] for gangrenous ulcers of her left foot. s/p angioplasty of proximal anastomosis of vein bypass graft [**3-25**] s/p Right below-knee popliteal to distal peroneal bypass graft with reversed saphenous vein graft [**2132-5-6**] s/p CABGx2 LIMA-LAD,SVG-PDA [**2-21**] s/p Simultaneous Kidney Pancreas Tx - [**Location (un) 5944**] [**2-22**] s/p Tx nephrectomy [**8-25**] s/p subtotal colectomy with ileostomy for toxic megacolon [**10-26**] failed renal transplant secondary to renal torsion, [**2-23**] s/p CRT #2 [**9-29**] s/p ex lap, LOA, resection of ileorectal anastmosis and ileoprostosmy [**7-28**] s/p lap PD cath placement [**9-27**] s/p removal of PD catheter [**9-29**] s/p ex lap w revision of ileostomy [**7-29**] s/p parastomal hernia repair [**7-29**] s/p cyso for removal of ureteral stent, s/p multiple RIJ and tunnel catheters for HD s/p CRT #3 [**2132-9-24**] Social History: lives with husband. She formerly smoked quit in [**2107**]. Used to be a cardiac nurse. Is able to walk around the house with a walker or cane. Family History: Adopted, unknown Physical Exam: -- per admitting resident -- Vitals - HR 110 SBP 132/79, SpO2 96% GENERAL: Sitting up in bed in NAD, eating lunch HEENT: anicteric, EOMI CARDIAC: grade II systolic murmur loudest at upper sternal border LUNG: clear bilaterally ABDOMEN: normal bowel sounds, colonostomy in place with green-brown liquid output, no surrounding erythema EXT: dressing on lower extremity ulcers, clean and dry no erythema NEURO: A+O X 3 Pertinent Results: ADMISSION LABS [**2135-1-18**] 12:30PM BLOOD WBC-3.6*# RBC-3.85* Hgb-13.8 Hct-39.9 MCV-104* MCH-36.0* MCHC-34.7 RDW-16.6* Plt Ct-154 [**2135-1-18**] 12:30PM BLOOD PT-13.0 PTT-27.6 INR(PT)-1.1 [**2135-1-18**] 12:30PM BLOOD Glucose-104* UreaN-10 Creat-1.1 Na-134 K-3.7 Cl-98 HCO3-25 AnGap-15 [**2135-1-18**] 12:30PM BLOOD ALT-22 AST-29 CK(CPK)-18* AlkPhos-138* [**2135-1-18**] 12:30PM BLOOD Albumin-4.2 Calcium-9.4 Phos-1.9* Mg-1.7 [**2135-1-18**] 12:36PM BLOOD Lactate-2.0 K-3.7 CT HEAD: (PRELIM READ) No intracranial hemorrhage or edema. No fracture. Bilateral maxillary sinus disease concerning for acute sinusitis. CT CSPINE: (PRELIM READ) 1. No fracture or malalignment of the cervical spine. 2. Multilevel degenerative disc disease, particularly at C4-5 and C5-6, similar to MRI [**2134-5-24**]. CT ABDOMEN/PELVIS: 1. Cholelithiasis. 2. Suboptimal evaluation of bowel just proximal to the left lower quadrant ostomy due to the lack of oral contrast and post-operative anatomy; therefore, infection is impossible to exclude. RIGHT UPPER QUADRANT US: Normal resistive indices and waveforms with no evidence of hydronephrosis. Somewhat limited exam and main renal artery could not be assessed. TTE: Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. An 3.7 cm long echogenic mass is present in the inferior vena cava extending past the orifice of the cava, approximately 1 cm into the right atrium. This most likely represents thrombus Compared with the findings of the prior study (images reviewed) of [**2135-1-19**], the mass present in the right atrium is significantly reduced in size, and is now seen to be contiguous with mass in the inferior vena cava, most likely representing thrombus. Brief Hospital Course: 51 yo female s/p renal tx X3 (most recent CRT [**9-29**]) and panc X2 (most recent [**2-27**]), severe PVD, HTN presents with rigors/[**Month/Year (2) 5162**] and mental status changes. # Sepsis / GPC Bactermia: Patient presented with fever, tachycardia and hypotension. initial evaluation with CXR negative, CT abdomen unrevealing, U/A negative, Renal Ultrasound unrevealing, Lactate 2.0, LFTs unremarkable. Patient does have history of VRE Peritonitis as well as an indwelling tunneled femoral line which was suspected as most likely source; CT did show maxillary sinusitis and pt did have recent complain of a persistant "head cold" per her husband. On day #1 patients blood cultures grew GPCs later speciated to CoNS, methicillin-resistant. She was treated initially with Vancomycin and Imipenem but this was subsequently narrowed to vancomycin only. Her tunneled line was removed and a new left femoral line was placed. Ideally, we would have had a line-free period in which her blood cultures would clear, but owing to very difficult IV access the left femoral line was replaced the same day as the prior line. Blood cultures promptly cleared the day that the old femoral line was pulled. In addition, a TTE was done which showed a thrombus in her right atrium. She will continue vancomycin for a four week course and follow up with ID in transplant clinic. . # Mental Status change- Patient with acute MS changes although events not clear at this time. Per her husband, pt has altered MS every time her BP drops. BP was low on EMS arrival. Pt does have labile BPs and takes both BB and fludrocortisone prn to manage her pressures. It is possible that infection precipitation hypotension causing the MS changes. CT head was negative. MS improved upon arrial to ICU with control of BP. . # Right Atrial thrombus - Pt had TTE done given positive blood cultures; thrombus in RA and IVD found; started on heparin, switched to Lovenox bridge to coumadin. Uncertain whether thrombus formation was [**1-25**] tunneled line. Patient will continue anticoagulation and follow up with cardiology. . # S/P Kidney/Pancreas Transplant - Pt's creatinine slightly above baseline on admission; likely prerenal given hypotension/sepsis. She was continued on Azathioprine and prednisone. Tacrolimus levels were high during admission, so it was redosed to a lower dose at discharge. . # h/o Hypertension/Orthostatic Hypotension - Toprol and Florinef held initially but resumed after BP stable . # CAD - ACE and BB continued . # Blindness [**1-25**] DMI: stable, She continued her home drops. - Cyclosporine 0.05% gtts; one in each eye QID - Acular 0.5% drops 1 gtt os q3D - Loteprednol Etabonate 0.2% drops 1 gtt ou [**Hospital1 **] Medications on Admission: Albuterol prn Alendronate 70mg qsunday Azathioprine 50mg daily Astelin spray Klonopin 0.5mg [**Hospital1 **] Creon 3 capsules with each meal Cyclosporine 0.05% gtts; one in each eye QID Desipramine 150mg daily Famotidine 20mg daily Florinef [**12-25**] tabsl q4 hrs prn for BP Fluticasone spray [**12-25**] sprays daily Folic acid 1mg daily Heparin 1000u/ml solution; 3.4cc to red port, 3.6cc blue port Hydrocortisone 2.5% cream Ipatropium Bromide [**12-25**] sprays per nostril [**Hospital1 **] prn Acular 0.5% drops 1 gtt os q3D Loteprednol Etabonate 0.2% drops 1 gtt ou [**Hospital1 **] Toprol XL 75mg daily Pred Forte 1% drops 1 gtt os q3d Prednisone 5mg daily Prograf 03mg SL mg [**Hospital1 **] Bactrim 400mg/80mg daily Effexor 37.5mg [**Hospital1 **] Ambien 5mg 1-2tabs prn aspirin 325mg daily Loratidine 10mg qam MVI Sodium Bicarbonate 650mg [**Hospital1 **] Imuran 50mg daily Discharge Medications: 1. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous once a day for 26 days: Started [**2135-1-21**], stops [**2135-2-18**] for total 4 week course. Disp:*QS for course specified * Refills:*0* 2. Line Care Please flush line with 10cc saline, followed by 2ml of 10 unit/ml Heparin (20 units of heparin) daily and after infusion / draw (SASH and PRN) 3. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection ASDIR for 6 weeks: Please flush with 10ml saline before and after medication infusion. Disp:*QS * Refills:*0* 4. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous ASDIR for 6 weeks: Please instill 2ml (20 units) after infusion. Disp:*QS * Refills:*0* 5. Outpatient Lab Work Please obtain vancomycin trough level before dose administered on [**2135-1-26**], fax results to ([**Telephone/Fax (1) 1353**], to the attention of Dr. [**Last Name (STitle) 724**]. 6. Outpatient Lab Work Please draw CBC with differential, BUN, and creatinine weekly on [**2135-1-26**], [**2135-2-2**], and [**2135-2-9**]. Fax results to Dr. [**Last Name (STitle) 724**] at ([**Telephone/Fax (1) 10739**]. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: on Sunday. 9. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Azelastine 137 mcg Aerosol, Spray Sig: One (1) NU Nasal [**Hospital1 **] (2 times a day). 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Creon Oral 13. Desipramine 150 mg Tablet Sig: One (1) Tablet PO once a day. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Fludrocortisone 0.1 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for blood pressure. 16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: [**12-25**] Nasal [**Hospital1 **] (2 times a day) as needed for rhinorrhea. 19. Ketorolac 0.5 % Drops Sig: One (1) gtt OS Ophthalmic q3d. 20. Alrex 0.2 % Drops, Suspension Sig: One (1) gtt OU Ophthalmic [**Hospital1 **] (2 times a day). 21. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QPM (once a day (in the evening)). 22. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 23. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:*180 Capsule(s)* Refills:*0* 25. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 28. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*28 syringes* Refills:*0* 29. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic QID (4 times a day). 30. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) gtt os Ophthalmic q3d. 31. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO once a day: Adjust as ordered to maintain INR 2.0 - 3.0. Disp:*75 Tablet(s)* Refills:*0* 32. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 33. Outpatient Lab Work Please draw INR on [**2135-1-26**] and fax to [**Company 191**] Anticoagulation Management Service at [**Telephone/Fax (1) 3534**]. 34. Outpatient Lab Work Please draw tacrolimus level on [**2135-1-26**] and fax results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 21335**]. 35. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 36. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 37. Multivitamins with Iron Tablet Sig: One (1) Tablet PO once a day. 38. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: SEPSIS LINE INFECTION / BACTEREMIA (COAG NEGATIVE STAPH) INTRA-ATRIAL THROMBUS Discharge Condition: Hemodynamically stable, afebrile, alert and oriented per baseline. Discharge Instructions: You were admitted to [**Hospital1 18**] with fever and with low blood pressure. We found a bacterial infection in your blood that likely started from your permanent femoral line. We also found evidence of blood clots in the right side of your heart and started blood thinners. With the assistance of IR, a new line was placed on your left side. Additionally during your hospitalization, a large blood clot was noted near the right side of your heart. You were started on blood thinners (anticoagulation) to prevent this clot from spreading. You tolerated anticoagulation and the antibiotics very well and have not had signs of persistant infection at this time. The following medications were changed during your hospitalization: ADDED enoxaparin (Lovenox) to thin your blood in the short-term until you reach an adequate level of warfarin in your blood ADDED warfarin for use as a longer-term blood thinner ADDED vancomycin to treat your infection CHANGED tacrolimus to achieve appropriate blood levels of this medication Followup Instructions: You are scheduled to follow up in the transplant infectious disease clinic with Dr. [**Last Name (STitle) 724**] on [**2135-2-8**], at 10AM. This appointment will be on the [**Location (un) 436**] of the [**Hospital Unit Name **]. You can contact his office to reschedule this appointment if needed by calling ([**Telephone/Fax (1) 3618**]. We would want you to follow up with him between 2-3 weeks after discharge. You are scheduled to meet with the cardiologist, Dr.[**Doctor Last Name 3733**], on [**2135-2-8**] at 2:20 PM. This appointment will be on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Center. You can contact his office to reschedule this appointment if needed by calling ([**Telephone/Fax (1) 3942**]. We would want you to follow up with him around 3 weeks after discharge. We would like you to follow up with your transplant nephrologist, Dr. [**Last Name (STitle) **], on [**2135-2-16**], at 8:30 AM. You can contact her office to reschedule this appointment if needed by calling ([**Telephone/Fax (1) 3618**]. We would want you to follow up with her between 2-3 weeks after discharge. Additionally, you will need periodic laboratory work done while you are on the vancomycin. These results will be faxed to Dr. [**Last Name (STitle) 724**] and your vancomycin dose may be changed if needed as a result. Your warfarin blood levels will be followed by the [**Company 191**] Anticoagulation Management Service. The levels will be drawn as coordinated between this service and your visiting nurse, and your warfarin dosage will be adjusted accordingly. You will be asked to discontinue your Lovenox (enoxaparin) injections once your warfarin level has been therapeutic for at least 24 hours. If you have any questions, please call the [**Company 191**] line at [**Telephone/Fax (1) 250**]. Please schedule a follow up appointment with your primary care doctor, Dr. [**Last Name (STitle) 9006**], within 1 month of discharge. You can set up an appointment with his office by calling ([**Telephone/Fax (1) 1300**]. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Completed by:[**2135-1-25**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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6265, 8995

358, 397

14266, 14335

4258, 4738

15413, 17633

3783, 3801

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297, 320

425, 2225

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3621, 3767

7,107

104,098

8873+8874

Discharge summary

report+report

Admission Date: [**2145-4-27**] Discharge Date: Date of Birth: [**2067-11-11**] Sex: F Service: [**Hospital Unit Name 153**] CHIEF COMPLAINT: Hypotension. HISTORY OF PRESENT ILLNESS: The patient is a 76 year old female with multiple medical problems including dysphagia, emphysema, congestive heart failure, coronary artery disease, who was recently discharged from the [**Hospital6 649**] on [**2145-4-23**], following treatment of Methicillin-resistant Staphylococcus aureus pneumonia and hypotension. The patient had previously been admitted to the Medicine Intensive Care Unit on the sepsis protocol, was hypotensive to the 60s without improvement following fluids and was also febrile to 102.8. In the Medicine Intensive Care Unit, hypotension was believed to be multifactorial (including hypovolemia in a preload dependent patient, bacterial versus viral infection and acute renal failure). Fluid resuscitated with improvement, briefly on pressors. Sputum growing Methicillin-sensitive resistant Staphylococcus aureus with chest x-ray showing left lower lobe infiltrate and the patient was started on a two week course of Vancomycin intravenously. Blood cultures showed no growth. She was ruled out for myocardial infarction with three sets of negative cardiac enzymes. She developed diarrhea which was improving at the time of discharge. Three sets of Clostridium difficile were negative. The patient had refused rehabilitation placement on previous admissions and was discharged with home services. Since discharge, the patient states that she had been eating and drinking well. On the day prior to admission she went to the grocery store and cooked a meal. Over the past day she noticed decreased urine output although continued to drink well (two to three glasses of water per day). The patient told the Emergency Room staff that she had been taking her Lasix since discharge. She told me upon admission she was not taking her Lasix. The patient was seen by her [**Hospital6 407**] on the day of admission and was concerned about the patient's condition. She went to see her primary care physician and was found to be hypotensive with systolic blood pressure in the 80s and unsteady on her feet. In the Emergency Department, she was still hypotensive with systolic blood pressure in the 80s although she appeared to be improving to the 100s with intravenous fluids. Her creatinine was elevated to 4.9 from a baseline of approximately 0.7. It is to note that the patient did suffer from acute renal failure in her Medicine Intensive Care Unit course earlier in [**Month (only) 958**], to a maximum creatinine of 2.3. PAST MEDICAL HISTORY: 1. Dysphagia, motility study in [**2144-1-29**] showed no esophageal contraction. 2. Prerenal, acute renal failure in [**2144-3-28**] secondary to poor p.o. intake and again in [**2145-3-29**] secondary to poor p.o. intake. 3. Obstructive sleep apnea on CPAP at 8 to 10 cm of water. 4. Emphysema on home oxygen 2 to 4 liters, nasal cannula. 5. Bronchiectasis. 6. Pulmonary hypertension. 7. Symptomatic bradycardia, status post VDD pacemaker in [**2143-11-29**]. 8. Gastroesophageal reflux disease. 9. History of Methicillin-resistant Staphylococcus aureus in her sputum following hernia repair and again in [**2145-3-29**] with documented pneumonia. 10. Status post hernia repair. 11. Right ventricular systolic function with echocardiogram from [**2145-3-29**] showing right ventricular dilation, borderline left ventricular dilation, ejection fraction greater than 55% and borderline normal right ventricular function, 1+ mitral regurgitation. 12. Coronary artery disease. 13. Hypertension. 14. Status post appendectomy. 15. Status post total abdominal hysterectomy. 16. Status post back surgery. 17. Status post right total hip. 18. Chronic lower back pain with questionable narcotic use recently. ALLERGIES: Penicillin, codeine and Bactrim. MEDICATIONS ON ADMISSION: 1. Colace 100 mg p.o. b.i.d. 2. Fluticasone 4 puffs inhaler b.i.d. 3. Salmeterol inhaler q. 12 hours. 4. Reglan 5 mg p.o. t.i.d., a.c. h.s. 5. Senna 8.6 b.i.d. 6. Levofloxacin 250 mg p.o. q. day to complete a two week course. 7. Valsartan 150 mg p.o. q. day 8. Atorvastatin 40 mg p.o. q.h.s. 9. Calcium carbonate 500 p.o. t.i.d. 10. Vitamin D 400 units p.o. q. day 11. Gabapentin 800 mg in the morning and 400 mg in the afternoon and 800 mg at night. 12. Vancomycin 1.5 gm intravenously q. 24 hours to complete a two week course. 13. Combivent 2 puffs inhaler b.i.d. SOCIAL HISTORY: History of tobacco use, rare alcohol use. Lives with her cousin. [**Name (NI) **] refused rehabilitation in the past and has visiting nurses. FAMILY HISTORY: The patient has a father and brother with chronic obstructive pulmonary disease. A sister with breast cancer. PHYSICAL EXAMINATION: On admission vital signs with temperature 98.3, blood pressure 108/52, pulse 70, respirations 14, 95% on 2 liters oxygen by nasal cannula. General: Lethargic, overweight woman answering questions appropriately but answering slowly. Left upper extremity and left lower extremity appeared to be twitching intermittently in no acute distress, breathing comfortably. Head, eyes, ears, nose and throat: Sclera anicteric, eyelids dropping bilaterally. Mucous membranes moist. Chest, decreased breath sounds at the left lower base, greater than right lower base, no egophony, scattered expiratory and inspiratory wheezing. Cardiovascular, regular rate and rhythm, II/VI diastolic murmur best heard at the left upper sternal border. Abdomen: Soft, obese, nontender. Good bowel sounds, no rebound, no guarding. Extremities: 2+ lower extremity pitting edema, left greater than right. Positive asterixes. Neurologic: Lethargic but easily arousable. Oriented times three. Speech fluent. Pupils asymmetric from previous cardiac surgery but reactive to light, able to close eyes against resistance bilaterally. Sensation over face intact. Says saliva comes out of the right corner of her mouth but face and smile appears symmetric. Able to puff cheeks against resistance. Tongue midline. Grip [**6-2**] bilaterally. Sensation intact bilaterally. Reflexes, toes equivocal bilaterally, no clonus, positive asterixes. LABORATORY DATA: Laboratory data on admission revealed white blood count 13.3 with 76 polys, 15 lymphocytes, no bands, hematocrit 32.3, platelets 408. Chemistry was significant for a potassium of 5.8, bicarbonate 23. His creatinine was 4.9, BUN 38. Electrocardiogram showed sinus rhythm at 70 with questionable right bundle branch block, no peak T waves, left axis deviation. Chest x-ray showed unchanged cardiomegaly and position of left-sided pacemaker. NO evidence of congestive heart failure or focal pulmonary parenchymal consolidation. Unchanged bibasilar and interstitial markings. HOSPITAL COURSE: (By problem) 1. Acute renal failure - The patient's urine electrolytes were checked and her FENA was found to be 0.3 indicating likely a prerenal etiology. Urine was negative for eosinophils. The patient had a renal ultrasound which was negative for hydronephrosis or obstruction. The patient's creatinine continued to climb in the initial 24 hours of admission. Her maximum creatinine was 6.0. At this time, the patient was still making a small amount of urine. A renal consult was obtained and followed the patient closely during her hospitalization. It was thought the patient may have a mixture of prerenal etiology as well as acute tubular necrosis. It is unclear if the patient had any ingestions prior to her admission as she was a poor historian. She does suffer from chronic lower back pain and may have ingested some non-steroidal anti-inflammatory drugs. The patient was also on Vancomycin since her last admission with extremely high levels of 73.1 on the day after admission. The patient's levels trended downward and on the day of this dictation are 37.4. It was thought that this may also have been renal toxic. At the time of this dictation, the patient's etiology of her renal failure remains somewhat unclear. [**Name2 (NI) **] [**Last Name (un) **] medication was held as well as any diuresis. The patient was given a small fluid challenge in the Intensive Care Unit with 1 unit of packed cells and approximately 2 liters of intravenous fluids. The patient's creatinine did respond to this and began to trend downward. Her urine output greatly improved and on the day prior to transfer to the floor, the patient was making urine at greater than 50 cc/hr. Please see addendum to this dictation for further workup and treatment of the patient's acute renal failure. 2. Delta MS - On the day after admission, the patient was found with a depressed mental status. she was alert to voice but not very arousable. A blood gas at that time showed a pH of 7.18, pCO2 of 67 and pO2 of 81. Lactate was 0.7. The patient's hypercarbia was felt to be due to some respiratory depression of unclear etiology. There was a possibility that the patient had ingested some narcotics for lower back pain at home prior to admission. The patient was transferred to the Intensive Care Unit after initiation of BiPAP on the floor on [**Hospital Ward Name 517**]. Upon arrival to the Intensive Care Unit, the patient continued to have hypercarbia. It was thought that the patient might be progressing towards intubation. However, a trial of intravenous Narcan times two at 0.4 mg was given to the patient for the thought of recent narcotic use. The patient had instant and dramatic improvement in her mental status upon injection of Narcan. It was thought that with the patient's acute renal failure, recent narcotic use may not have cleared. The patient's mental status continued to improve and her blood gases began to look less hypercarbic. She was transitioned to a nasal cannula at 4 liters and did well over the next two days. The patient was continued on her BiPAP at 10/5 in the evening for her known obstructive sleep apnea. The patient maintained good saturations during her admission and oxygenation was not an issue. The patient's hypercarbia was likely contributing to poor mental status and once resolved, the patient's mental status was at her baseline. 3. Fevers - The patient has a questionable left lower lobe infiltrate on her x-ray with a recent confirmed Methicillin-resistant Staphylococcus aureus pneumonia. Her Vancomycin level remained very elevated during her admission and she would not redose Vancomycin during her [**Hospital Unit Name 153**] course. Upon transfer to the floor, she was on day #10 of Vancomycin. She was also treated empirically with Levaquin beginning on her last admission for presumed community acquired pneumonia. She is currently on day #10 of this, at renal dosing. The patient was pancultured with no growth to date on her cultures during this admission. 4. Hypotension - The patient's hypotension resolved after initial overnight stay on the regular medicine floor. The patient's blood pressure medications were held. She was given gentle fluid challenges during her stay in the Intensive Care Unit with good response. On day of transfer to the floor, the patient actually became hypertensive, it was thought that we should continue to hold her [**Last Name (un) **] and now a trial of Nifedipine was started as this was thought to increase renal blood flow. 5. Obstructive sleep apnea - The patient was continued on her BiPAP at 10/5 during this admission. 6. Coronary artery disease - The patient had no acute chest pain during this admission, however, she did have a troponin leak with normal MB index. The patient's electrocardiogram was without any changes. It was thought that the patient may have had a troponin leak in the setting for initial hypotension and in the setting of acute renal failure, this was difficult to interpret. There was no workup for acute ischemia, and the patient's troponin began to trend down. She was continued on her Atorvastatin. She was not started on Aspirin in the setting of her acute renal failure. She is not on a beta blocker currently and we did not start one in her [**Hospital Unit Name 153**] course due to her chronic obstructive pulmonary disease, intermittent wheezing and oxygen requirement. 7. Fluids, electrolytes and nutrition - The patient was kept NPO for her stay in Intensive Care Unit until her mental status improved. Once her mental status improved she had a great appetite. She was started on PhosLo for a phosphorus of 7.7. 8. Prophylaxis - The patient was given subcutaneous heparin and intravenous Famotidine and was switched to p.o. Famotidine. 9. Contacts - The patient's brother [**Name (NI) **] as well as her cousin were the patient's contacts. The patient's cousin and proxy was currently hospitalized at [**Hospital6 1708**]. The most contact with the patient's cousin was made through the patient's primary care physician, [**Last Name (NamePattern4) **] .[**Doctor Last Name **]. DISPOSITION: The patient was discharged to the floor on [**2145-5-1**] in stable condition. Please see addendum to this discharge summary for further discharge planning and medications as well as hospital course upon transfer to general medical service. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **], 17-AFO Dictated By:[**Last Name (NamePattern1) 9244**] MEDQUIST36 D: [**2145-5-1**] 18:08 T: [**2145-5-1**] 18:39 JOB#: [**Job Number 30897**] Admission Date: [**2145-4-27**] Discharge Date: [**2145-5-4**] Date of Birth: [**2067-11-11**] Sex: F Service: ACOVE FIRM ADDENDUM TO PREVIOUS DISCHARGE SUMMARY FROM [**2145-4-2**]: Since being transferred from the ICU to the general medical service, the patient began to spontaneously diurese. However, she still remained clinically volume overloaded and, therefore, was started on diuretics with a goal to keep the patient negative 1 liter a day. The patient's creatinine slowly improved. In addition, the patient felt symptomatic relief with decreasing shortness of breath, and decreasing peripheral edema. At the time of this dictation, the patient is on 2 liters nasal cannula. She is maintained on BiPAP overnight while sleeping. The renal consult team continued to follow the patient. The etiology of her acute renal failure is still unclear. However, ATN in the setting of hypovolemia and high serum vancomycin doses remains high on the differential. Given that her serum level of vancomycin was elevated, it was discontinued, and her level remained in the therapeutic range. She, therefore, received the equivalent of a 14-day course of vancomycin for presumed MRSA pneumonia. For better control of hypertension, the patient's medication was changed from nifedipine to diltiazem with good results. Diltiazem was changed to extended release prior to discharge. She is being discharged to an extended care facility. DISCHARGE CONDITION; On 2 liters nasal cannula, tolerating PO diet, peripheral edema greatly improved, alert and oriented, well-appearing, diuresing well, and creatinine trending downward. DISCHARGE DIAGNOSES: 1. Acute renal failure, probably secondary to acute tubular necrosis. 2. Congestive heart failure. 3. Hypercarbic respiratory failure. 4. Hypertension. 5. Coronary artery disease. 6. History of Methicillin resistant Staphylococcus aureus pneumonia. 7. Obstructive sleep apnea. 8. Chronic obstructive pulmonary disease. 9. Bronchiectasis. 10.Pulmonary hypertension. 11.Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Fluticasone 4 puffs [**Hospital1 **]. 2. Salmeterol 1 puff q 12 h. 3. Acetaminophen 325-650 po q 4-6 h prn. 4. Vitamin D 400 U po qd. 5. Albuterol neb q 4-6 h prn. 6. Ipratropium neb q 6 h. 7. Calcium acetate 667 mg po tid with meals. 8. Atorvastatin 10 mg po qd. 9. Colace 100 mg po bid. 10.Senna 8.6 mg po bid. 11.Famotidine 20 mg po bid. 12.Miconazole powder prn. 13.Gabapentin 300 mg po q 48 h (This dose will be increased as renal function improves towards the patient's output dosing of 800, 400 and 400.). 14.Subcu heparin. 15.Lasix 40 mg po bid. 16.Diltiazem ER 240 mg po qd. FOLLOW-UP: The patient to follow-up with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the next 2 weeks. At that time, gabapentin will be titrated upwards as renal function improves. The patient to follow a 1-1/2 liter fluid restriction a day, 2 gm sodium diet, and daily weights. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 17526**] MEDQUIST36 D: [**2145-5-4**] 11:09 T: [**2145-5-4**] 11:11 JOB#: [**Job Number 30898**]

[ "428.0", "584.5", "491.21", "401.9", "414.01", "276.5", "V09.0", "518.84", "482.41" ]

icd9cm

[ [ [] ] ]

[ "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

4726, 4838

15227, 15629

15652, 16796

3971, 4548

6899, 15206

4861, 6881

163, 177

206, 2666

2688, 3945

4565, 4709

5,727

189,570

51920

Discharge summary

report

Admission Date: [**2154-6-20**] Discharge Date: [**2154-6-25**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 678**] Chief Complaint: Fever. Major Surgical or Invasive Procedure: Blood transfusion. History of Present Illness: 57 year-old male with coronary artery disease, diabetes mellitus type II, end-stage renal disease presenting with from HD Wednesday after spiking a temperature to 101.7. Blood cultures were drawn and the patient received vancomycin and gentamycin. Of note, the patient had missed HD Monday after "feeling not good." The patient complained of cough productive of green sputum x 1 week. The patient also complained of shortness of breath over that time frame. The patient complained of recent diarrhea but this had resolved prior to admission and the patient denies abdominal pain, nausea, vomiting, melena, BRBPR. On admission the patient complained of chest pain at the site of his tunnelled HD catheter, sharp, nonradiating. Of note, the patient has a history of cocaine use and last used a few days prior to admission. . In the ED, VS: 102.1 105-120 150-193/70-90 24 100% 4L. The patient was given ceftriaxone and azithromycin for presumptive pneumonia. BNP > 20,000. The patient was given lasix for attempted diuresis with minimal response. . Review of systems: As above. Otherwise negative for dysuria. Review of systems otherwise negative in detail. . In the MICU, the patient was continued on ceftriaxone and azithromycin for presumptive pneumonia. The patient received an extra session of dialysis for having missed one session the week of admission. . On transfer, the patient states he has not had fevers since admission. Cough persists and is productive of green sputum. Shortness of breath improved. No other complaints. Past Medical History: 1. Type II diabetes mellitus 2. CAD s/p MI, MIBI in [**11-18**] showed reversible defects inferior/latateral 3. CHF with EF 20-30% and severe global hypokinesis 4. Hypertension 5. Dyslipidemia 6. Atrial fibrillation 7. Hisrory of gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli 8. Chronic pancreatitis 9. Hepatitis C 10. GERD 11. CRF, baseline 3.9-5.3 12. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**] 13. Depression, s/p multiple hospitalizations due to SI 14. Polysubstance abuse: crack cocaine, EtOH, tobacco 15. Erectile dysfunction, s/p inflatable penile prosthesis [**5-/2148**] Social History: Patient lives in [**Location 686**] with his wife. [**Name (NI) **] used to be an electrician for [**Company 31653**] for 30 years, but has been on disability. Tob: 45 pack-yr, currently smokes 3 cigarettes per day EtOH: History of abuse with hospitalizations for delirium [**Company 107492**] and detoxification. Patient states he now drinks rarely but admits to one drink one week prior to admission. Illicits: 15 year history of crack cocaine use, last used a few days prior to admission. Family History: His father with alcoholism, an uncle who committed suicide by hanging, and a cousin with [**Name2 (NI) 14165**] cell anemia. His mother died of renal failure at age 58. He states that his twin brother and his son also have kidney disease. Physical Exam: On admission to the MICU: VSS Gen: Tachypnic, somewhat uncomfortable appearing male, oriented x3 HEENT: MMM, neck supple CV: Tachy, split s2 Lung: Bibasilar crackles Chest: HD cath line site slightly tender, no oozing/drainage/erythema Abd: Soft, NTND, NABS Ext: Trace edema . On transfer to the floor: VITALS: T 97.7 HR 93 BP 142/71 RR 24 sO2 100% 4L GEN: NAD HEENT: No acleral icterus, OP clear without lesions, MMM LUNGS: Decreased breath sounds right base HEART: Irregularly irregular, rate 90s, normal S1 and S2, no murmurs, gallops and rubs CHEST: HD cath line site slightly tender, no oozing/drainage/erythema ABDOMEN: Normal bowel sounds, soft, nontender, nondistended EXTREMITIES: No clubbing, cyanosis, ecchymosis, or edema NEUROLOGIC: Responds appropriately, moving all extremities well Pertinent Results: Labwork on admission: [**2154-6-20**] 06:26AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2154-6-20**] 06:26AM URINE RBC-0 WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 [**2154-6-20**] 05:23AM GLUCOSE-343* UREA N-19 CREAT-3.4* SODIUM-141 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12 [**2154-6-20**] 05:23AM ALT(SGPT)-15 AST(SGOT)-26 CK(CPK)-118 ALK PHOS-124* TOT BILI-0.4 DIR BILI-0.1 INDIR BIL-0.3 [**2154-6-20**] 05:23AM CK-MB-5 cTropnT-0.24* [**2154-6-20**] 05:23AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2154-6-20**] 05:23AM WBC-6.0 RBC-3.23* HGB-8.5* HCT-26.6* MCV-82 MCH-26.3* MCHC-32.0 RDW-18.2* [**2154-6-20**] 05:23AM PLT COUNT-233 [**2154-6-20**] 01:30AM CK-MB-NotDone cTropnT-0.24* proBNP-[**Numeric Identifier **]* [**2154-6-20**] 01:30AM CK(CPK)-98 [**2154-6-19**] 07:25PM PT-12.8 PTT-28.5 INR(PT)-1.1 [**2154-6-19**] 09:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG . CHEST (PORTABLE AP) [**2154-6-19**] IMPRESSION: Mild-to-moderate pulmonary edema, with bilateral pleural effusions, right greater than left. Right basilar consolidation is difficult to exclude. . ECG Study Date of [**2154-6-19**] 9:26:52 PM Atrial flutter with rapid ventricular response Borderline right axis deviation Modest right ventricular conduction delay pattern Left ventricular hypertrophy and consider also biventricular hypertrophy Nonspecific ST-T abnormalities Since previous tracing of [**2154-5-18**], atrial flutter now present and axis appears more rightward Intervals Axes Rate PR QRS QT/QTc P QRS T 120 0 96 [**Telephone/Fax (2) 107498**]03 -103 . ECG Study Date of [**2154-6-20**] 9:34:32 AM Sinus rhythm Atrial premature complex Left atrial abnormality and consider biatrial abnormality Modest right ventricular conduction delay pattern Left ventricular hypertrophy and consider also biventricular hypertrophy Nonspecific T wave abnormalities Since previous tracing of the same date, atrial flutter and axis appears less rightward . CHEST (PA & LAT) [**2154-6-22**] Impression: Findings suggestive of pulmonary edema. A superimposed infectious etiology would be difficult to completely exclude. . Labwork on discharge: [**2154-6-25**] 05:40AM BLOOD WBC-8.1 RBC-3.35* Hgb-9.0* Hct-26.9* MCV-80* MCH-26.7* MCHC-33.4 RDW-17.4* Plt Ct-339 [**2154-6-25**] 05:40AM BLOOD Glucose-110* UreaN-27* Creat-3.5*# Na-139 K-4.4 Cl-103 HCO3-27 AnGap-13 Brief Hospital Course: 57 year-old male with coronary artery disease, diabetes mellitus type II, end-stage renal disease presenting with fever likely due to pneumonia and multifactorial hypoxia. . 1. Hypoxia: Likely multifactorial due to pneumonia, fluid overload after missing hemodialysis, anemia, and history of smoking. The patient received antibiotics as above for pneumonia. The patient's BNP was [**Numeric Identifier **] on admission; the patient was dialyzed to remove fluid. The patient was given one unit packed red blood cells for anemia. The patient was advised to stop smoking. The patient's oxygen saturation was 96% on room air and 91% with ambulation on discharge. . 2. Fever: The patient was afebrile since admission. The fever was likely due to pneumonia given the patient's productive cough and x-ray findings versus viral bronchitis. The patient was initially treated with ceftriaxone and azithromycin which was changed to levofloxacin prior to discharge to complete a seven-day course. There was initial concern for line infection and the patient was treated with vancomycin but this was discontinued once cultures remained negative for greater than 72 hours. Urine culture was negative. No stools studies were sent as the patient's diarrhea had resolved prior to admission. . 3. Chest pain: The patient's left-sided chest discomfort was due to his tunnelled catheter. The patient was ruled out for myocardial infarction on admission. . 4. Coronary artery disease: No active issues. The patient was continued on an ACE-inhibitor and statin. The patient is not on beta-blockers for history of cocaine use. The patient is not on aspirin, likely for his history of gastrointestinal bleed. The patient will follow-up with his primary care physician regarding the need for aspirin. . 5. Hypertension: The patient's blood pressures were systolic 140-150 and were not at goal <135/85. The patient received hemodialysis for volume status. The patient had multiple dietary indiscretions during admission and again received diet education. The patient's outpatient regimen was continued and titration of his regimen was left to the outpatient setting. . 6. Diabetes mellitus type II: The patient's outpatient regimen was continued. The patient had dietary indiscretions during admission and again received diet education. . 7. End-stage renal disease on hemodialysis: The patient's schedule is Monday, Wednesday, Friday. The patient received an extra session the day of admission (Thursday) as he had missed his Monday session. The patient was followed by the Renal team during admission. . 8. Substance abuse: Recent cocaine use. History of alcohol abuse. The patient declined a meeting with the substance abuse social worker during admission. The patient will follow-up with his primary care physician regarding his substance abuse. . 9. Atrial fibrillation: Intermittently in sinus rhythm. The patient was rate-controlled with diltiazem. The patient is not on anti-coagulation likely due to history of gastrointestinal bleed. . 10. Anemia: Due to renal failure. Stable during admission. The patient received epogen at hemodialysis. The patient received one unit packed red blood cells on admission for symptomatic hypoxia as above. Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous QAM. 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QPM. 8. Novalog Sig: Sliding scale four times a day. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous QAM. 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QPM. 8. Novalog Sig: Sliding scale four times a day. 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses: Take levofloxacin for two more doses on Thursday [**6-27**] and Saturday [**6-29**]. [**Month (only) **]:*2 Tablet(s)* Refills:*0* 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Fever 2. Pneumonia 3. Congestive heart failure 4. Hypoxia 5. Anemia . Secondary: 1. Type II diabetes mellitus 2. CAD s/p MI, MIBI in [**11-18**] showed reversible defects inferior/latateral 3. CHF with EF 20-30% and severe global hypokinesis 4. Hypertension 5. Dyslipidemia 6. Atrial fibrillation 7. Hisrory of gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli 8. Chronic pancreatitis 9. Hepatitis C 10. GERD 11. CRF, baseline 3.9-5.3 12. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**] 13. Depression, s/p multiple hospitalizations due to SI 14. Polysubstance abuse: crack cocaine, EtOH, tobacco 15. Erectile dysfunction, s/p inflatable penile prosthesis [**5-/2148**] Discharge Condition: Afebrile, vital signs stable. Oxygen saturation 96% on room air at rest and 91% on room air with ambulation. Discharge Instructions: You were hospitalized with fever. This was likely due to pneumonia. You should take levofloxacin (an antibiotic) for two more doses for treatment. . Your oxygen saturation was low during admission. This was likely due to your pneumonia, fluid overload from missing hemodialysis, low red blood cell counts, and history of smoking. You were treated for pneumonia with antibiotics, had fluid removed during hemodialysis, and were given a blood transfusion for your low blood counts. You should stop smoking to prevent further injury to your lungs and should discuss ways to stop smoking with your primary care doctor. . For your heart failure: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: One liter . Please contact a physician if you experience fevers, chills, chest pain, shortness of breath, increased cough, abdominal pain, nausea, vomiting, diarrhea, pain with urinating, or any other concerning symptoms. . Please take your medications as prescribed. - You should take levofloxacin for two more doses on Thursday, [**6-27**] and and Saturday, [**6-29**]. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with your primary care physician: [**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2154-7-10**] 10:30 . Previously [**Month/Day/Year 1988**] appointments: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2154-9-4**] 10:20 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2153-11-18**] Discharge Date: [**2153-11-20**] Date of Birth: [**2077-7-1**] Sex: M Service: MEDICINE Allergies: Morphine / Coumadin Attending:[**First Name3 (LF) 7881**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 24110**] is a 76 y/o M with a history of multiple sclerosis, paroxysmal atrial fibrillation on aspirin and [**Known lastname 4532**], hypertension, hyperlipidemia, previously diagnosed "vasovagal syncope," prostate cancer, neurogenic bladder with chronic suprapubic cath, history of ESBL UTI, chronic constipation, and left parietal AVM, presenting from home after a syncopal episode. Patient apparently woke up this morning feeling extremely weak and tired. Per his wife, he was also difficult to arouse with multiple episodes of somnolence. EMS was called in the morning, but patient refused to be taken to the hospital as he felt well by their arrival. Patient was then eating a bowl of fruit this afternoon, and his wife found him slumped in a chair. He regained conciousness several minutes later. EMS was subsequently called again. Patient has no recollection of passing out, nor did he feel any prodrome of chest pain, nausea, diaphoresis, SOB, dizziness. On EMS arrival, HR 30s BP 70s, and patient was asymptomatic. . On arrival to the ED, HR was in the 30s-40s, BPs labile 80s-120s. Patient had no symptoms during low BPs. He was given IV cipro for history of UTI, 2L NS and sent to the unit. His Hct was 26 and was guiac negative in the ED. On transfer to the unit, patient was afebrile HR 44, 114/49 18 100% on 2L NC. . Of note, patient had been admitted in [**Month (only) **] for a similar episode of unresponsiveness with a negative workup, as well as prior synopal workups in the past. He reports that todays episode was similar in nature in that he did not feel any prodrome and did not remember passing out. He also has had several episodes of diagnosed "vasovagal syncope," prior to which he sometimes feels weak and nauseous. On review of prior notes, patient is also chronically bradycardic with HRs in 40s at [**Month (only) 5348**], with transient episodes of hypotension. He has a Holter monitor in our system from [**2141**], which showed no ectopy, HRs 49-70, with prolonged PR intervals .24. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. Of note, he had a EGD/colonoscopy on [**11-11**] for workup of Fe deficiency anemia, which showed a non-bleeding adenoma. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. His last bowel movement was 1.5 weeks ago, whichg he states is roughly his [**Month/Year (2) 5348**]. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: 1. Multiple sclerosis - followed by Dr.[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 45435**] at [**Hospital1 2025**]. 2. Neurogenic bladder - suprapubic catheter in place; followed by Dr. [**Last Name (STitle) 9125**]. 3. Hypertension 4. Severe constipation - followed by Dr. [**Last Name (STitle) 10689**]. 5. Glaucoma 6. Prostate cancer - s/p hormonal therapy and radiation. He has been pursuing watchful waiting since the Spring [**2149**]. He is followed at the [**Hospital3 328**] Cancer Institute. 7. Pneumonia 8. Cellulitis 9. Osteoarthritis 10. Hyperlipidemia 11. Depression 12. History of AVM in the left parietal lobe 13. Obstructive sleep apnea utilizing CPAP at night 14. Peripheral neuropathy 15. Thoracic outlet syndrome 16. PE - [**3-21**] 17. Gastroesophageal reflux disease 18. History of MRSA 19. History of left foot fracture 21. Osteopenia 22. Atrial Fibrillation on [**Month/Year (2) **] 22. Shingles - [**2151**] Social History: Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via AA. Quit cigars a few years ago. Retired judge (at age 68 due to fatigue). Family History: Per notes, daughter and cousin with MS, mother with AD, father with leukemia, brother with arrhythmia. Physical Exam: VS: T= 97 BP= 108/57 HR= 44 RR= 12 O2 sat= 100% RA GENERAL: 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 of 6 cm. 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: Distended, firm. Hypoactive bowel sounds. Nontender, no guarding or rebound. EXTREMITIES: No c/c/e. 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: 1. Labs on admission: [**2153-11-18**] 05:40PM BLOOD WBC-7.8 RBC-3.31* Hgb-8.7* Hct-26.8* MCV-81*# MCH-26.4* MCHC-32.6 RDW-15.3 Plt Ct-178 [**2153-11-18**] 05:40PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2* [**2153-11-19**] 05:00AM BLOOD Glucose-159* UreaN-16 Creat-0.9 Na-139 K-3.6 Cl-112* HCO3-23 AnGap-8 [**2153-11-19**] 05:00AM BLOOD CK(CPK)-40* [**2153-11-18**] 05:40PM BLOOD cTropnT-<0.01 [**2153-11-19**] 05:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2153-11-19**] 05:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0 [**2153-11-18**] 05:54PM BLOOD freeCa-1.08* . 2. Labs on discharge; [**2153-11-20**] 05:59AM BLOOD WBC-5.2# RBC-3.80*# Hgb-9.9*# Hct-30.7*# MCV-81* MCH-26.0* MCHC-32.3 RDW-14.6 Plt Ct-161 [**2153-11-20**] 05:59AM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-111* HCO3-23 AnGap-10 [**2153-11-20**] 05:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0 . 3. Imaging/diagnostics: - CXR ([**2153-11-18**]): No acute cardiopulmonary process. - EKG ([**2153-11-19**]): Sinus bradycardia and A-V conduction delay with slight shortening of the P-R interval as compared to the previous tracing of [**2153-11-18**]. The Q-T interval remains prolonged. No diagnostic interim change. - Tilt-table test ([**2153-11-20**]): *preliminary finding*: delayed neurally mediated syncope with orthostatic hypotension, systolic blood pressure drop from 160s to 60s. Final report to follow. Brief Hospital Course: Mr [**Known lastname 24110**] is a 76 y/o M with a history of multiple sclerosis, paroxysmal atrial fibrillation on aspirin and [**Known lastname 4532**], hypertension, hyperlipidemia, previously diagnosed "vasovagal syncope," neurogenic bladder with chronic suprapubic cath, history of ESBL UTI, chronic constipation, and left parietal AVM, presenting from home after a syncopal episode. . #. Syncope: EKG on admission showed first degree heart block. Patient did not have any other arrythmia throughout the hospital course. Symptoms similar to prior vaso-vagal episodes. Tilt table test was done which showed delayed neurally mediated syncope with orthostatic hypotension (sBP 160s-->60s). Patient to follow-up with outpatient cardiologist. . #. Atrial Fibrillation: Remained in sinus bradycardia and was kept on home regimen of aspirin/[**Known lastname 4532**] rather than coumadin in the context of known AVM. . # HTN: Kept on home enalapril. New home [**Known lastname 4085**] amlodipine was stopped. . # HLD: Continue one home simvastatin . # Chronic UTI: History of ESBL UTI with suprapubic catheter site. Urinanalysis on admission was positive and urine culture grew out E. coli. Speciation at the time of discharge was not available. Per outpatient urologist, this is consistent with chronic colonization and will be treated with outpatient antibiotics regimen by urologist. . #. Multiple Sclerosis: Continue baclofen. . # Neurogenic bladder: Patient was on oxybutynin while in patient and discharged with home darifenacin on discharge. . #. Constipation: Secondary to neuropathy from MS, chronic problem. Aggressive bowel regimen administered with effect. . Medications on Admission: - Amlodipine 7.5 mg daily - Baclofen 20 mg qhs - Brimonidine .1% drops TID - [**Known lastname **] 75 mg daily - Darifenacin 7.5 mg daily - Dorzolamide-timolol 1 drop TID - Enalapril 20 mg [**Hospital1 **] - Latanoprost 1 drop qhs - Macrobid 100 mg daily one out of 3 weeks - Omeprazole 40 mg [**Hospital1 **] - Peg-electrolyte solution 420 1 bottle daily - Simvastatin 10 mg qhs - Aspirin 325 mg daily - Calcium 600 mg + D daily - Cascara - Colace - Multivitamin - Omega-3 fatty acids Discharge Medications: 1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. baclofen 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. darifenacin 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). 13. carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2 times a day) for 4 days. 14. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 15. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary: Vasovagal syncope Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([**Hospital1 **] or cane). Discharge Instructions: You were seen in the hospital because a syncopal episode. This episode was likely secondary due a vasovagal cause. You had a tilt table test to explore possible causes for your syncopal episode, which showed a drop in your blood pressure with tilting. You will need to follow up with your cardiologist Dr. [**Last Name (STitle) **] (appointment below) to discuss the final results. . We made the following changes to your medications: STOPPED Amlodipine . It was a pleasure taking care of you during your hospital stay. Followup Instructions: -You have an appointment scheduled with Dr. [**Last Name (STitle) **]: Monday [**2153-11-26**] at 11:30 AM -You should also make a follow up appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Completed by:[**2153-11-20**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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41586+58458

Discharge summary

report+addendum

Admission Date: [**2107-3-31**] Discharge Date: [**2107-4-16**] Date of Birth: [**2045-7-13**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Brain mass Major Surgical or Invasive Procedure: [**4-1**] EVD Placement [**4-6**] Left craniotomy for tumor resection History of Present Illness: History is obtained from outside records. Patient was in her usual state of health, although reportidly with altered personality as of the past month. She had spoken to her friend around 8:40 this morning before getting into the shower and was found around 11 am with slurred speech. EMS was called at this time. On their arrival the patient had right sided weakness and developed respiratory distress and was intubated. Upon arrival at the outside facility a CT was obtained that showed a large parietal tumor with significant midline shift. She was given 25 of mannitol, 500mg of Keppra and sedated and transferred on sedation. Past Medical History: HTN, diabetes, Gastric bypass, history of a meningoma resected by Dr. [**First Name (STitle) **] five years ago. Social History: unknown Family History: unknown Physical Exam: Gen: intubated sedated on propofol. HEENT: Pupils: 1.5 minimally reactive Lungs: CTA bilaterally. Cardiac: RRR. Abd: Soft, Extrem: Warm and well-perfused. Neuro: Unarousable to voice or deep stimuli, grimaces to pain only. No corneal on the right, positive on left. Positive cough with deep suction Motor: withdraws to nox on right and moves left spontaneously. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. Toes downgoing bilaterally Upon discharge: neuro exam intact, wound well healed PHYSICAL EXAM UPON DISCHARGE: ******* Pertinent Results: [**4-1**] Head CT: 1. Interval decompression of the entrapped left lateral ventricle status post placement of an external ventricular drain. 2. Hyperdense lesion in the trigone of the left lateral ventricle along with satellite lesions is consistent with meningiomas. 3. Unchanged slight rightward deviation of the normally midline structures. No evidence of uncal or transtentorial herniation. [**3-31**] BRAIN MRI: Left atrial memingioma with trapped left temporal and occipital horns with periventricular edema [**4-2**] Head CTA: IMPRESSION: 1. Continued interval decompression of the entrapped left temporal [**Doctor Last Name 534**] status post placement of an external ventricular drain. 2. Stable hyperdense lesions in the trigone of the left lateral ventricle compatible with meningiomas. [**4-4**] Head CTA: IMPRESSION: 1. Unchanged dense, enhancing lesions in the trigone of the left lateral ventricle, likely meningiomas. Distention of the temporal [**Doctor Last Name 534**] of the left lateral ventricle has improved in the presence of the ventriculostomy catheter. 2. Unremarkable CTA and CTV of the head. [**4-6**] Brain MRI: IMPRESSION: Limited enhanced MR examination, re-demonstrating the uniformly-enhancing intraventricular mass centered in the left lateral ventricular atrium, with imaging characteristics most suggestive of meningioma. There is continued "trapping" of this occipital [**Doctor Last Name 534**], while the temporal [**Doctor Last Name 534**] has been decompressed by ventriculostomy. [**4-6**] CT Head: IMPRESSION: Post-surgical changes with peri-operative appearance of left craniotomy and tumor resection. Details as above. Follow up as clinically indicated. [**4-7**] MRI Head: IMPRESSION: 1. Post-surgical changes, with enhancement of the left-sided dura as well as the surgical resection cavity margins. Evaluation for residual tumor is limited. Consider followup evaluation to assess stability/progression. 2. Mild mass effect with shift of the midline structures to the right side, with a moderate-sized pneumocephalus, which is seen to indent the left cerebral hemisphere,as seen on the prior CT study. Attention on close followup as clinically indicated. 3. Difuse mucosal thickening/fluid in the left mastoid air cells. Other details as above. Brief Hospital Course: Pt admitted to the ICU on the Neurosurgical service for q1hr neuro checks. An MRI brain with contrast was obtained STAT. She was started on Decadron 4mg Q6hrs, Keppra 500mg to be given in ED, then 1000mg [**Hospital1 **] and Pepcid. SBP was kept less than 140 and she was preopped for surgery. In the AM [**4-1**] she was taken to the OR and had a ventriculostomy placed into her trapped ventricle. Surgery was without complication and she tolerated it well. Post op head CT revealed good placement of catheter and no hemorrhage. After surgery she was purposeful with all of her extremities and was intermittently following commands. On [**4-2**] and [**4-3**] she remained in the ICU on the ventilator while awaiting surgical plan. On [**4-4**] she was deemed fit to extubate which was done so without complication. She was taking a PO diet and was planned for the OR on Wednesday [**4-6**]. On 3.2 she was taken to the OR for a left sided craniotomy for resection of her left intraventricular tumor. While in the OR her EVD was removed. She tolerated the procedure well, was extubated in the OR and transported to the ICU for further care. She was verbally responsive and moving all of her extremities in the immediate post-op period. Head CT revealed post op changes. Dilantin level was 3 therefore it was reloaded. On 3.3 she was neurologically stable and cleared for transfer to the stepdown. She remained in the ICU due to bed shortage. An MRI was obtained which revealed limited residual tumor. On 3.4 she was cleared for transfer to the floor. PT And OT were consulted for assistance with discharge planning. She remained stable over the weekend while awaiting dispo to rehab. She began getting screened on [**4-11**]. Her steroids were weaned to off. She was maintained on therapeutic levels of dilantin - she had level of 4.7 on [**4-14**] and received bolus of 500mg. She was discharged to rehab on the afternoon of [**2107-4-15**] Medications on Admission: ASA, Tuiamterene, HCTZ, lachydrin Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 10. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP>160. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Heritage Manor Discharge Diagnosis: meningioma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please return to the office in [**8-14**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**7-18**] at 11:15AM on [**Hospital Ward Name 23**] 4 for MRI then at 1PM at The Brain [**Hospital 341**] Clinic on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ??????You will need an MRI of the brain with and without gadolinium contrast. You also require a blood test to measure your BUN and Cr within 30 days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **] please make sure to have these results with you, when you come in for your appointment. ***Please have your daughter call The Brain [**Hospital 341**] Clinic to sign a release for medical records. Completed by:[**2107-4-15**] Name: [**Known lastname 14285**],[**Known firstname **] Unit No: [**Numeric Identifier 14286**] Admission Date: [**2107-3-31**] Discharge Date: [**2107-4-16**] Date of Birth: [**2045-7-13**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 599**] Addendum: Pt remained in the hospital until [**2107-4-16**] because she her/her family refused the facility transfer yesterday. Her asa was restarted and her BTC appointment changed to allow for more immediate follow up. Discharge Disposition: Extended Care Facility: Heritage Manor [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2107-4-16**]

[ "780.39", "278.00", "348.30", "250.00", "V45.86", "348.5", "225.2", "331.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "01.51", "96.6", "02.39" ]

icd9pcs

[ [ [] ] ]

11487, 11665

4224, 6173

319, 392

7378, 7378

1897, 1907

9602, 11464

1230, 1239

6257, 7259

7344, 7357

6199, 6234

7529, 9579

1254, 1618

269, 281

1869, 1878

1801, 1839

420, 1052

1634, 1785

3446, 4201

1916, 3437

7393, 7505

1074, 1189

1205, 1214

24,471

156,001

29996

Discharge summary

report

Admission Date: [**2144-2-14**] Discharge Date: [**2144-3-3**] Date of Birth: [**2086-4-23**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: 3.26 CABG x 2 (LIMA->LAD, SVG->RAMUS) History of Present Illness: 57 yo M went to ER [**2-12**] with c/o chest pain. Known CAD since [**2138**]. Past Medical History: IDDM, HTN, MI, hyperchol, R fibula fracture [**10/2143**] treated now with PT, obesity Social History: disabled, used to work in school maintenance - tob - etoh Family History: Mother deceased at age 68 from " severe HTN" Physical Exam: NAD, HR 56, RR 18 B/P right 115/78 Lungs CTAB ant/lat CV RRR Abd soft/NT/ Obese Extrem with 1+LE edema Pertinent Results: [**2144-2-14**] 05:19PM GLUCOSE-175* UREA N-12 CREAT-0.8 SODIUM-142 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15 [**2144-2-14**] 05:19PM ALT(SGPT)-27 AST(SGOT)-25 LD(LDH)-232 ALK PHOS-95 AMYLASE-38 TOT BILI-0.4 [**2144-2-14**] 10:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.031 [**2144-2-14**] 10:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2144-2-14**] 05:19PM PT-12.0 PTT-24.8 INR(PT)-1.0 [**2144-2-14**] 05:19PM PLT COUNT-265 [**2144-2-14**] 05:19PM WBC-15.0* RBC-4.72 HGB-12.8* HCT-38.7* MCV-82 MCH-27.1 MCHC-33.1 RDW-15.4 [**2144-2-17**] ECHO The left and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. [**2144-2-20**] Chest CT 1. Post-surgical changes are seen from recent CABG, including a clean sternotomy defect and subcutaneous air. There is a small fluid collection posterior to the sternotomy defect, without associated findings concerning for superimposed infection. 2. Pericardial effusion and small bilateral pleural effusions. 3. Small left apical pneumothorax. [**2144-2-23**] Chest CT 1. Typical postoperative appearance with moderate pericardial effusion and small amount of retrosternal fluid without clear abscess identified. There is a prevascular lymph node measuring 1.2 cm in short axis as well as scattered subcentimeter mediastinal lymph nodes. 2. Air is identified within the lumen of the bladder. Please correlate with recent instrumentation. [**2144-2-29**] CXR The patient is status post sternotomy. There is cardio megaly. There is blunting of the left costophrenic angles consistent with the pleural effusion. The lungs are clear with no evidence of any consolidation. Right PICC catheter is in situ, the tip of which is in the SVC. Brief Hospital Course: Mr. [**Known lastname 16479**] was admitted to cardiac surgery preoperatively, He was taken to the operating room on [**2-17**] where he underwent a CABG x 2 (LIMA->LAD, SVG->Ramus). He was transferred to the ICU in critical but stable condition. He was extubated later that same day. He was seen in consultation by [**Last Name (un) **] for his history of diabetes and high preop hemoglobin A1C. He was restarted on his lantus and avandia. He was transferred to the floor on POD #1. He went into rapid afib and was started on amiodarone and eventually heparin and coumadin. He was found to have some sternal drainage and was started on vancomycin and cipro. His blood sugars continued to be high and he was followed closely by [**Last Name (un) **] who continued to increase his Lantus and humalog insulin. CT scan of his chest showed no evidence of infection. Strict sternal precautions were maintained. Cultures of his sternal drainage were negative however given the amount of drainage, antibiotics were continued. The drainage subsided, and at the time of discharge he had no sternal drainage for four days, he will take Levofloxacin for 2 weeks. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Atorvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* 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:*0* 8. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200 mg [**Hospital1 **] for 6 days, then 200 mg daily ongoing. Disp:*60 Tablet(s)* Refills:*0* 10. Lantus 100 unit/mL Cartridge Sig: 56 QAM/52 QPM units Subcutaneous once a day: 56 units lantus QAM 52 units lantus QPM. Disp:*QS 1 month* Refills:*0* 11. Humalog 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous four times a day. Disp:*QS 1 month* Refills:*0* 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 13. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime for 2 doses. Disp:*60 Tablet(s)* Refills:*0* 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: 40 [**Hospital1 **] x 10 days then 20 mg daily as prior to surgery. Disp:*30 Tablet(s)* Refills:*0* 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 10 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: CAD IDDM HTN MI lipids right fibula fracture obesity Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No lifting more than 10 pounds or driving. Shower, no baths, no lotions, creams or powders to incisions. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 29070**] 2 weeks Wound check 1 week Coumadin to be followed by Dr. [**Last Name (STitle) **]. Completed by:[**2144-3-3**]

[ "423.9", "250.92", "411.1", "414.01", "512.1", "E878.8", "E849.7", "401.9", "278.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.93", "36.11", "39.61" ]

icd9pcs

[ [ [] ] ]

6532, 6615

3331, 4484

288, 328

6712, 6720

823, 3308

6990, 7216

637, 684

4507, 6509

6636, 6691

6744, 6967

699, 804

238, 250

356, 436

458, 546

562, 621

1,217

145,268

145

Discharge summary

report

Admission Date: [**2125-4-5**] Discharge Date: [**2125-4-12**] Date of Birth: [**2072-2-15**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 53-year-old gentleman who went to see his primary care physician for his yearly physical. At that time, he reported a 1-year history of burning substernal chest pain with exertion. He underwent an exercise treadmill test which was positive and subsequently underwent cardiac catheterization which showed an ejection fraction of 55%, 90% left main coronary artery, 90% proximal left anterior descending artery, 60% to 80% left circumflex, and a proximally occluded right coronary artery. The patient was referred to Dr. [**Last Name (STitle) 1537**] for urgent coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia 3. Gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg by mouth once per day. 2. Lipitor 40 mg by mouth once per day. 3. Zantac 150 mg by mouth twice per day. SOCIAL HISTORY: The patient lives at home with his wife and his two children. He works in construction. Positive tobacco with half a pack per day for 40 years. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to [**Hospital1 69**] and taken to the operating room on [**2125-4-6**] with Dr. [**Last Name (STitle) 1537**] for a coronary artery bypass graft times three. Left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. The patient had an intra-aortic balloon pump placed in the Cardiac Catheterization Laboratory due to his difficult anatomy and that remained during his surgery. The patient was transferred to the Intensive Care Unit in stable condition on a Neo-Synephrine infusion. Postoperatively, the patient requried a moderate amount of volume resuscitation. Due to his elevated filling pressures and some minor postoperative electrocardiogram changes, a transesophageal echocardiogram was performed at the bedside which showed a normal ejection fraction with no wall motion abnormalities. The patient's hemodynamics improved over the next couple of hours. On postoperative day one, the patient was weaned and extubated from mechanical ventilation. The intra-aortic balloon pump was removed without difficulty. The Neo-Synephrine was weaned to off. On postoperative day two, the patient was started on Lopressor which he tolerated well. On postoperative day three, the patient's chest tubes were removed without difficulty as well as his pacing wires. On postoperative day four, the patient's hematocrit was noted to be down to 21. The patient was not symptomatic and had stable vital signs. It was discussed with Dr. [**Last Name (STitle) 1537**], and a transfusion was deferred. On postoperative day five, the patient continued to ambulate with Physical Therapy. On postoperative day six, the patient's hematocrit was noted to be down to 20.8. The decision was made to transfuse the patient; however, the patient refused a blood transfusion. The risks of refusing a transfusion were discussed with him. As the patient remained hemodynamically stable, with no evidence of orthostasis, a stable blood pressure, and stable oxygen saturation, the blood transfusion was deferred. The patient had been started on iron and vitamin C. On postoperative day seven, the patient worked with Physical Therapy and was able to walk 500 feet and climb one flight of stairs. The patient's hematocrit had risen to 21.1, and it was felt the patient was appropriate for discharge to home. CONDITION AT DISCHARGE: Temperature maximum was 99.2, pulse was 82 (in sinus rhythm), blood pressure was 119/66, respiratory rate was 16, and oxygen saturation 96% on room air. Laboratory data red white blood cell count was 9.2, hematocrit was 21.1, and platelet count was 330. Potassium was 4, blood urea nitrogen was 27, and creatinine was 1. Neurologically, the patient was awake, alert, and oriented times three. Heart regular in rate and rhythm without murmurs. Breath sounds were clear bilaterally. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Tolerating a regular diet. The sternal incision was clean, dry, and intact. The sternum was stable. Lower extremities revealed 1 to 2+ pitting edema. Vein harvest site was clean, dry, and intact. There was no erythema or drainage. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft. 3. Postoperative anemia. MEDICATIONS ON ADMISSION: 1. Lopressor 75 mg by mouth twice per day. 2. Lasix 20 mg by mouth twice per day (times seven days). 3. Potassium chloride 10 mEq by mouth twice per day (times seven days). 4. Colace 100 mg by mouth twice per day. 5. Zantac 150 mg by mouth twice per day. 6. Enteric-coated aspirin 325 mg by mouth every day. 7. Lipitor 40 mg by mouth once per day. 8. Niferex 150 mg by mouth once per day. 9. Vitamin C 500 mg by mouth twice per day. 10. Ibuprofen 600 mg by mouth q.6h. as needed. 11. Dilaudid 2 mg to 6 mg by mouth q.6h. as needed. 12. Multivitamin one tablet by mouth once per day. DISCHARGE STATUS: The patient to be discharged to home. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**Last Name (STitle) 1538**] in one to two weeks. 2. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in three to four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2125-4-12**] 16:25 T: [**2125-4-12**] 16:50 JOB#: [**Job Number 1542**]

[ "278.00", "530.81", "285.1", "272.0", "305.1", "411.1", "414.01", "429.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "88.56", "88.72", "37.22", "37.64", "37.61", "88.53", "36.15" ]

icd9pcs

[ [ [] ] ]

4556, 4658

4685, 5356

5413, 5925

1286, 3721

5371, 5380

176, 783

805, 924

1104, 1257

27,661

108,415

31449+57753

Discharge summary

report+addendum

Admission Date: [**2129-7-9**] Discharge Date: [**2129-8-25**] Date of Birth: [**2050-1-29**] Sex: M Service: CARDIOTHORACIC Allergies: Haldol / Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: Transfer from [**Hospital1 **] for persistent fevers Major Surgical or Invasive Procedure: [**8-12**] AVR (#21 Biocor) History of Present Illness: 79 yo male with very complicated pmhx including critical AS s/p valvuloplasty, IDDM, PAF, MRSA pneumonia and c-diff, recently discharged from [**Hospital1 18**] on [**2129-7-1**] after being admitted for hypotension, and fevers, thought to be secondary to pseudomnal pneumonia. The patient was initially on broad spectrum antibiotics, which were eventually narrowed to Ciprofloxacin once sensitivities were obtained. The patient was discharged to [**Hospital3 **] for further treatment and rehab. He completed his course of Cipro on [**2129-7-4**], but then spiked on [**2129-7-5**]. Vancomycin and Ceftaz were started, cultures were sent. Sputum culture returned with evidence of pseudomonas, resistant to Ciprofloxacin, and MRSA. The patient also had an episode of a-fib with RVR which responded well to oral diltiazem. Given that the patient has had intermittent fevers since admission to [**Hospital1 **] and has poor progress in weaning from the ventilator, the patient's family requested transfer back to [**Hospital1 18**] ICU. In addition, the family notes great concern over the patients increasing lethargy. . On arrival to the [**Hospital Unit Name 153**], the patient denies pain or difficulty breathing, able to follow minimal commands. On speaking with the daughter, she states that her father had the recurrent fever a few days ago, seemed improved after the antibiotics were restarted, but then appeared more lethargic yesterday. She states that at his baseline his is alert, aware of his surroundings, able to move his L arm, wiggle his toes, and move his ankles. Past Medical History: (obtained from prior dc summary as pt unable to provide) 1. s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month hospital stay at [**University/College **], with trach placed [**2129-5-25**] after several intubations for hypercarbic respiratory failure 2. CAD- left heart cath done at [**University/College **] revealed non-obstructive CAD, severe AS, mod pulm htn, nml EF (60%) 3.chronically depressed mental status critical 4. AS s/p valvuloplasty- done in [**4-4**] at [**University/College **], repeated 2 weeks later 3. A fib 4. chronic b/l pleural effusions 5. anemia 6. MRSA PNA 7. pseudomonal PNA 8. Diabetes 9. chronic, severe generalized myopathy with mild membrane instability, and evidence for a moderate peroneal neuropathy at the right fibular neck seen on EMG on [**5-/2129**] Social History: Non-smoker. Currently at [**Hospital **] rehab. Has several children. Daughter [**First Name8 (NamePattern2) **] [**Name2 (NI) 74057**] is a nurse and makes many of his health decisions. Family History: non-contributory Physical Exam: vitals: 101.2/108/ 36/ 101/74/ 100% vent: AC/.60/450(366)/14(22)/5 GEN: elderly male, lying semi-upright, appears somewhat distressed HEENT: atraumatic, anicteric sclera, EOMI, dry mucosa, OP clear NECK: difficult to assess JVP, no LAD, trach in place, site clean CV: tachy, irregular, [**2-1**] holosystolic murmur radiates to axilla, radial pulses equal LUNGS: coarse BS, crackles at bases B/L, no wheeze ABD: soft, nt, nd, NABS, G-tube in place, site clean EXT: 3+ pitting edema, anasarca. Multiple petichiae on UE B/L, DP pulses faint but palpable. Right PICC site appears clean NEURO: awake, able to follow commands including open his eyes, move his tongue, does not move extremities on command or spontaneously, diminished reflexes B/L Pertinent Results: Labs from rehab: sputum [**7-5**]: pseudomonas, sensitive to cefepime, ceftaz, gent, imipenem, zosyn sputum [**7-1**]: pseudomonas and MRSA- MRSA sensitive to Bactrim urine culture [**7-5**]: no growth blood culture [**7-5**]: 1/4 bottles CNS ABG [**7-9**]: 7.49/51/89/39 INR- 1.4 CBC [**7-8**]: . prior studies- Echo [**2129-6-27**]: IMPRESSION: Moderate aortic valve stenosis. Mild symmetric left ventricular hypertrophy with normal cavity sizes and regional/global biventricular systolic function. Mild mitral regurgitation. . EEG [**7-5**]: IMPRESSION: Abnormal portable EEG due to the generalized bursts of slowing, including very sharp features and sharp waves in the central regions bilaterally. These finding suggest a midline disturbance but are not specific with regard to etiology. The sharp features are evidence of cortical hypersynchrony and could be related to an epileptic process but also to a metabolic disturbance. There were no prominent focal areas of slowing. The background reached acceptable frequencies but was disorganized, raising the possibility of an encephalopathy, as suggested by the clinical report. . MR HEAD [**6-4**]: 1. No evidence of an acute infarction. 2. Small chronic lacunar infarction in the body of the right caudate nucleus. 3. Mucosal thickening and air/fluid level of the right maxillary sinus consistent with acute sinusitis. 4. No arterial occlusion or evidence of stenosis in the circle of [**Location (un) 431**]. 5. Possible fenestration of the proximal basilar artery. . LABS AT [**Hospital1 18**] [**2129-7-9**] 11:01PM BLOOD WBC-12.8*# RBC-2.49* Hgb-7.3* Hct-22.8* MCV-92 MCH-29.4 MCHC-32.0 RDW-16.9* Plt Ct-209 Neuts-91.9* Lymphs-3.0* Monos-4.2 Eos-0.5 Baso-0.3 PT-23.7* PTT-51.3* INR(PT)-2.4* Glucose-113* UreaN-50* Creat-1.0 Na-139 K-4.0 Cl-95* HCO3-41* AnGap-7* ALT-74* AST-65* LD(LDH)-153 AlkPhos-256* Amylase-21 TotBili-0.9 Lipase-15 Albumin-2.1* Calcium-8.4 Phos-3.5 Mg-2.3 [**2129-7-9**] 11:17PM BLOOD Type-ART pO2-114* pCO2-56* pH-7.49* calTCO2-44* Base XS-17 Lactate-1.4 [**2129-7-10**] 03:01PM BLOOD Lactate-1.0 [**2129-7-10**] 10:38AM BLOOD ALT-64* AST-52* AlkPhos-232* TotBili-0.9 [**2129-7-12**] 04:32AM BLOOD WBC-9.3 RBC-2.55* Hgb-7.6* Hct-23.6* MCV-93 MCH-30.0 MCHC-32.3 RDW-16.9* Plt Ct-264 PT-23.0* PTT-48.1* INR(PT)-2.3* Glucose-64* UreaN-51* Creat-1.2 Na-138 K-3.9 Cl-98 HCO3-34* AnGap-10 Calcium-8.6 Phos-3.8 Mg-2.4 [**2129-7-12**] 08:05AM BLOOD Genta-7.0 TROUGH [**2129-7-12**] 09:48AM BLOOD Genta-11.4* PEAK . ABG'S: [**2129-7-10**] 12:31PM BLOOD Type-ART pO2-36* pCO2-58* pH-7.46* calTCO2-42* Base XS-14 [**2129-7-10**] 03:01PM BLOOD Type-ART Temp-36.8 Rates-14/15 Tidal V-400 PEEP-10 FiO2-40 pO2-72* pCO2-49* pH-7.50* calTCO2-40* Base XS-12 -ASSIST/CON Intubat-INTUBATED [**2129-7-11**] 05:31AM BLOOD Type-ART Temp-38.2 Rates-26/14 Tidal V-450 PEEP-5 FiO2-40 pO2-90 pCO2-53* pH-7.46* calTCO2-39* Base XS-11 Intubat-INTUBATED Vent-CONTROLLED [**2129-7-12**] 03:30PM BLOOD Type-ART Temp-36.9 Rates-/32 Tidal V-380 PEEP-5 FiO2-40 pO2-67* pCO2-62* pH-7.38 calTCO2-38* Base XS-8 Intubat-INTUBATED Vent-SPONTANEOU . MICRO: [**2129-7-9**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [**2129-7-10**] URINE URINE CULTURE-FINAL NO GROWTH [**2129-7-10**] URINE Legionella Urinary Antigen -FINAL NEGATIVE [**2129-7-10**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [**2129-7-10**] 5:22 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2129-7-12**]** GRAM STAIN (Final [**2129-7-10**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2129-7-12**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM------------- 1 S PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S . [**2129-7-10**] 9:27 am STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2129-7-12**]** FECAL CULTURE (Final [**2129-7-12**]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2129-7-12**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2129-7-11**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [**2129-7-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEGATIVE . ECG Study Date of [**2129-7-10**] 2:28:04 AM Atrial fibrillation with controlled ventricular response. Occasional ventricular premature beats. Underlying intraventricular conduction delay. Compared to tracing of [**2129-6-27**] no definite change. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Rate PR QRS QT/QTc P QRS T 96 0 110 342/395.57 0 -29 123 . IMAGING [**2129-7-9**] PORTABLE CXR: IMPRESSION: AP chest compared to [**6-13**] through [**6-29**]: Severe consolidation in the right lung has worsened since [**6-27**]. Milder interstitial abnormality in the left lung probably represents residual edema or scarring. Moderate cardiomegaly unchanged. Pleural effusion may be present, but is not appreciable in size. Tracheostomy tube in standard placement. No pneumothorax. [**2129-7-12**] PORTABLE CXR: The tracheostomy is in unchanged position. The diffuse pulmonary process, more severe in right lung, has not significantly changed since the previous exam but overall is gradually worsening since [**6-29**]. The bilateral pulmonary edema is of unchanged stability. The mild cardiomegaly is stable. Small bilateral pleural effusions are again noted, although cannot be precisely appreciated due to the fact that the most lateral costophrenic angles were not included in the field of view. IMPRESSION: Probable, overall slight worsening of pulmonary edema and right lower lobe consolidation. . [**7-18**] Echocardiogram: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. . Chest CT [**2129-7-26**]: 1. Dense calcification of the aortic valve. 2. Pulmonary edema. A component of chronic interstitial lung disease may be present . Colonoscopy [**2129-7-27**]: Multiple diverticuli, no obvious bleeding Cardiology Report ECHO Study Date of [**2129-8-19**] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. H/O cardiac surgery. Left ventricular function. Height: (in) 76 Weight (lb): 266 BSA (m2): 2.50 m2 BP (mm Hg): 131/71 HR (bpm): 84 Status: Inpatient Date/Time: [**2129-8-19**] at 11:27 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W038-0:14 Test Location: West SICU/CTIC/VICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.0 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 70% (nl >=55%) Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm) Aortic Valve - Peak Velocity: *3.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 40 mm Hg Aortic Valve - Mean Gradient: 22 mm Hg Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - E Wave Deceleration Time: 239 msec TR Gradient (+ RA = PASP): *26 to 43 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV systolic function. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Increased AVR gradient. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Conclusions: The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is normal. The aortic root is mildly dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2129-7-18**], the aortic valve has been replaced. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2129-8-19**] 12:35. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] RADIOLOGY Final Report CHEST (PORTABLE AP) [**2129-8-19**] 4:54 AM CHEST (PORTABLE AP) Reason: s/p AVR w/hypotension-r/o PTX [**Hospital 93**] MEDICAL CONDITION: 79 year old man with AVR w/ hx of pna prior to surgery REASON FOR THIS EXAMINATION: s/p AVR w/hypotension-r/o PTX INDICATION: Pneumonia and AVR surgery. FINDINGS: In comparison with the study of [**8-17**], the patient is no longer obliqued. There is again evidence of median sternotomy and aortic valve replacement. The cardiac silhouette remains grossly enlarged, though stable. There is again prominence of interstitial markings. Elevation of the right hemidiaphragm is again seen, making it difficult to evaluate the lung behind it. Probable small bilateral pleural effusions. Tracheostomy tube remains in place. Right central catheter extends to just above the carina. IMPRESSION: Little overall interval change. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: FRI [**2129-8-19**] 10:22 AM [**2129-8-19**] 9:30 am URINE Source: Catheter. **FINAL REPORT [**2129-8-22**]** URINE CULTURE (Final [**2129-8-22**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R CIPROFLOXACIN--------- =>8 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2129-8-25**] 03:37AM 10.1 2.92* 8.8* 26.5* 91 30.1 33.1 17.0* 177 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2129-8-25**] 03:37AM 177 Source: Line-aline 15.0* 38.4* 1.3* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2129-8-25**] 03:37AM 127* 50* 1.1 142 3.6 107 30 9 Brief Hospital Course: 79 yo male s/p [**Year (4 digits) 8751**] with multiple medical problems, s/p trach placement in [**2129-4-29**], vent-dependent, who was recently discharged from [**Hospital1 18**] after being treated for pneumonia, admitted for persistent fevers and increased lethargy, being treated for VAP, now with intermittently decreasing HCT and severe AS. . Preoperatively, Balancing blood pressure with volume overload was challenging, as diuresis limited by hypotension. Hypotension improved with decreased PEEP. It was felt that his volume overload and hypotension were most likely secondary to his atrial fibrillation and severe aortic stenosis. Cardiac surgery was consulted who felt that valve replacement had only approximately a 30% chance of success but agreed to perform the procedure. Prior to surgery he was placed on a lasix drip to attempt to remove some volume with modest success. He was transferred to the CCU prior to valve replacement. His platelet count dropped and he had a negative HIT/SRA. Patient with slow GI bleed throughout this hospitalization with black tarry stool. He had evidence of gastritis and duodenotis on EGD on [**7-18**] without evidence of active bleeding. He had multiple blood transfusions. He underwent colonoscopy on [**7-27**] which showed evidence of diverticulosis but no evidence of active bleeding. His trach was changed 3x secondary to persistent leak, tracheomalacia extending to both mainstem bronc's noted, currently with 8.0 [**Last Name (un) **]. He had evidence of a resistant pseudomonal VAP sensitive to imipenim and cefepime from culture results from [**Hospital1 **] and [**Hospital1 18**]. Treated with imipenem and then cefepime for total of 14d pseudomonal coverage. Also treated MRSA given sensitivities of sputum culture from OSH (Was on bactrim [**2039-7-9**], vanc [**2044-7-14**]). His sputum has continued to grow the same pansensitive organism as previously, likely colonization. On [**2129-8-12**] he was taken tot he operating room where he underwent AVR with 21mm biocor valve. He was transferred to the ICU in critical but stable condition. He was transfused several times. His #8 trach was replaced on [**8-14**]. His vasoactive drips were weaned to off by POD #4. Aggressive diuresis continued. Over the next week he continued to be diuresed and his betablockers were restarted. Post operatively the patient was seen by the GI service as he had intermittant guiac positive stool but no melana or [**Month/Year (2) **] bleeding, he was transfused w/PRBC's and PPI was changed to [**Hospital1 **] dosing. He was scoped from above and below just before surgery, at that time he was found to have diverticulosis and mild gastritis. By POD13 it was felt the patient was stable and ready for discharge to [**Hospital3 **] Center. Medications on Admission: meds on transfer: Aspirin bacitracin ointment ceftazidime (started [**7-5**]) vancomycin (started [**7-5**]) citalopram vitamin B12 thiamine folate diltiazem colace iron lasix atrovent insulin- 35 units glargine/humalog sliding scale multivitamins ranitidine warfarin albuterol Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: Through [**8-28**]. 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month hospital stay at [**University/College **], with trach placed [**2129-5-25**] after several intubations for hypercarbic respiratory failure 2. CAD- left heart cath done at [**University/College **] revealed non-obstructive CAD, severe AS, mod pulm htn, nml EF (60%) 3.chronically depressed mental status critical 4. AS s/p valvuloplasty- done in [**4-4**] at [**University/College **], repeated 2 weeks later 3. A fib 4. chronic b/l pleural effusions 5. anemia 6. MRSA PNA 7. pseudomonal PNA 8. Diabetes 9. chronic, severe generalized myopathy with mild membrane instability, and evidence for a moderate peroneal neuropathy at the right fibular neck seen on EMG on [**5-/2129**] Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No baths, no lotions, creams or powders to incisions. Followup Instructions: Dr. [**Last Name (STitle) **] 1 month or after d/c from rehab Dr. [**First Name (STitle) **] after discharge from rehab Completed by:[**2129-8-25**] Name: [**Known lastname 2977**],[**Known firstname 785**] L Unit No: [**Numeric Identifier 12265**] Admission Date: [**2129-7-9**] Discharge Date: [**2129-8-25**] Date of Birth: [**2050-1-29**] Sex: M Service: CARDIOTHORACIC Allergies: Haldol / Heparin Agents Attending:[**First Name3 (LF) 4551**] Addendum: Discharge diagnosis should also read: AS s/p AVR (#21 Biocor) [**8-12**] Major Surgical or Invasive Procedure: [**8-12**] AVR (#21 Biocor) Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU Discharge Diagnosis: 1)s/p AVR(#21 Biocor tissue) 2)UTI-VRE(tx w/Linesolid) PMH: 1)s/p MVC with multiple traumas in [**2-2**] with prolonged 4 month hospital stay at [**University/College 12215**], with trach placed [**2129-5-25**] after several intubations for hypercarbic respiratory failure 2)CAD- left heart cath done at [**University/College 12215**] revealed non-obstructive CAD, severe AS, mod pulm htn, nml EF (60%) 3)chronically depressed mental status 4)AS s/p valvuloplasty- done in [**4-4**] at [**University/College 12215**], repeated 2 weeks later 5)A fib 6)chronic b/l pleural effusions 7)anemia 8)MRSA PNA 9)pseudomonal PNA 10)Diabetes 11)chronic, severe generalized myopathy with mild membrane instability, and evidence for a moderate peroneal neuropathy at the right fibular neck seen on EMG on [**5-/2129**] 12)Diverticulosis [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2129-8-31**]

[ "276.3", "428.0", "562.12", "482.1", "999.9", "427.31", "E929.0", "V46.11", "287.5", "359.81", "414.01", "424.1", "V09.0", "482.41", "599.0", "584.9", "535.50", "458.29", "933.1", "416.0", "518.83", "311", "535.60", "V12.51", "519.09", "250.80", "280.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "39.61", "45.23", "38.93", "35.21", "96.56", "96.6", "96.72", "99.07", "97.23", "45.13", "99.04", "33.21", "99.05", "89.60" ]

icd9pcs

[ [ [] ] ]

23255, 23321

17146, 19948

23202, 23232

22344, 22352

3842, 11109

22572, 23164

3043, 3061

20277, 21463

15058, 15113

23342, 24323

19974, 19974

22376, 22549

11135, 14764

3076, 3823

250, 305

15142, 17123

401, 1993

14796, 15021

2015, 2822

2838, 3027

19992, 20254

23,450

152,360

51159

Discharge summary

report

Admission Date: [**2161-9-18**] Discharge Date: [**2161-9-22**] Date of Birth: [**2085-4-1**] Sex: M Service: MEDICINE CCU HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with past medical history of coronary artery disease status post three vessel CABG in [**2156**]. He had a LIMA to the LAD, saphenous vein graft to the PDA, and saphenous vein graft to OM-1. This was stented four years ago, congestive heart failure with an ejection fraction of 25%, chronic renal insufficiency, and left bundle branch block, who presented to the Emergency Room after an episode of bradycardia with his heart rate in the 30s, and was found to have 2:1 heart block. The patient states that he had been well until today. He exercised on a treadmill 30 minutes every 3-4 days. The morning of admission he noted some blurry vision, some nausea, vomiting and dizziness. He rested and the symptoms resolved. Later in the morning he had three further episodes of lightheadedness with standing, but no syncope. He had taken his blood pressure and it was 116/60 with a heart rate of 35. He called his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who had told him to go to the Emergency Room. The patient denied any chest pain, shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, increasing edema, or palpitations. He has had a history of syncopal episode in [**2161-12-12**], after which he was admitted to [**Hospital **] Hospital. All of his cardiac workup had been negative. He did have a stress test at that time, and a 24 hour Holter monitor, which did not show an explanation for his syncope. The patient has not recently had any medication changes or any new medications added to his regimen. REVIEW OF SYSTEMS: He has no other complaints. No numbness or tingling, no loss of bowel or bladder continence. No fever or chills. No abdominal pain. No recent insect bites. In the Emergency Room, he had a right IJ placed through which a temporary wire was placed, and he was VVI paced at 50 with a threshold of 0.5 to 1 milliamps. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction and coronary artery bypass graft in [**2156**]. 2. Congestive heart failure with an ejection fraction of 20-25%. 3. Gout. 4. Hypertension, normal runs 116/60. 5. Prostate cancer status post XRT and hormone therapy. 6. Obese. 7. Ocular melanoma in his left eye status post proton-beam therapy. 8. Chronic renal insufficiency. 9. Cholecystectomy. MEDICATIONS: 1. Aspirin 325 q day. 2. Zestril 20 q day. 3. Metoprolol 50 [**Hospital1 **]. 4. Lipitor 20 q day. 5. Terazosin 2 mg q hs. 6. Folic acid. 7. Flonase nasal spray. 8. [**Doctor First Name **] 60 q day. 9. Allopurinol 100 q day. 10. Zantac. ALLERGIES: He has an allergy to contrast dye years ago when he had his cholecystectomy. Since then, he has received contrast and had no adverse reactions. SOCIAL HISTORY: He is married with two children. He has social alcohol use in his teen years. No recent alcohol use, no tobacco smoking. FAMILY HISTORY: His father died at 68 of "cardiac causes." PHYSICAL EXAMINATION: Vital signs in the Emergency Room, he was afebrile. His temperature was 97.5, blood pressure 125/47, heart rate of 50, which was ventricular paced, sating 96% on room air. In general, he was an elderly white male sleeping comfortably in bed in no apparent distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Cardiovascular: Regular, rate, and rhythm, normal S1, S2. No murmurs, rubs, or gallops. No jugular venous distention, no carotid bruits. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, bowel sounds are present, no masses, guarding, or rebound tenderness, no hepatosplenomegaly. Extremities: No cyanosis, clubbing, or edema. He did have an area of 3 x 2 erythematous lesion on his left shin, which looked like a tinea infection. LABORATORIES ON ADMISSION: His white count was 6.6, hematocrit was 29.4, which was down from his baseline of 34. His Chem-7 was within normal limits. His CPK was 99, troponin was negative. STUDIES: Electrocardiogram on admission at 4:16 showed 2:1 heart block with an atrial rate of 70, ventricular rate of 35 consistent with second degree A-V delay type two. He also has an underlying left bundle branch block with a P-R interval of 320. Electrocardiogram at 18:17 just showed paced rhythm, heart rate of 50. The patient was admitted to Medicine to the CCU service. HOSPITAL COURSE BY SYSTEMS: 1. Cardiovascularly: For coronary arteries, he was continued on his aspirin, Lipitor, and ACE inhibitor. His beta blocker was held given the risk of complete heart block and his heart rate being in the low 50's. His cardiac enzymes were cycled and they were all negative. Of note, the date after admission, his electrocardiogram was consistent with complete heart block. Otherwise throughout his hospital stay, he was V-paced. The patient was awaiting permanent pacemaker placement on [**Last Name (LF) 766**], [**First Name3 (LF) **] the temporary pacemaker wire was left in until he had his permanent pacemaker. Myocardium: The patient's ejection fraction was 20-25%. This was unchanged. He was continued on his current medical management as he had no signs or symptoms of congestive heart failure at this time. The patient was started on the 11th on cefazolin 1 gram q8 x6 doses prior to pacemaker placement. On the afternoon of the 11th, the pacemaker was placed without event. The patient was started on Vancomycin 1 gram q12h x4 doses. Chest x-ray post pacemaker placement showed the leads in good position. 2. Heme: The patient's hematocrit had decreased from his baseline. A repeat hematocrit showed the hematocrit to be 28.5. Stool guaiac was done and it was negative, yet it was felt to be anemia secondary to blood loss, and the patient was transfused 1 unit. After the 1 unit, the patient's hematocrit remained stable throughout his hospital course. 3. Renal: The patient has chronic renal insufficiency. His hematocrit was at his baseline. His ACE inhibitor was continued as he was medically stable on this regimen. 4. Pulmonary wise: The patient took fluticasone and Atrovent as an outpatient, so he was continued on is outpatient inhalers. 5. Rheum: The patient has a history of gout. He was continued on his Allopurinol. 6. Allergy: He has seasonal rhinitis. He was continued on his [**Doctor First Name **]. 7. Prostate cancer status post XRT and hormone therapy: He was continued on his terazosin. 8. Infectious disease/tinea: The patient was started on Lamisil cream [**Hospital1 **]. 9. Fluids, electrolytes, and nutrition: The patient did have some magnesium replaced on the 11th, and the patient was in stable condition throughout his hospital course. He was discharged home the day after pacemaker placement. He remained afebrile throughout his hospital course and had no events overnight on telemetry. DISCHARGE INSTRUCTIONS: If he experienced any symptoms prior to those he experienced before his pacemaker was placed, had been given an instructions book about pacemakers, and if he were to have any questions he was given the number from the pacemaker clinic. He is to take all of his regular medicines per his normal routine except for the metoprolol. He was discharged with Percocet for pain. He is to take one tablet every 4-6 hours prn as needed. He was to continue using the cream for his rash for seven days. If this did not clear in seven days, to contact his PCP or dermatologist. He was being discharged on a three day course of Keflex. He was instructed to take one tablet po four times a day for three days and to take all pills. FINAL DIAGNOSIS: 1. Status post pacemaker placement. 2. Complete heart block. 3. Coronary artery disease status post coronary artery bypass graft. 4. Congestive heart failure. 5. Gout. 6. Tinea infection. 7. Prostate cancer. 8. Chronic renal insufficiency. RECOMMENDED FOLLOWUP: Follow up at your [**Hospital **] Clinic within the next week and call for the appointment. MAJOR SURGICAL OR INVASIVE PROCEDURES: He had an EP study and a DDD pacemaker placement. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. [**Doctor First Name **] 60 mg capsule po q day. 2. Atorvastatin 20 mg po q day. 3. Terazosin one 2 mg tablet po q hs. 4. Allopurinol 100 mg po q day. 5. Aspirin 325 mg po q day. 6. Terbinafine 1% cream applied topically [**Hospital1 **] as needed for rash x5 days. 7. Lisinopril 20 mg po q day. 8. Percocet one tablet po q4-6 as needed for pain. 9. Keflex 250 mg capsule po qid x3 days. CONDITION ON DISCHARGE: Stable. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2161-9-24**] 21:34 T: [**2161-9-27**] 11:17 JOB#: [**Job Number 106188**] cc:[**Last Name (NamePattern1) **]

[ "414.01", "110.5", "426.13", "428.0", "V45.82", "280.0", "V45.81", "412", "426.3" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.26", "37.72", "37.78" ]

icd9pcs

[ [ [] ] ]

8369, 8378

3106, 3150

8401, 8793

7899, 8347

7157, 7882

4667, 7132

3173, 4077

1789, 2109

169, 1769

4092, 4639

2131, 2948

2965, 3089

8818, 9124

29,092

104,637

43452

Discharge summary

report

Admission Date: [**2170-3-18**] Discharge Date: [**2170-3-22**] Date of Birth: [**2129-6-22**] Sex: M Service: MEDICINE Allergies: Aspirin / Hydralazine / Pyridium / Bactrim / Nitrofurantoin / Dapsone / Quinine / Quinidine / Methylene Blue Attending:[**First Name3 (LF) 3561**] Chief Complaint: Hypoglycemia. Major Surgical or Invasive Procedure: N/A History of Present Illness: 40 yo man with h/o VonGierke's dx with h/o hypoglycemia who presented to the ED [**3-18**] with 4-5 days of labile blood sugar and fatigue. He called EMS as he felt week. BG in field was 140 (after ensure) but on arrival in ED was 29. On arrival in the icu he is reticent to answer questions and refers me to his father. [**Name (NI) **] does acknowledge feeling thirsty, having poor po, and feeling constipated. He denies fevers, chills, dizziness, chest pain, sob, palpitations, n/v/abdominal pain. Further discussion with his parents reveals subacute decline since receiving alpha interferon therapy in [**2169-10-28**]. He has had weight loss of approx 25 lbs since then (? poor appetite vs. poor mastication as seems unable to chew/swallow). Additionally he has had diarrhea, which recently may have been slightly better, thought to represent poor absorption of corn starch, along with labile BG. He has been fatigued with generalized weakness to the point he has difficulty getting out of chair and has been using a walker for ambulation. The past 2 days he has been so weak he has been unable to ambulate and requested to come to the hospital (despite disliking hospital). He In the ED, VS: T 98.4 HR 119 BP 92/74 RR 22 Sat 95%. BG 29, given 1 amp D50 then started on D10 1/2 NS gtt. ROS: Per pt above, per parents: + for wt loss, fatigue, weakness, poor appetite, difficulty with mastication (all as above), poor sleep (chronic), decreased UOP, occaisional feet falling asleep, and diarrhea, that may be slightly better, though he currently feels constipated, rash bilateral feet since previous hospitalization. Negative for HA, f/c/ns, congestion, cough, sob, cp, palpitations, abdominal pain, nausea, vomitting, melena, BRBPR, dysuria, focal weakness. Per his parents he has been tachycardic on all previous admits but baseline HR unknown. Past Medical History: 1) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] disease: followed by Dr. [**Last Name (STitle) **]; with hepatic angiomas, hemangiomas, LD (no surgical intervention per previous not for liver lesions), hyperuricemia [**12-30**] gsd, on allopurinol 2) s/p porto-caval shunt 3) Anemia 4) NSAID related duodenal ulcer/GIB ([**2-3**]) Social History: Lived independently in [**Location (un) 745**] until recently, now lives with parents. No current tobacco, alcohol, or IVDA. Family History: Brother passed away from complications of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] diease (developed malignancy related to blood transfusion). Physical Exam: VS: T: 99.1 HR: 117 BP: 97/65 RR: 24 Sat: 99% RA Gen: NAD, A&Ox3 HEENT: NC/AT, + scleral icterus, temporal waisting, MM very dry with crusting dried blood, ? whitish plaques Neck: Supple, JVP flat; 2cm x 2cm very firm area at the left base of posterior cervical chain (?LAD) no other lad Resp: CTAB, no w/r/r CV: Tachycardic but no m/r/g, regular rhythm Abdomen: Protuberant, distended (per pt at baseline) with caput medusa, well-healed RUQ, LM scars, NT, +BS, massive hepatomegally Ext: 1+ PE B LE to thigh, no c/c Neuro: A&O x3, CN II-XII intact, strength 4/5 UE/LE B, 2+ DTR's, no asterixis Skin: + jaundice, no rash or ulcerations. Pertinent Results: Admission labs: [**Age over 90 **]|95|17 --------<20 lactate 10.3 AG 16 5.6|21|0.5 Comments: Na: Anion Gap Verified K: Hemolysis Falsely Elevates K . ALT: 21 AP: 3886 Tbili: 7.2 Dir 5.1 I 2.1 AST: 101 Dbili: 7.2 LDH: 341 Tprot 5.9 Glob 3.6 Lip: 11 Hapto: Pnd ammonia 65 7.0 16.0>--<575 24.1 N:81 Band:9 L:8 M:2 E:0 Bas:0 Hypochr: 2+ Anisocy: 2+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+ Target: 1+ ROULEAUX FORMATION AND RBC AGGLUTINATION PRESENT PT: 18.0 PTT: 39.5 INR: 1.6 UA [**3-18**]: Color Amber Appear Clear SpecGr 1.021 pH 6.5 Urobil 4 Bili Lg Leuk Neg Bld Tr Nitr Neg Prot Tr Glu Neg Ket Tr Micro: Urine Cx [**3-18**] pending Blood Cx [**3-18**] pending x2 CXR [**3-18**]: (my read, not radiology) AP portable, pt rotated, cardiomegally, low-lung volumes, no effusion or infiltrate. Brief Hospital Course: Patient was admitted with hypoglycemia secondary to [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 93504**] glycogen storage disease, not amenable to treatment at home with corn starch. He was treated with increasing levels of 10% dextrose solution. Given that his requirement of dextrose was so elevated, after discussion with Glycogen storage disease specialist Dr. [**Last Name (STitle) **], and the liver consult service, it was determined that patient's overall long-term prognosis due to progressive liver dysfunction, would remain poor without transplant. Transplant was not a consideration for the patient or the family, who did not want to pursue such aggressive measures. It was then determined to focus on patient's comfort, and his pain was treated with intravenous morphine and lorazepam. He expired on [**2170-3-22**] at 11:55 PM from a bradycardic arrest. Medications on Admission: Allopurinol 300 mg by mouth DAILY Corn Starch Powder 55gm by mouth every four hours (Per protocol) iron 160mg daily (since [**3-9**]) nizatidine 150mg [**Hospital1 **] (since [**3-12**] Discharge Disposition: Expired Discharge Diagnosis: Liver Failure Bradycardic Arrest Discharge Condition: Expired Followup Instructions: N/A Completed by:[**2170-3-23**]

[ "E849.8", "785.0", "271.0", "532.70", "285.9", "572.8", "584.9", "783.7", "E935.9", "228.04" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

5600, 5609

4474, 5362

383, 389

5686, 5696

3649, 3649

5719, 5754

2806, 2976

5630, 5665

5388, 5577

2991, 3630

330, 345

417, 2272

3665, 4451

2294, 2648

2664, 2790

61,186

191,261

13352

Discharge summary

report

Admission Date: [**2157-8-21**] Discharge Date: [**2157-8-24**] Date of Birth: [**2080-2-12**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain and increasing DOE. Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 77 yo woman w/ h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN, dyslipidemia presents with chest pain and SOB x2 days, off and on. Also feeling "exhaustion" with minimal exertion. Sharp-type pain, substernal in location, burning and traveling up to her throat. Similar to her anginal type pain. She says the pain has been coming and going intermittently during the last two days, sometimes occurring at rest. Typically her pain is relieved with nitroglycerin. . She presented to [**Hospital **] Hospital night of [**8-20**] because the pain had worsened and was not resolving with 3 SL nitro and an ASA. Her VS were T 98.4, HR 86, BP 118/63, RR 18, satting 96% RA. On exam she had clear breath sounds with normal cardiac exam. Labs were remarkable for hct 27, chem 7 notable for creatinine 1.2; LFTs were normal. CK was 49 with CKMB-I of 5.3. TropI was 0.07, repeat 0.14. Her EKG showed ST depressions in the lateral leads (I, aVL, and V4-V6). There was ST elevation in lead aVR. She was admitted to the ICU at OSH and started on heparin gtt, nitro gtt, Integrillin gtt, mucomyst and continued on amlodipine 10 mg, ASA 81 mg, Plavix 75 mg, Lasix 20 mg PO, metoprolol 50 mg TID, and simvastatin 80 mg qday. She was also started on 2units of blood for Hct <30 in setting of ischemia. She was then transferred to [**Hospital1 18**] for management. . She was transferred directly from OSH to CCU. At time of arrival to CCU, she is CP free. Denies palpitations, lightheadedness, or dizziness. . Of note, she presented to [**Hospital1 18**] with an NSTEMI in [**2157-4-24**] and underwent catheterization with BMS placed to a 90% stenotic but protected LM. The overlap segment was postdilated to 3.5mm. Final angiography revealed 0% residual stenosis, no angiographically apparent dissection and timi3 flow. The patient left the lab free of angina and in stable condition. She says that after this procedure she was CP free for several weeks, but believes that her anginal symptoms have worsened progressively since. . At baseline, says she can walk one flight of stairs before becoming SOB. Endorses lower extremity edema; sleeps on one pillow at night; denies orthopnea, paroxysmal nocturnal dyspnea. No new cough. No fevers. No melena or hematochezia. She has a history of anemia, says that "she is bleeding internally, but [**Last Name (un) 15025**] knows where." No fevers, chills, night sweats, weight loss of which she is aware. Past Medical History: # (+) Diabetes, (+) Dyslipidemia, (+) Hypertension # Coronary Artery Disease s/p CABG x 4 # HTN # Peripheral Vascular Disease s/p stenting of her lower leg # Hyperlipidemia # Diabetes Mellitus x40 years, insulin dependent # s/p left tibial fracture 2 years ago # Hearing Impaired # Possible COPD vs Asthma - negative w/u for COPD as per patient. # Myelodyplastic syndrome - Hct on last hospitalization was mid 30's # Rotator cuff injury # Fib-tib fracture [**2154**] Social History: Lives with son and two granddaughters. Independent in ADLs and IADLs. Tobacco history: has not smoked for 16 years. History of smoking 2PPD x40 years. ETOH: None. Illicit drugs: None Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T97.6, HR 68, BP 153/46, O2 98% 2L NC GENERAL: elderly woman, hearing impaired, NAD HEENT: NCAT, pupils constricted, mildly dysconjugate gaze, NECK: JVD 2-3cm above clavicle at 45 degrees CARDIAC: RRR, no M/R/G LUNGS: Bibasilar rales, otherwise clear breath sounds ABDOMEN: softly distended, no masses, no rebound no guarding. EXTREMITIES: wwp, L>R non-pitting LE edema, SKIN: wwp, nevi on back PULSES: 2+ carotid pulsations, 1+ DP pulses bilaterally, Pertinent Results: [**2157-8-21**] CK(CPK)-57 [**2157-8-21**] CK-MB-NotDone cTropnT-0.08* [**2157-8-21**] WBC-4.4# RBC-3.23* HGB-10.7* HCT-30.1* MCV-95 MCH-33.1* MCHC-34.8 RDW-15.2 [**2157-8-21**] NEUTS-65.7 LYMPHS-20.5 MONOS-9.4 EOS-4.0 BASOS-0.5 [**2157-8-21**] PLT COUNT-202 [**2157-8-21**] PT-14.4* PTT-96.0* INR(PT)-1.3* [**2157-8-21**] GLUCOSE-205* UREA N-37* CREAT-1.0 SODIUM-136 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14 [**2157-8-21**] ALT(SGPT)-23 AST(SGOT)-25 LD(LDH)-215 CK(CPK)-56 ALK PHOS-85 TOT BILI-0.6 [**2157-8-21**] CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-1.9 [**2157-8-21**] PT-13.6* PTT-70.6* INR(PT)-1.2* [**2157-8-21**] CK-MB-NotDone cTropnT-0.05* proBNP-6377* . CT Head: No evidence of hemorrhage, edema mass, or recent infarction. If acute infarct is a consideration, MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is the most sensitive modality. . ECHO [**2157-8-22**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal inferior hypokinesis. Overall left ventricular systolic function is normal (LVEF55-60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR [**2157-8-21**]: As compared to the previous radiograph, the left-sided pleural effusion has almost completely resolved. A small right-sided pleural effusion has newly occurred. There is unchanged cardiomegaly with signs of mild overhydration. Focal parenchymal opacities suggestive of recent pneumonia are not seen. The sternal wires and clips after bypass surgery are unchanged. . Cardiac Cath (logged only, not official): LMCA - patent stent LAD - total occlusion ostial. native fillls via LIMA. Mild luminal irregularity. LCx - total occlusion mid vessel. OMI fills via LMCA stent with mid dx tortous vessel. SVG - RCA patent with serial 50-60% lesions LIMA 0 LAD - widely patent Brief Hospital Course: 77 yo woman h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN, dyslipidemia presents with chest pain and SOB x 2 days concerning for unstable angina. EKG shows ST-segment depressions in the lateral leads concern of stent re-stenosis. Cardiac cath demonstrates patent LMCA stent. .. # CORONARIES: Stents patent. Continue CAD prevention. Chest pain could be secondary to demand ischemia related to anemia. Consider increasing hematocrit with procrit as outpatient. Continue CAD prevention: High-dose statin, ASA 325, Plavix 75. Increased Imdur from 30 mg [**Hospital1 **] to 90 mg qd. Consider increasing hematocrit using procrit. . # PUMP: Mildly elevated JVD, bibasilar rales, and elevated BNP. No echo in system. CXR demonstrates small right sided effusion. Gave Lasix 20 mg IV, re-started outpatient Lasix 20 mg po. . # RHYTHM: Normal sinus rhythm currently. Continue to monitor on telemetry. . # Hypertension: Poorly controlled, SBP ranged from 137-161. Re-start outpatient BP meds and was better controlled. Converted Metoprolol 100 mg [**Hospital1 **] to Toprol 200 mg qd, otherwise continued outpatient HTN meds. . # Anemia: Normocytic, elevated Ferritin, most likely anemia of chronic disease. Continue outpatient procrit injections q-weekly, try to increase baseline HCT due to demand ischemia. Medications on Admission: # Lantus 10 U qhs # Regular insulin with meals # Norvasc 10 mg qday # Plavix 75 mg qday # Isordil 30 mg PO BID # Potassium 20 meQ qday # Simvastatin 40 mg qday # Avapro 150 mg [**Hospital1 **] # Metoprolol 100 mg PO BID # Lasix 20 mg qday # SL NG prn # ASA 81 mg qday # Fe Pills - unknown dose # Procrit qweekly for anemia Discharge Medications: 1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous at bedtime. 11. Insulin Regular Human 100 unit/mL Solution Sig: as directed as per sliding scale Injection qACHS. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Hypertension Anemia [**12-25**] to myelodysplastic syndrome Diabetes Discharge Condition: stable. Discharge Instructions: You had some heart strain likely from anemia. In the hospital you underwent a cardiac catheterization that showed that the blood vessels in your heart have adequate blood supply. You received a blood transfusion and your medicines were adjusted because your blood pressure was high. You were hypoglycemic (low blood sugar) in the hospital. Please resume your outpatient prescriptions as you had previously and discuss adjusting your regimen with your PCP. [**Name10 (NameIs) **] the mean time, it should be safe for you to resume your home insulin regimen if that has been working for you in the past. Finally, it is recommended that in the future you keep a copy of your ECG and bring it with you to the hospital whenever possible. . We made the following changes to your medicines: 1. Isosorbide Mononitrate 90mg daily 2. Toprol XL 200mg daily 3. Regular insulin SS - new scale provided. . Please make sure you take your medicines as planned. Please call Dr. [**Last Name (STitle) 40075**] if you have any symptoms of chest pain, trouble breathing, increased fatigue, fevers, or dizziness. Followup Instructions: Primary Care: [**Last Name (LF) 40075**], [**Name8 (MD) 333**], MD Phone: [**Telephone/Fax (1) 40076**] Date/Time: [**9-13**] at 1:30pm, [**Hospital 40600**] Medical Building, [**Apartment Address(1) 40601**]. . Cardiology: [**Last Name (LF) 8579**], [**First Name3 (LF) 518**] Phone: [**Telephone/Fax (1) 40602**] Date/Time: Monday, [**9-12**] at 11:00am, [**Hospital 40600**] Medical Building, [**Apartment Address(1) 40603**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2157-8-26**]

[ "401.9", "443.9", "V45.82", "412", "272.4", "238.75", "V45.81", "V58.67", "414.01", "250.80", "285.22", "410.71" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.52", "88.55" ]

icd9pcs

[ [ [] ] ]

9240, 9289

6489, 7789

312, 338

9402, 9412

4076, 4750

10558, 11147

3502, 3584

8163, 9217

9310, 9381

7815, 8140

9436, 10535

3599, 4057

242, 274

366, 2794

4759, 6466

2816, 3285

3301, 3486