ChanBeDu/relevant_section_length · Datasets at Hugging Face

24,582

114,179

618

Discharge summary

report

Admission Date: [**2129-1-5**] Discharge Date: [**2129-1-12**] Service: MEDICINE Allergies: Ciprofloxacin / Cisapride / Metoclopramide / Bactrim Attending:[**First Name3 (LF) 3984**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M w/ multiple medical problems (see below) who presents from [**Hospital 100**] Rehab hypoxic and febrile with CP and bilat infiltrates requiring intubation in the ED. At baseline per the son Mr. [**Known lastname 4749**] is a wheelchair bound, russian speaking alert and lively gentleman. He last saw his father on [**Name2 (NI) **] [**2129-1-2**] and he was at his baseline. Per the records from the rehab the patient was well up until the day of admission when he vomitted a large ammount of bilious vomit x2 and appeared to be shaking and cyanotic. Vitals at the time were T 104 (rectal) BP 120/60 O2 89%on RA. Aspiration pna was suspected and he was tx to [**Hospital1 18**] for further care. . In the ED the patient was found to be febrile to 103 but otherwise hemodynamically stable. Patient then experienced oxygen desaturation to 70's and was intubated. Patient was found to have large mucous plugs on suctioning consistent with aspiration. Dopamine was started for low BP while on vent. Past Medical History: CRI (b/l 1.3-1.9 1.5 yrs ago) (Cr 2.3 on [**12-28**]) Afib/CHF s/p Pacemaker, EF 60% with 1+MR and mod PA HTN [**10/2128**] echo COPD, recent steroid taper and augmentin regemin completed [**12-29**] Urinary Retention (BPH) Hypothyroidism Restless Legs Arthritis DM type2 Depression Gastritis Glaucoma Cataracts Hard of Hearing Persistent lyme disease Pneumovax [**8-/2123**] Social History: FH: Non-contributory . SH: lives at [**Hospital **] rehab, married, but 2nd wife in [**Country 532**], sone [**Name (NI) **] is HCP currently out of country, paperwork from [**Hospital 100**] Rehab says DNR/DNI since [**4-6**], but son [**Name (NI) **], youngest wants Full CODe, distant smoker, no etoh, no drugs Physical Exam: VS: T 103 P 60 BP 113/30 R 20 O2 97 AC 600/20/60/8 Gen - intubated, sedated HEENT - PERRL, op clear, dry MM Cor - RRR difficult to hear over breath sounds Chest - diffuse ronchi, bilaterally Abd- distended, soft, + BS Ext - w/wp no c/c/e Pertinent Results: ADMISSION LABS: [**2129-1-5**] 05:00AM BLOOD WBC-6.7 RBC-4.30* Hgb-13.4* Hct-39.8* MCV-93 MCH-31.1 MCHC-33.6 RDW-15.2 Plt Ct-155 [**2129-1-5**] 05:00AM BLOOD Neuts-64 Bands-12* Lymphs-8* Monos-3 Eos-2 Baso-0 Atyps-7* Metas-4* Myelos-0 NRBC-2* [**2129-1-5**] 05:00AM BLOOD PT-13.5* PTT-22.1 INR(PT)-1.2 [**2129-1-5**] 05:00AM BLOOD Plt Smr-NORMAL Plt Ct-155 [**2129-1-6**] 05:59PM BLOOD Fibrino-500* [**2129-1-6**] 06:35PM BLOOD FDP-10-40 [**2129-1-5**] 05:00AM BLOOD Glucose-81 UreaN-106* Creat-3.1*# Na-135 K-5.8* Cl-102 HCO3-22 AnGap-17 [**2129-1-5**] 05:00AM BLOOD ALT-28 AST-15 CK(CPK)-58 AlkPhos-64 Amylase-82 TotBili-0.3 [**2129-1-5**] 05:00AM BLOOD cTropnT-0.25* [**2129-1-5**] 02:14PM BLOOD CK-MB-NotDone cTropnT-0.23* [**2129-1-5**] 09:57PM BLOOD CK-MB-6 cTropnT-0.18* [**2129-1-6**] 02:02AM BLOOD CK-MB-7 cTropnT-0.17* [**2129-1-5**] 05:00AM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.7 Mg-2.0 [**2129-1-5**] 05:43PM BLOOD Cortsol-14.4 [**2129-1-5**] 08:46PM BLOOD Cortsol-13.8 [**2129-1-5**] 09:22PM BLOOD Cortsol-15.1 [**2129-1-6**] 02:02AM BLOOD Vanco-8.1* [**2129-1-5**] 05:20AM BLOOD Type-ART PEEP-10 FiO2-100 pO2-210* pCO2-40 pH-7.35 calHCO3-23 Base XS--3 AADO2-482 REQ O2-80 Intubat-NOT INTUBA Vent-SPONTANEOU [**2129-1-5**] 05:04AM BLOOD Lactate-2.0 [**2129-1-5**] 05:56PM BLOOD Glucose-96 K-5.1 [**2129-1-6**] 02:20AM BLOOD freeCa-1.12 . DISCHARGE LABS: [**2129-1-11**] 03:12AM BLOOD WBC-21.8*# RBC-3.62* Hgb-11.1* Hct-32.4* MCV-90 MCH-30.7 MCHC-34.3 RDW-15.5 Plt Ct-224# [**2129-1-11**] 03:12AM BLOOD Plt Ct-224# [**2129-1-11**] 03:12AM BLOOD PT-18.8* PTT-115.5* INR(PT)-2.5 [**2129-1-11**] 03:12AM BLOOD Glucose-161* UreaN-89* Creat-2.4* Na-138 K-4.3 Cl-102 HCO3-21* AnGap-19 [**2129-1-6**] 02:02AM BLOOD CK(CPK)-131 [**2129-1-11**] 03:12AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.2 [**2129-1-11**] 04:20AM BLOOD Type-ART pO2-71* pCO2-40 pH-7.46* calHCO3-29 Base XS-4 [**2129-1-11**] 04:20AM BLOOD Glucose-152* K-4.2 Brief Hospital Course: A/P: [**Age over 90 **] yo man with multiple medical problems here with multi-focal pneumonia, intubated for hypoxic respiratory failure. The pt was initially intubated for hypoxia, likely secondary to multifocal MRSA pneumonia, which may also have been due to aspiration given emesis x2 prior to arrival. Pt had also been on steroids and lived in nursing home, thus was felt to be at higher risk for nocosomial pneumonia. Patient may also had a component of underlying COPD exacerbation. The pt was treated with vanc/CTX emperically, given aggressive inhalers and steroids for COPD, diuresed with lasix initially, and was placed on heparin infusion for a LENI study positive for DVT. Hyperkalemia was treated and aldactone was discontinued. Stress dose hydrocort/fludrocort were initiated. The pt was felt to have prerenal failure and had some boluses of fluid (recognizing that his volume status was tenuous). Troponin showed no increase. . CODE: pt was originally DNR/DNI, which was reversed just prior to admission because the pt's son and HCP was out of the country and could not be contact[**Name (NI) **]. In his absence, the other son wanted his father to be full code. This was readdressed and the pt was made dnr/dni. On [**1-11**], he was made CMO and passed away thereafter. Medications on Admission: recently on prednisone stopped [**12-29**] Robitussin AC RISS/NPH 18units qam, 8 units qpm levothyroxine 150mcg qday albuterol/atrovent inhaler lido patch 5% to L deltoid posterior qday 12 hrs on/12 off tamusolin 0.4mg qday trazodone 75mg qpm Avandia 2mg qam glyburide 2mg qam lasix 100mg qday aldactone 12.5 mg recently d/c'd for hyperkalemia Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2129-6-2**]

[ "414.01", "427.31", "038.9", "518.81", "584.5", "995.92", "250.02", "276.7", "458.9", "453.41", "428.0", "482.41", "585.9", "V09.0", "276.51", "600.01", "287.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "00.17", "57.94", "38.91", "89.62", "96.07", "96.04" ]

icd9pcs

[ [ [] ] ]

6011, 6020

4293, 5588

280, 286

6072, 6082

2343, 2343

6134, 6293

5983, 5988

6041, 6051

5614, 5960

6106, 6111

3711, 4270

2084, 2324

220, 242

314, 1336

2359, 3694

1358, 1737

1753, 2069

32,099

148,004

31222

Discharge summary

report

Admission Date: [**2150-1-11**] Discharge Date: [**2150-1-15**] Date of Birth: [**2112-5-23**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Mental slowing and lethargy s/p cranioplasty Major Surgical or Invasive Procedure: s/p right subdural collection evacuation History of Present Illness: 37yF well known to our service recently s/p cranioplasty who presents with mental slowing and lethargy x several days. She is s/p MVA resulting in a right subdural hematoma, s/p emergent hemicraniectomy on [**9-29**] with partial frontal and temporal lobectomies c/b a right PCA infarction likely due to herniation as well as traumatic thrombosis of the left transverse, sigmoid and internal jugular venous systems, ultimately requiring anticoagulation. She has known frontal abulia and executive frontal network dysfunction. She has exhibited no dysarthria or neurologic deficits, but has been reluctant to speak, lethargic, and with her baseline flat affect. Past Medical History: Traumatic Brain Injury ([**9-16**]) - R SDH, s/p emergent hemicraniectomy [**9-29**], - s/p R PCA infarction likley due to herniation, - h/o traumatic thrombosis of L transverse, sigmoid and IJ venous systems (on coumadin) - frontal abulia - Hyperthyroidism - Alcoholism - Cranioplasty Social History: Lives with sister, brother in law and 2 nephews in [**Name (NI) 73559**]. Had worked as bartender and presented at the time of her accident with a high blood alcohol level. Endorses one drink three times a week. No tobacco or illicit drugs. She has one child, who she hasn't seen in a long time. Family History: NC Physical Exam: On admission: O: T:97.9 BP: 110/74 HR: 110 R: 16 O2Sats 97ra Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, flat affect Orientation: Oriented to person, place, and date. Recall: [**4-12**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 9 to 7 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 in lower extremities. Hypertonicity in lower extremities bilaterally. No abnormal movements, tremors. Strength full power [**6-14**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 3 3 3 3 - Left 3 3 3 3 - Toes upgoing bilaterally Coordination: Finger-nose-finger with pass pointing bilaterally, normal heel to shin bilaterally Pertinent Results: [**2150-1-13**] 02:40AM BLOOD WBC-6.5 RBC-3.20* Hgb-9.6* Hct-28.6* MCV-89 MCH-30.0 MCHC-33.5 RDW-13.0 Plt Ct-460* [**2150-1-12**] 02:58AM BLOOD WBC-6.2 RBC-3.32* Hgb-10.2* Hct-30.2* MCV-91 MCH-30.7 MCHC-33.7 RDW-13.1 Plt Ct-524* [**2150-1-11**] 06:15PM BLOOD WBC-5.6 RBC-3.60* Hgb-10.8* Hct-31.9* MCV-89 MCH-30.1 MCHC-33.9 RDW-13.2 Plt Ct-442* [**2150-1-11**] 06:15PM BLOOD Neuts-65.8 Lymphs-27.1 Monos-4.7 Eos-1.6 Baso-0.8 [**2150-1-13**] 02:40AM BLOOD Plt Ct-460* [**2150-1-12**] 02:58AM BLOOD Plt Ct-524* [**2150-1-12**] 02:58AM BLOOD PT-13.7* PTT-23.3 INR(PT)-1.2* [**2150-1-11**] 06:15PM BLOOD Plt Ct-442* [**2150-1-11**] 06:15PM BLOOD PT-13.4 PTT-24.5 INR(PT)-1.2* [**2150-1-13**] 02:40AM BLOOD Glucose-101 UreaN-6 Creat-0.5 Na-141 K-4.1 Cl-104 HCO3-28 AnGap-13 [**2150-1-12**] 02:58AM BLOOD Glucose-101 UreaN-6 Creat-0.5 Na-141 K-3.3 Cl-102 HCO3-28 AnGap-14 [**2150-1-11**] 06:15PM BLOOD ALT-11 AST-15 AlkPhos-83 Amylase-47 TotBili-0.2 [**2150-1-13**] 02:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.7* [**2150-1-12**] 02:58AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8 [**2150-1-11**] 06:15PM BLOOD TSH-0.94 [**2150-1-11**] 06:15PM BLOOD T4-7.2 [**2150-1-11**] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT head [**2150-1-11**]: IMPRESSION: 1. Increased size of right-sided extra-axial collection, now with mixed fluid and air, and highly concerning for infection. There is significantly increasing mass effect and subfalcine herniation, as described above. 2. Increased extracranial fluid collection, also with foci of air and concerning for infection, perhaps communicating internally. CT head [**2150-1-12**]: No significant interval change in large right extra-axial air or fluid collection producing marked mass effect and subfalcine herniation. CT head [**2150-1-13**]: There has been interval placement of a drain within the large right extra-axial fluid collection which has decreased in size, now measuring approximately 13 mm in greatest transverse dimension. Small area of hyperattenuation is seen superiorly likely representing acute hemorrhage, which is unchanged. There is 11 mm leftward subfalcine herniation and mass effect on the right lateral ventricle, which has decreased compared to the prior study. Moderate amount of pneumocephalus is noted. The right occipital hypodensity is unchanged. Small hypodensities of the left centrum semiovale and thalamus are again seen. The superficial fluid collection has largely been drained. IMPRESSION: Interval placement of a drain into the right extra-axial fluid collection which is mildly decreased in size with resultant mild decrease in leftward subfalcine herniation and mass effect on the right lateral ventricle. Brief Hospital Course: 37yF recently s/p cranioplasty with increased lethargy x [**3-15**] days and CT changes showing extra-axial fluid collection with 1.7cm midline shift. Neurologic symptoms include BLE hypertonicity with hyperrefelxia throughout; flat affect which is baseline for the patient; and pass pointing on finger to nose bilaterally. [**2150-1-11**] unable to access the fluid collection via the old superior burr hole, but we were able to evacuate 7cc from the right, lateral, superficial collection. The procedures were done in sterile fashion. She was admitted to ICU, started on ceftriaxone until [**1-15**], resumed home medications, 100% NRB face mask to try to reduce the pneumocephalus [**2150-1-12**] she was taken to OR for R subdural drain placement, with bulb drain maintained to [**2-11**] suction. On [**1-13**] she had a CT which showed the drain was in the proper location. Her mental status improved and she was transferred to the floor. Aspirin was also restarted that day. Her drain was removed on [**1-14**]. On [**1-15**] a bed became available at [**Hospital1 **]. The patient's mental status was stable. She was moving all 4 extremities spontaneously, following commands, able to converse but maintained a flat affect, which she has had since her accident. She was taking in food PO and was working on mobility and ambulation with PT. She was deemed safe to be discharged to rehab on [**1-15**]. Medications on Admission: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY 2. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID 3. CONCERTA 18 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO qday (). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Sertraline 25 mg Tablet Sig: Three (3) Tablet PO once a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 10. Ceftriaxone 2 gram Recon Soln Sig: Two (2) grams IV Intravenous once a day for 10 days: last dose 12/6. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal QDAY () as needed for nasal allergy. 12. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID 13. Modafinil 100 mg Tablet Sig: One (1) Tablet PO DAILY 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. CONCERTA 18 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO qday (). 4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Modafinil 100 mg Tablet Sig: One (1) Tablet PO daily (). 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 1 doses: Should receive one last dose at midnight. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: cranioplasty/ s/p right subdural collection evacuation Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE REMOVE ALL SURGICAL STAPLES ON [**2150-1-22**]. THIS CAN BE DONE IN REHABILITY FACILITY OR DR[**Doctor Last Name **] OFFICE (PLEASE CALL [**Telephone/Fax (1) 1669**] FOR APPOINTMENT) PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Please call ([**Telephone/Fax (1) 1703**] to make a follow-up appointment with Dr. [**First Name (STitle) **] from behavioral neurology. Completed by:[**2150-1-15**]

[ "244.9", "310.0", "907.0", "E929.0", "738.19", "998.13", "348.8", "303.90", "E878.6" ]

icd9cm

[ [ [] ] ]

[ "01.26", "01.24" ]

icd9pcs

[ [ [] ] ]

10083, 10153

5972, 7387

364, 407

10252, 10276

3233, 5949

11661, 12199

1737, 1741

8575, 10060

10174, 10231

7413, 8552

10300, 11638

1756, 1756

280, 326

435, 1099

2287, 3214

1770, 1997

2012, 2271

1121, 1408

1424, 1721

19,319

177,792

842

Discharge summary

report

Admission Date: [**2200-4-7**] Discharge Date: [**2200-5-30**] Date of Birth: [**2166-12-24**] Sex: M Service: MEDICINE Allergies: Codeine / Ceftriaxone Attending:[**First Name3 (LF) 2641**] Chief Complaint: MS changes (tx'd from OSH) Major Surgical or Invasive Procedure: [**2200-4-11**]- R Hip washout secondary to infected hardward [**2200-4-17**]- R Hip Hardware removed [**2200-4-24**]- R Hip washed out and wound closed [**2200-5-8**]- Removal of infected hematoma in R hip [**2200-5-22**]- R hip Washout History of Present Illness: 33 y/o male with PMH significant for AVR, NIDDM, h/o polysubstance abuse, initially admitted to OSH on [**2200-3-25**] for s/p tonic-clonic seizure resulting in a fall and broke right hip requiring R hip ORIF on [**2200-3-31**]. It was felt that seizure was secondary to benzo withdrawal as pt was taking 5 mg of Xanax tid at home. He was then to d/c'd to transitional care rehab on [**2200-4-2**] to be later admitted on [**2200-4-3**] for AMS/seizures. In the ED at OSH, loaded with 1 gm dilantin, 2 mg ativan, and 2 mg dilaudid and admitted. Per records, pt not on benzos while at rehab. EEG from [**4-4**] and [**4-5**] showed no localizing seizure activity. On [**2200-4-6**], pt became lethargic, tachypneic w/rr in 40's and hypoxic. He was also reportedly febrile (unknown temp). He received one dose of CTX which resulted in a skin rash. He was then transferred to the ICU with concerns for NMS vs. sertonin syndrome vs. benzo-withdrawal vs. infection/sepsis. ICU course at OSH notable for start of ativan gtt and psychotropic meds, including risperdal, seroquel, wellbutrin, and xanaflex. WBC count at 11, Cr 4.4, LFTs wnl at that time. Dilantin level 7.7 at that time. Daily head CT's from [**4-4**] to [**4-6**] were all normal. During this time, pt became hyperkalemic to 5.4 and acidotic with bicarb of 18. ABG on [**2200-4-6**] was 7.2/24/72/16. Pt was then started on a bicarb gtt. Lactate was 1.2, serum and urine tox unremarkable except for benzos. Pt was ROMI with enzymes during his course. TTE today showed preserved EF, moderate AS/AI, moderate MR, elevated RV pressures of 91. Past Medical History: 1)AVR in [**2190**] for Enterococcus faecalis endocarditis 2)Cellulitis x 6 3) DM II, diagnose in [**4-21**], treated with glipizide 4)Polysubstance use (cocaine, opiates, benzos, anabolic steroids) 5) H/O pancreatitis in [**2194**] 6) Cluster HA's 7) Neck and back pain - has been to musculoskeletal specialist as well as PT 8) Anxiety 9) ADHD/ADD 10) Left pectoral and biceps tear, s/p surgery Social History: Recently divorced, currently lives with girlfriend. Moved to [**Location (un) 86**] 6 months ago from [**State 5864**]. h/o IVDU. Unemployed. Family History: DM Hyperlipidemia Fibromyalgia (sister) Multiple staph infections DVT Physical Exam: VS - 99.6, 110/59, 112, 25-30 95%/3LNC General - Somnolent, awakens with loud voice and tactile stimulation HEENT - NC/AT, PERRL, EOMI. MM dry Neck - supple Chest - CTA-B, no w/r/r CV - RRR s1 s2 normal, + mechanical click Abd - obese, NT/ND, pos BS Ext - no c/c/e, pulses 2+ b/l Neuro - Somnolent, awakens to loud voice, able to say he is in [**Location (un) 86**]. Moves all four extremities. Nl muscle tone Pertinent Results: ADMISSION LABS: [**2200-4-7**] 07:36PM TYPE-ART PO2-74* PCO2-35 PH-7.40 TOTAL CO2-22 BASE XS--1 [**2200-4-7**] 07:36PM GLUCOSE-237* LACTATE-1.2 [**2200-4-7**] 07:36PM HGB-10.4* calcHCT-31 O2 SAT-95 [**2200-4-7**] 07:36PM freeCa-1.12 [**2200-4-7**] 07:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2200-4-7**] 07:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2200-4-7**] 07:15PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 [**2200-4-7**] 06:32PM GLUCOSE-247* UREA N-70* CREAT-5.8*# SODIUM-131* POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17 [**2200-4-7**] 06:32PM ALT(SGPT)-22 AST(SGOT)-19 LD(LDH)-332* CK(CPK)-157 ALK PHOS-110 AMYLASE-174* TOT BILI-0.5 [**2200-4-7**] 06:32PM LIPASE-228* [**2200-4-7**] 06:32PM CALCIUM-8.4 PHOSPHATE-6.6*# MAGNESIUM-2.2 [**2200-4-7**] 06:32PM PHENYTOIN-<0.6* [**2200-4-7**] 06:32PM WBC-11.2* RBC-3.25*# HGB-9.6*# HCT-27.4*# MCV-84 MCH-29.7 MCHC-35.3* RDW-17.7* [**2200-4-7**] 06:32PM NEUTS-76.6* BANDS-0 LYMPHS-13.1* MONOS-4.2 EOS-5.8* BASOS-0.3 [**2200-4-7**] 06:32PM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL [**2200-4-7**] 06:32PM PLT SMR-NORMAL PLT COUNT-440 [**2200-4-7**] 06:32PM PT-31.0* PTT-31.8 INR(PT)-3.3* [**2200-4-7**] 06:32PM FIBRINOGE-697* [**2200-4-7**] 07:36PM BLOOD Type-ART pO2-74* pCO2-35 pH-7.40 calHCO3-22 Base XS--1 [**2200-4-7**] 07:15PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2200-4-7**] 07:15PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 . IMAGING: [**4-7**] CXR on admission: No evidence of pneumonia or CHF. . [**4-8**] Renal U/S: 1. Left renal cortical scarring. 2. No evidence of mass, hydronephrosis or calculus within either kidney. 3. Normal renal vascular flow. . [**4-9**] Hip Films: 1. No evidence of hardware fracture, or fracture of the right pelvis or right femur. 2. Benign-appearing lucency of the left femoral neck as described above. . [**4-9**] TTE: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A mechanical aortic valve prosthesis is present. The transaortic gradient is probably mildly elevated for this type of prosthesis (although some elevation is expected in the presence of tachycardia). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2194-5-27**], the aortic valve gradient is similar. Mitral regurgitation may now be slightly more prominent. . [**4-10**] Hip Films: There has been placement of a bipolar hemiarthroplasty within the right hip. There are no signs for hardware complications. No bony fractures are identified. There is a lateral surgical skin staples seen. . [**4-10**] EEG: Mildly abnormal EEG in the waking and drowsy states due to the mild slowing of the background with occasional bursts of generalized slowing. This suggests a mild encephalopathy although some background frequencies were normal. Medications, metabolic disturbances, and infection are among the most common causes. There were no focal abnormalities or epileptiform features. A tachycardia was noted. . [**4-14**] Difficult Crossmatch: DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname **] has newly identified red cell alloantibodies, anti-Cw and anti-Jkb, as well as a previously identified, anti-E. All of these antibodies can cause hemolytic transfusion reactions. E and Cw are members of the Rh blood group system while Jkb is a member of the Kidd blood group system. In the future he should receive red cells that are Jkb, E, and Cw negative. . [**4-16**] Hip Films: A single frontal radiograph of the right hip demonstrates the patient to be status post right hip hemiarthroplasty. The stem of the femoral component projects over the center of the medullary canal of the proximal femur. Surgical staples project over the lateral right hip. No discrete fracture is evident. Tubing overlying the right hip may represent a surgical drain. . [**4-16**] TEE: The left atrium is normal in size. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is moderately depressed. The right ventricular cavity is mildly dilated. There is moderate global right ventricular free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. A bileaflet aortic valve prosthesis is present. A mechanical aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. Trace aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] There is a probable vegetation on the mitral valve. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. PERFOERATED ANTERIOR MITRAL LEAFLET (A2) scallop. ***Please note that this echo report was re-read, and it was felt that there was NO vegetation. . CXR [**2200-4-25**]: SUPINE AP VIEW OF THE CHEST: Patient is status post median sternotomy and aortic valve replacement. Cardiac and mediastinal contours are normal. The right PICC has been removed. The lungs are clear and the pulmonary vascularity is normal. There are no effusions or pneumothorax. Osseous structures are normal. IMPRESSION: No pneumonia. . CXR [**2200-4-28**]: FINDINGS: There has been interval placement of a right-sided PICC line with the tip malpositioned in the right neck. The patient is again noted be status post aortic valve replacement. The lungs remain clear. No effusion or pneumothorax is seen. IMPRESSION: Malpositioned right PICC line. Results were discussed with the IV access team immediately following completion of the study. . CXR [**2200-4-30**]: COMMENTS: Portable supine AP radiograph of the chest is reviewed, and compared to the previous study of [**4-28**], [**2199**]. The tip of the left-sided PICC line is identified at cavoatrial junction. The lungs are clear. The heart and mediastinum are within normal limits. The patient has prior AVR and median sternotomy. The right costophrenic angle is not included in the radiograph. . [**2200-5-19**]: AP pelvis: A right hip prosthesis is present, with methyl methacrylate surrounding the metallic femoral head component. This femoral head prosthesis is dislocated superiorly from the acetabulum. The acetabulum is enlarged, of abnormal morphology, with loss of the cortical rim superolaterally and may be paretially resorbed. There is heterotopic ossification about the dislocated proximal femur. The femoral prosthesis remains seated within the shaft of the proximal femur. Allowing for osteopenia, no definite loosening is identified. The remainder of the pelvic girdle is within normal limits. IMPRESSION: Dislocation of right femoral prosthesis from acetabulum. ? acetabular debridement or resorption. . Micro: [**2200-4-26**]: blood cx neg x2 [**2200-4-25**]: blood cx 1/4 bottles w/E. coli (anaerobic) [**2200-4-25**]: urine cx neg [**2200-4-24**]: blood cx neg x4 [**2200-4-22**]: blood cx neg x4 [**2200-4-22**]: urine cx neg [**2200-4-20**]: blood cx neg x4 [**2200-4-20**]: urine cx neg [**2200-4-18**]: blood cx neg x2 [**2200-4-17**]: blood cx neg x2 [**2200-4-17**]: urine cx neg [**2200-4-15**]: blood cx neg x4 [**2200-4-13**]: blood cx neg x2 [**2200-4-12**]: urine cx neg [**2200-4-12**]: blood cx neg x2 [**2200-4-11**]: blood cx neg x2 [**2200-4-11**]: wound swab: enterococcus ([**First Name9 (NamePattern2) **] [**Last Name (un) 36**]), coag neg staph, corynebacterium [**2200-4-11**]: blood cx neg x2 [**2200-4-10**]: catheter tip: coag neg staph [**2200-4-10**]: urine cx: enterococcus, [**Month/Day/Year **] sensitive [**2200-4-9**]: blood cx [**12-21**] coag neg staph [**2200-4-7**]: blood cx neg x2 [**2200-4-7**]: urine cx neg [**2200-5-8**] 11:30 am SWAB Site: HIP RIGHT HIP WOUND. R/O MRSA. INTRA-OPERATIVE . GRAM STAIN (Final [**2200-5-9**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2200-5-14**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES) CONSISTENT WITH SKIN FLORA. FURTHER WORK-UP PER DR. [**First Name (STitle) **] [**2200-5-12**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ESCHERICHIA COLI. RARE GROWTH. ESCHERICHIA COLI. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 16 I 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- 32 I 32 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final [**2200-5-14**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA LACTAMASE POSITIVE. ACID FAST SMEAR (Final [**2200-5-9**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. [**2200-5-26**]- WOUND CULTURE (Final [**2200-5-28**]): ESCHERICHIA COLI. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 16 I AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: # Altered mental status: Likely multifactorial on admission, secondary to polypharmacy, benzodiazepine withdrawal, seizure, uremia. There was no evidence of NMS during this hospital course. The patient had been on an ativan gtt at the time of transfer from the OSH, and was noted to be somnolent. When the ativan gtt was discontinued his mental status gradually improved. He was initially kept on a CIWA scale for benzodiazepine withdrawal, but he required little valium and this was discontinued after a few days. As noted in the HPI, the patient had had seizures in the setting of benzodiazepine withdrawal. He was initially treated with dilantin at the OSH, but this was not continued as benzo withdrawal was considered to be the cause of the seizures. Patient was insisted on being treated with demerol for pain despite seizure risk. Several discussions were had regarding this. He receieved up to 400 mg IV demerol per days which he tolerated well and had no further evidence of seizure activity. . # ARF: Cr 5.8 on admission from baseline 4. The etiology of the patient's chronic renal insufficiency was not entirely clear. On admission, the patient was felt to by hypovolemic, with pre-renal etiology of his acute on chronic renal failure. Renal ultrasound revealed no hydronephrosis. Creatinine improved somewhat with hydration. There was no acute indication for hemodialysis. At times the patient became somewhat hyperkalemic to the mid-5's, which responded to kayexelate, but this was also felt to be realted to . His creatinine remained stable at 2.6 by discharge but exhibited variation from day to day up to 3.5 for unclear reasons. Patient continued to make adequate amounts of urine. . # Septic Arthritis of the Hip/infectious disease: The patient had fever to 104F at the OSH, with no clear source initially. He sustained a complex femoral neck fracture, which was managed with a hemiarthroplasty at an outside hospital. He now presented to the [**Hospital1 69**] with a large buttock hematoma and evidence of bacteremia with continued hip pain. The patient has been taken to operating room on [**2200-4-11**] for debridement and wound cultures which revelaed enterococcus, coag negatve staph and CORYNEBACTERIUM. He returned to the OR on [**4-16**] for washout and hip spacer placement and a wound vac was placed. He returned to OR on [**4-23**] for washout and wound closure. He was noted to have serosanguinous drainage from the wound site, and a hematoma at the site. He again returned to the OR on [**2200-5-8**], where he was found to have an infected hematoma in the R hip surgical site. The hip was washed out and cultures sent, which grew e.coli, enterococcus and coag negative staph and a wound vac was replaced and was changed Q3-4 days. The patient also had enterococcus in a urine culture and coag negative staph from 2/4 bottles of a set of blood cultures and from the tip of a PICC line which was removed early in the hospital course. An ID consult was obtained and the patient was started on cipro, vanco, flagyl. TTE and TEE were done to evaluate his valves in the setting of bacteremia (see below). These studies were read as having a question of mitral valve vegetation, as well as old mitral valve perforation, but no involvement of the prosthetic aortic valve was noted. AP of the pelvis was obtained on [**5-19**] because his hip was internally rotated and films revleaed dislocation so he was taken back to the OR for relocation on [**5-22**] at which time his spacer was removed, washed and replaced and a wound vac was left in place. Subsequent wound culture taken on [**5-26**] grew sparse E.coli, interterminent sensitivity to Cipro. ID felt that this was the same organism previously ([**5-8**]) cultured from his hip, now with resisence to cipro. Therefore his abx regimen was changed from Cipro to Unasyn, but day one of abx treatment will remain [**2200-5-8**], the day of removal of infected hematoma. He should complete a 6 week course of ABX from then-(Vancomycin 1gm IV Q24H, Ampicillin-Sulbactam 3 gm IV Q8H, and Metronidazole 500 mg PO TID)needing 19 additional days after discharge. After this course is completed, he will have a one month waiting period without antibiotics to see if the infection has actually cleared. Orthopedic Surgery will see him at the end of this month, and will do a hip aspirate to eval for infection. If his wound has closed, he is afebrile, and his aspirate is clear of bacteria, he will have his hip hardware replaced and should not require antibiotics afterwards. He will need Q3-4 day wound vac dressing changes at rehab. He will additionally follow up with infectious disease for antibiotic management. He will need Q 3day labs including Chem10, and PTT/INR and weekly LFTs while on antibiotics. # Pain: The patient complained of continual severe hip pain throughout his hospital course, and he made frequent and repeated requests for increasing doses of pain medications. He has a history of polysubstance abuse, making the management of his pain more complicated. The pain management service was consulted, and many different regimens were tried to control his pain, including morphine and dilaudid PCA, increasing doses of methadone, lidocaine patch, fentanyl patch, and the addition at various times of neurontin, topamax, and muscle relaxants to his regimen. At the time of discharge, his pain was controlled with a regimen of Methadone 80mg PO four times a day, Dilaudid IV PCA with 0.37mg given every 6 minutes with no basal rate, Morphine Sulfate 15mg IV Q3-4 hours PRN, Diazepam 15mg PO Q8H, and Meperidine 100 mg IV BID PRN for Wound Vac Changes. Many discussions were had with the patient regarding pain control. Limit setting was essential in allowing for pain control without the patient being oversedated. Psychiatry was consulted to manage his anxiety. They had no specific recommendations at this time for longterm treatment, but he should follow up as an outpatient. . # Polysubstance abuse: At the time of admission, the patient was currently clean and on methadone. Pain was managed as noted above. . # DM2: Oral hypoglycemics were held on admission. [**Last Name (un) **] was consulted for help with management of his diabetes. His blood sugars were initially difficult to control in the setting of infection. Glargine insulin was started and was titrated up for good glycemic control. Humalog insulin sliding scale was also used. . # s/p AVR: The patient was on coumadin at home for anticoagulation. When the need for operative management of his hip arose, coumadin was discontinued and he was put on a heparin gtt. TTE and TEE were done to evaluate his valves when blood cultures grew coag negative staph. These studies were read as having a question of mitral valve vegetation, as well as old mitral valve perforation, but no involvement of the prosthetic aortic valve was noted. This was re-read as having NO vegetation on the mitral valve. The patient was treated for endocarditis with vancomycin, with a plan for this to be continued for 6 weeks. On [**2200-5-27**], Coumadin 5mg QHS was begun. His Heparin ggt was continued, but can be d/c'd once his INR is therapeutic with a goal of 2.5-3.5. Upon discharge, INR was 2.5, PTT was 114; however will continue Heparin drip, given the fact that INR cannot be interpreted with elevated PTT. . # Tachycardia: Sinus tachycardia on admission was felt to be possibly [**12-19**] hypovolemia or benzo withdrawal and pain. He was given IV hydration and was put on CIWA scale with valium which he rarely required, as noted above. . # Pulmonary HTN: This was reported on TTE at OSH. The patient had no signs or symptoms of RV strain. Mild pulmonary artery hypertension was also noted on TTE done here. . # Pancreatitis: Patient was noted to have elevated amylase and lipase on admission, but without abdominal pain. This was felt to be related to medications, as the patient never developed any symptoms of pancreatitis. . # Code: Full Medications on Admission: amlodipine 10 mg qd tylenol prn colace 100 mg [**Hospital1 **] oxycodone 10 mg q4 prn coumadin 3 mg qhs hydroxyzine 50 mg q6 prn ambien 10 mg qhs ativan 1-2mg q 1hr prn methadone 20 mg [**Hospital1 **] NPH (unclear dose) ativan gtt 1 mg/hr propranolol 20 mg qid Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. 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* 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours). Disp:*3600 ML(s)* Refills:*2* 6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*qs * Refills:*2* 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:*qs ML(s)* Refills:*2* 8. Diazepam 5 mg Tablet Sig: Three (3) Tablet PO Q 8H (Every 8 Hours). Disp:*qs Tablet(s)* Refills:*2* 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 19 days. Disp:*60 Tablet(s)* Refills:*0* 10. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO QID (4 times a day). Disp:*240 Tablet, Soluble(s)* Refills:*2* 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*1 Tablet(s)* Refills:*2* 12. Ampicillin-Sulbactam [**12-18**] g Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 19 days. Disp:*2 Recon Soln(s)* Refills:*0* 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Gram Intravenous Q 24H (Every 24 Hours) for 19 days. Disp:*19 Gram* Refills:*0* 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs * Refills:*0* 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*2* 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 17. Hydromorphone 4 mg/mL Solution Sig: 0.37mg Injection ASDIR (AS DIRECTED): 0.37mg IV PCA every 6 minutes for pain. No basal rate. Disp:*qs * Refills:*2* 18. Morphine Sulfate 15 mg IV Q3-4H:PRN 19. Meperidine Sig: 100mg Intravenous (only) twice a day as needed for pain: Only given for wound vac changes. Disp:*qs * Refills:*1* 20. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 21. Insulin Glargine 100 unit/mL Solution Sig: Fifty Four (54) units Subcutaneous at bedtime. 22. Humalog 100 unit/mL Solution Sig: Per sliding scale. units Subcutaneous QACHS: See attached sliding scale. 23. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 24. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Per protocol Intravenous ASDIR (AS DIRECTED): Please give per attached protocol. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: 1. Septic R artificial hip, s/p hardward removal & washout 2. Bacteremia 3. Seizure related to benzodiazepine withdrawl 4. Acute Renal Failure Secondary: 1. Diabetes type II 2. Anemia secondary to blood loss 3. Hyperkalemia 4. Hypertension Discharge Condition: Hemodynamically stable, afebrile, glucose well controlled. Discharge Instructions: You were admitted to the hospital with a change in your mental status and seizure, and found to have an infected R hip. You were treated for this with surgery, antibiotics, and pain medications. You should call your doctor or return to the hospital if you have fever >101, chills, significantly increased pain, or signs of infection. Please take all of your medications as directed. Please keep all of your follow up appointments. Followup Instructions: Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-7-1**] 8:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2200-7-1**] 8:40 You have the following appointment at infectious disease clinic. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-6-20**] 10:00 You should call to schedule a follow up appointment with a primary doctor 1-2 weeks after you complete rehab. Please call [**Telephone/Fax (1) 5867**] to set up an appointment with a new primary doctor. Completed by:[**2200-5-30**]

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icd9cm

[ [ [] ] ]

[ "79.85", "83.39", "84.55", "78.65", "88.72", "99.04", "83.45", "84.56", "86.22", "38.93", "93.59", "80.85" ]

icd9pcs

[ [ [] ] ]

26685, 26757

15399, 15409

309, 549

27051, 27112

3291, 3291

27595, 28314

2773, 2845

23741, 26662

26778, 27030

23454, 23718

27136, 27572

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243, 271

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15424, 23428

2200, 2598

2614, 2757

53,567

132,531

50053

Discharge summary

report

Admission Date: [**2183-1-20**] Discharge Date: [**2183-2-11**] Date of Birth: [**2125-3-17**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache/ SAH/ ACOMM aneurysm Major Surgical or Invasive Procedure: [**2183-1-20**] placement of right frontal external ventricular drain [**2183-1-21**] Coiling of ACOMM aneurysm [**2183-1-24**] cerebral angiogram with interarterial verapamil [**2183-1-29**] Trach placement [**2183-2-6**] PEG placement [**2183-2-7**] Angio with completion of aneurysm coiling History of Present Illness: This is a 55 year old woman with no significant PMHx presented to OSH lethargic. Her husband [**Name (NI) 104513**] that patient complained of a headache at 10am the day before with morning with nausea. She spent most of the day in bed and the next day at 10am, patient attempted to get out of bed and collapsed to the side of the bed. Her husband came to her aide and found her "very sleepy" and difficult to arouse. She was taken to OSH where a head CT was performed and showed SAH with IVH. She was intubated for airway protection and transferred to [**Hospital1 18**]. On route she was given 3mg of ativan and 300mg of fentanyl. Past Medical History: hypotension, hypothyroidism Social History: no tobacco, +ETOH Family History: Aunt with history of head bleed Physical Exam: At admission: Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E:1 V:1 Motor:5 Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils: 2.5-2mm bilaterally +corneals +gag +cough BUE localize BLE w/d At discharge: EO to voice, smiles, interacts, will mouth words. Follows very simple commands when cooperative. BUE purposeful, BLE spont. PERRL. Tracks. Pertinent Results: [**2183-1-20**] CXR Single supine AP portable view of the chest was obtained. Endotracheal tube is seen, terminating approximately 2.6 cm above the level of the carina. Nasogastric tube is seen, side port at the level of the expected position in the gastric fundus with distal tip also in the expected location of the stomach. There is mild elevation of the right hemidiaphragm. Right lung base atelectasis is seen. There is thickening in the right minor fissure versus possible small amount of pleural fluid. There are relatively low lung volumes. There is mild central vascular pulmonary engorgement. Left base retrocardiac opacity Could be due to atelectasis, although underlying aspiration or infection is not excluded. [**2183-1-20**] CTA head 1. 5.5 x 4 mm aneurysm of the ACA with a 4 mm neck. 2. Bilateral subarachnoid and intraventricular hemorrhage with interval placement of a intraventricular catheter. The ventricular size is mildly decreased since the prior exam. [**2183-1-21**] EKG Sinus bradycardia. Otherwise, findings are within normal limits. No previous tracing available for comparison [**2183-1-21**] CTA head 1. Residual subarachnoid hemorrhage, with majority of the subarachnoid hemorrhage distributed in the left Sylvian fissure. 2. The patient is status post coiling of an anterior communicating artery aneurysm and right frontal burr hole, with a small amount of blood along the tract of the drainage catheter, there is mild enlargement of the left temporal ventricular [**Doctor Last Name 534**], close attention to this finding is recommended in the followup examination. 3. The CTA demonstrates mild narrowing of the left A1 and M1 segments, suggesting mild vasospasm. [**2183-1-21**] Chest AP single view of the chest has been obtained with patient in sitting semi-upright position. A left-sided subclavian approach central venous line is seen and noted to terminate overlying the right-sided mediastinal structures at a level 1 cm below the carina. This is compatible with a position in the mid portion of the SVC. No pneumothorax has developed. Also noted is the patient is intubated, the ETT terminating in the trachea 5 cm above the level of the carina. An NG tube has been passed and reaches well below the diaphragm. There is no evidence of acute pulmonary infiltrates, no pneumothorax, and no pulmonary vascular congestion. [**2183-1-24**] Cerebral Angiogram: Mild to moderate spasm of the right ACA. [**Known firstname **] [**Known lastname **] underwent cerebral angiography and instillation of 10 mg of verapamil into the anterior cerebral artery on the right side. There were no complications during the procedure. [**2183-1-28**] FINDINGS: There is interval decrease in the amount of left parietal subarachnoid hemorrhage. Residual intraventricular hemorrhage is noted in the bilateral lateral ventricular occipital horns. The right frontal approach ventriculostomy catheter is noted with its tip at the level of the foramen of [**Last Name (un) 2044**], which is unchanged. There is unchanged small amount of hemorrhage along the ventriculostomy tract. The ventricles are stable in size since the prior study. There is no evidence of midline shift. There is no evidence of new hemorrhage or acute infarct. A metallic coil is again noted at the expected location of the anterior communicating artery aneurysm. The visualized maxillary sinuses and mastoid air cells are clear. Post cataract extraction status is noted of bilateral globes. IMPRESSION: 1. Interval decrease in the amount of left parietal subarachnoid hemorrhage. Residual intraventricular hemorrhage is noted in the bilateral lateral ventricular occipital horns. 2. Unchanged position of right frontal ventriculostomy catheter with small amount of hemorrhage along the ventriculostomy tract. The ventricles are stable in size since the prior study. 3. A metallic coil at the expected location of the anterior communicating artery aneurysm. 4. No evidence of new hemorrhage or acute infarct. CXR [**1-29**] Dobhoff tube tip is in the stomach, but the upper portion of the Dobhoff tip is still in the distal esophagus and should be advanced for more standard position. Tracheostomy tube is in standard position. Left subclavian catheter tip is in the upper SVC. There are low lung volumes. Cardiomegaly is stable. The apices of the lungs are obscured by the patient's chin. Enlarging bibasilar opacities are consistent with increasing atelectasis. There is mild vascular congestion. CT Head [**1-31**] 1. New small area of low attenuation may represent a small infarct in the right basal ganglia. 2. Unchanged position of right EVD with stable size of the ventricles. 3. Resolution of the hemorrhage surrounding the EVD catheter. 4. Decrease in the amount of intraventricular and subarachnoid hemorrhage. No new evidence of hemorrhage. CT head [**2-1**] 1. Since the [**2183-1-31**] examination, there has been no interval change. A possible right basal ganglia infarct is less conspicuous on today's examination. 2. Unchanged right EVD positioning. 3. Unchanged trace blood products within the lateral ventricles. 4. No new hemorrhage or new mass effect is detected. CXR [**2-2**] Compared to the prior study, there is no significant interval change. The Dobbhoff tube is again seen to be just below the GE junction, too high to be used for feeding. The appearance of the lung is unchanged. Tracheostomy and subclavian lines are in similar positions. Abdominal X-ray [**2183-2-3**] Two supine radiographs of the abdomen are submitted for review, limited by motion artifact and soft tissue attenuation. A feeding tube is seen entering the stomach, projecting into the region of the pylorus or possibly the duodenal bulb. The bowel gas pattern is nonobstructive. There is no dilated bowel loops identified. There is no pneumatosis, bowel wall thickening, or supine evidence of free air on this technically limited study. CT torso [**2183-2-6**] 1. Normal gastric anatomy. No bowel loops anterior to the stomach. 2. Bibasilar atelectasis. 3. Incidental right parapelvic renal cysts [**2183-2-6**] G tube placement Successful placement of 12 French Wills-[**Doctor Last Name **] feeding tube within the stomach [**2183-2-6**] abdominal X-ray A single supine portable view of the abdomen which excludes the upper abdomen and left flank is submitted for review. A PEG tube is newly noted projecting over the epigastric region, incompletely evaluated on this study. A rectal tube is also noted. Though evaluation is limited on this study, there is no supine evidence of free air, and there is no bowel wall thickening or pneumatosis. There are no dilated bowel loops to definitely suggest obstruction. [**2183-2-6**] CXR AP single view of the chest has been obtained with patient in supine position. Comparison is made with the next preceding similar study of [**2183-2-3**]. Tracheostomy as before with unchanged position of the tube in the trachea. No pneumothorax has developed. Position of previously described left subclavian central venous line is unchanged. There are multiple external wires overlying the chest, but no other indwelling line can be identified. As before relatively high positioned right-sided diaphragm but no evidence of pleural effusions in the lateral pleural sinuses on either side and no pneumothorax in the apical area. No new parenchymal infiltrates can be identified on this portable examination when compared with the previous study of [**2183-2-3**]. Cerebral Angiogram [**2183-2-7**] [**Known firstname **] [**Known lastname **] underwent cerebral angiography and coil Preliminary Reportembolization of an anterior communicating artery aneurysm that was uneventful. Preliminary ReportThere were no complications and recoiling of an anterior communicating artery Preliminary Reportaneurysm that was uneventful. There were no complications Head CT w/o contrast [**2183-2-11**] Stable head CT, mild increase in vent size but no hydrocephalus, no new hemorrhage. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the SICU under the care of Dr. [**First Name (STitle) **] for SAH. She had an EVD placed in the ED. She was started on nimodipine and dilantin. On [**1-21**] she underwent a cerebral angiodram with coiling of ACA aneurysm. CTA was done on [**1-21**] and there was no vasospasm per Dr. [**First Name (STitle) **]. Pressors were stopped. Dilantin was chnaged to Keppra. On [**1-22**] she was weaned toward extubation but failed. Propofol was converted to fentanyl boluses. CT head showed bleeding. ASA was continued anyway. In the am of [**1-23**], her exam was stable: PERRL, no EO/ + grimace / localizes L>R, w/d's LE L>R. She was febrile to 103.7F and CSF was sent from EVD. She started to be cooled to normothermic. She was shievring and requiring more propofol, then paralytics. In the afternoon, her exam was worse with no purposeful movement. TCD report on this day showed moderate Vasospasm L MCA. ICP was [**7-10**] (17x1 after bath). CSF results were as follows.: 3+PMNs, no orgs, R [**Numeric Identifier 45189**] W 250 G 67 P 59. On [**1-23**], patient was febrile to 103.7, cooling was intiated. TCDs showed moderate vasospasm in the L MCA. Propofol was increased and triple HHH therapy started. ICPs were stable [**7-10**]. On [**1-24**], she was taken to angiogram and verapamil was given for mild spasm in R ACA. Angiogram was done successfully and patient was transferred to the ICU. She remained paralyzed. On post angio check, patient's pupils were PERRL and groin site with no hematoma. EEG reports showed bifrontal or generalized eleptiform activity. [**Date range (1) **] Patient was taken off paralytics and placed on fentanyl and versed for sedation. She continued to have fevers. Cooling measures were initiated along with around the clock administration of Motrin and Tylenol. On [**1-27**] she was taken off the arctic sun and was afebrile with Motrin and tylenol. CTA was performed because after some time off of sedation she had still not improved. Her CTA did not reveal significant spasm. [**1-28**] patient was clinically improved. Standing Tylenol and Motrin were discontinued, and she spiked a fever again to 102.4. Full cultures were sent. On [**1-29**] patient finished her course of antibiotics for treatment of H.flu pneumonia. A tracheostomy was placed without complication. The following morning a clamping trial of her EVD was initiated. Her aspirin was discontinued in anticipation of possible shunt. [**2-1**] patient continued to clinically improve. A repeat head CT was stable and her EVD was removed. Overnight patient spiked a temp of 101.8 and cultures were resent. U/A was negative. On [**2-2**], patient was seen sitting in chair more alert. She did not follow commands, but was purposeful in BUE and w/d BLE. Her eyes were open to voice. She remained stable overnight into [**2-3**]. On morning rounds her exam was stable and she was deemed fit for transfer to the stepdown unit. On [**2-4**] her exam was stable and she was planned for PEG placement by the ACS service. ACS was unable to eprform her PEG secondary to her body habitus and thus recommended that her PEG be placed via IR. She was stable overnight into [**2-5**] and IR was contact[**Name (NI) **] to place the PEG. They plan to place it on [**2-6**]. Her exam on morning rounds was stable as well. She underwent PEG palcment on [**2-6**] without incidence via IR. Later in the day her temperature went to 103.2 and she was pancultured and a CXR, KUB, LFT's, UA, and sputum culture were ordered. Her CXR, KUB, LFT's, and UA were all without signs of infectious process or abnormality. On AM rounds on [**2-7**] she was noted to not move the LUE which was new. Otherwise her exam was stable. She was taken to the angio suite on [**2-7**] as well for completion of coiling. Both femoral arteries angiosealed. LUE weakness then found to have resolved after the procedure. On [**2-8**] her Tmax was 100. Wound Cultures negative. C-diff negative. CXR negative. LENIS were negative. Her neuro exam was stable. Blood cultures with growth of staph in one bottle (other bottle pending). No Abx coverage. On [**2-9**] Fever 100.3. Thought [**1-30**] ? central causes. Defervesced thereafter however continued to have mild leukocytosis with WBC 12 on [**2183-2-10**]. Cultures remained negative, no further growth on blood culture with staph. On [**2-11**], she was afebrile and exam unchanged. She was discharged to rehab after a follow-up CT. Medications on Admission: None Discharge Medications: 1. atorvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 2. levetiracetam 100 mg/mL Solution [**Month/Year (2) **]: 1500 (1500) mg PO BID (2 times a day). 3. ibuprofen 100 mg/5 mL Suspension [**Month/Year (2) **]: 400-800 mg PO Q8H (every 8 hours) as needed for fevers. 4. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Month/Year (2) **]: One (1) Appl Ophthalmic PRN (as needed) as needed for dryness. 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Month/Year (2) **]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 6. heparin (porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 7. acetaminophen 325 mg/10.15 mL Suspension [**Month/Year (2) **]: 325-650 mg PO Q6H (every 6 hours) as needed for pain, fever. 8. levothyroxine 25 mcg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 9. aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: subarachnoid hemorrhage fever of unknown origin hydrocephalus intraventricular hemorrhage ventilatory acquired pneumonia seizure respiratory failure cerebral vasospasm anterior communicating artery aneurysm 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: General Instructions ?????? Take ASA 325mg daily ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you 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 have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy 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. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a MRI/MRA ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2183-2-11**]

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icd9cm

[ [ [] ] ]

[ "96.6", "99.29", "31.1", "02.21", "43.11", "39.72", "96.72", "33.24", "88.41" ]

icd9pcs

[ [ [] ] ]

15647, 15717

9916, 14430

336, 632

15968, 15968

1870, 9893

17521, 17733

1400, 1434

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15738, 15947

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1711, 1851

267, 298

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29,040

137,140

46240

Discharge summary

report

Admission Date: [**2143-6-16**] Discharge Date: [**2143-6-18**] Service: MEDICINE Allergies: Codeine / Peanut Attending:[**First Name3 (LF) 898**] Chief Complaint: Salmon salad stuck in throat. Major Surgical or Invasive Procedure: Upper endoscopy Elective endotracheal intubation History of Present Illness: HPI: 85 y/o man with a hx of atrial fibrillation and blindness presents following episode of not fully swallowing some of the salmon salad he ate for lunch at 1500. Immediately after taking a particularly large bite of his salad, he noticed that the food seemed not to pass into his stomach. He had a pressure sensation in his epigastric region extending towards his sternum. Pt tried swallowing hard, with no improvement. He denies shortness of breath, diaphoresis, radiation, but does endorse nausea ane a minor change in his voice. The pt has had a [**11-18**] year history of food "getting stuck" [**1-6**] times per year. Usually the sensation goes away within [**2-5**] hours. 10 years ago, he was evaluated with a barium swallow, which was normal. The patient was evaluated in the ED and referred to the CCU for elective EGD to remove the food presumed to be lodged in the patient's esophagus. Past Medical History: PMH: - Atrial fibrillation x 4 years. Rate controlled. - Bilateral blindness - Hypertension Past Surgical History: L Inguinal Hernia repair [**12/2134**]. Social History: Social Hx: Lives in [**Location **]. No Etoh or Tobacco Family History: Family Hx: Fa MI. Physical Exam: PE: VS: T 97.1 BP 120/61 HR 75 RR 20 98% 550x12 Fio2 1.0, peep 5 GEN: NAD, intubated and sedated HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM, no LAD, no stridor. CV: irregularly irregular, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits NEURO: CN II-XII grossly intact. No asterixis. Pertinent Results: EGD: Normal mucosa in the stomach Blood in the stomach Normal mucosa in the duodenum Diverticulum in the lower third of the esophagus just proximal to the hiatal hernia Small hiatal hernia Food in the lower third of the esophagus (foreign body removal) [**2143-6-16**] 09:21AM GLUCOSE-116* UREA N-25* CREAT-1.1 SODIUM-144 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-29 ANION GAP-15 [**2143-6-16**] 09:21AM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.4 [**2143-6-16**] 09:21AM WBC-14.0* RBC-4.95 HGB-15.1 HCT-46.0 MCV-93 MCH-30.4 MCHC-32.8 RDW-13.3 Brief Hospital Course: 85 year old gentleman admitted to the MICU then transferred to the floor after food disimpaction via EGD. He is resting comfortably and complains only of dysphagia. 1. Food impaction: Removed by GI during EGD while in the ICU under intubation. He was transferred to CC7 when stable and had no complications other than some transient dysphagia. The patient was found to have esophagitis. He was also found to have a large distal esophageal diverticulum and is at risk for recurrence. Video swallow study confirmed the patient had chronic aspiration events. Their recommendations were passed on in the discharge instructions. He was started on a PPI [**Hospital1 **] and to follow for a repeat EGD in [**7-16**] weeks. 2. New Oxygen requirement/ Leukocytosis: Patient has a new requirement for 4L O2. This resolved over the course of his stay as his sats returned to >95% on room air while walking. His lung exam and multiple CXRs made aspiration pneumonitits unlikely, however chronic aspiration may have played a role. The patient's leukocytosis resolved as well without fever or antibiotics. 3. Atrial fibrillation: The patient was rate-controlled on Atenolol and anti-coagulated with Coumadin with an INR between [**1-6**] during his stay. 4. Hypertension: The patient was maintained on Atenolol & Cardura. Medications on Admission: Cardura (Doses Unknown) Atenolol (Doses Unknown) Coumadin 5mg PO Qday Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 2. 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* 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1)Food impaction 2)Aspiration 3)Hypoxemia 4)Leukocytosis Secondary diagnoses: 1)Esophagitis 2)Atrial fibrillation 3)Hypertension Discharge Condition: Stable Discharge Instructions: 1)You were admitted to the hospital since you had food stuck in your gastrointestinal tract. You underwent an upper endoscopy and the food was moved into your stomach. In addition, you were found to have an outpoutching called a diverticulum. You have been scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in gastroenterology. The time and date of your appointment is listed below. You will also need to have an upper endoscopy repeated as well. This will be scheduled by Dr. [**Last Name (STitle) **] when you see him. 2)Please take all medications as listed in the discharge instructions. You have been started on one new medication called Pantoprazole, since you were found to have some inflammation of your gastrointestinal tract. Please continue this until you are told to stop by your primary care physician. [**Name10 (NameIs) **] addition, please continue to get your INR checked since you are on Coumadin. 3)You were found to be aspirating during your hospital stay. This means that some of the fluid you were eating was going into the wrong pipe, into your lungs. As a result, you may have had some difficulty breathing. You are instructed to be on the following diet with additional recommendations: - Nectar thick liquids and regular solids - Also follow these precautions: Swallow with chin tucked to chest, at least 2 repeat swallows, intermittent cough to clear possible penetration. - Lastly, you will need a repeat swallowing study in 2 weeks. You will be contact[**Name (NI) **] regarding the date and time. If you don't hear from them, please contact [**Telephone/Fax (1) 3731**] to schedule this appointment. 4)If you experience any fevers, chills, chest pain, shortness of breath, abdominal pain, difficulty with swallowing, or any other concerning symptoms, please return to the emergency room. Followup Instructions: 1)Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2143-6-24**] 2:30 2)Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2143-7-12**] 9:30

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icd9cm

[ [ [] ] ]

[ "98.02", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

4400, 4406

2558, 3879

253, 304

4599, 4608

1992, 2535

6514, 6843

1503, 1522

4000, 4377

4427, 4504

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1372, 1414

1537, 1973

4525, 4578

184, 215

332, 1235

1257, 1349

1430, 1487

5,506

111,309

45093

Discharge summary

report

Admission Date: [**2115-9-28**] Discharge Date: [**2115-10-20**] Date of Birth: Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old male with past medical history significant for CAD status post CABG, Class IV CHF with an EF of 35%, AFib status post ICD pacer and chronic renal insufficiency, transferred to [**Hospital1 18**] from nursing home facility due to increased respiratory rate and lethargy on day of admission. Patient had a recent hospital admission for pneumonia, and had just completed a seven day course of Augmentin, which was finished on the day of this current admission. Patient had been noticed to be increasingly lethargic with decreased p.o. intake by the nursing home staff. He also notes diffuse achiness and feeling chilly. Patient is a poor historian. Upon arrival to [**Hospital1 18**], his blood pressure was 167/68, heart rate of 60, respiratory rate of 30, and satting 86% on 5 liters. He was placed on 100% nonrebreather with his sats improving to the 90s. He received 80 mg of IV Lasix, and his oxygen requirement then decreased to 4 liters. He also received a dose of Levaquin and was started on a nitroglycerin drip. PAST MEDICAL HISTORY: 1. Coronary artery disease status post CABG x3 in [**2096**] with redo in [**2108**]. P-MIBI in [**2115-4-16**] showing moderate reversible inferior defect, status post dual lead pacer and defibrillator placed in [**2114-8-16**], bilateral pleural effusions. 2. Class IV CHF with EF of 35%. 3. AFib. 4. Chronic renal insufficiency with baseline creatinine of 2.2. 5. Hyperlipidemia. 6. Hypertension. 7. Monoclonal gammopathy. 8. Prostate cancer status post prostatectomy. 9. Tophaceous gout. 10. Cervical spondylosis. 11. Status post appendectomy. 12. GAVE syndrome. 13. Status post knee surgery. 14. Status post spinal cyst removal. 15. History of lower gastrointestinal bleed. MEDICATIONS: 1. Protonix. 2. Digoxin. 3. Colace. 4. Isosorbide mononitrate. 5. Epogen. 6. Hydralazine. 7. Toprol XL. 8. Bumetanide. 9. Timoptic eyedrops. 10. Senna. 11. Allopurinol. 12. Remeron. 13. Multivitamin. ALLERGIES: Morphine. SOCIAL HISTORY: Currently residing at [**Hospital 33092**] Rehab. Lives alone. Daughter in [**Name2 (NI) 4565**]. Quit tobacco 40 years ago. No current alcohol use. FAMILY HISTORY: Noncontributory. LABORATORIES ON ADMISSION: White count 11.2, hematocrit 34.7. Sodium 154, potassium 4.9, chloride 116, bicarb 24, BUN 106, creatinine 2.6. Urinalysis: 100 protein, 21-50 RBC, and few bacteria. Chest x-ray: Cardiomegaly, bilateral basilar dense opacities with air bronchograms in the right middle lobe and right lower lobe consistent with pneumonia with superimposed pulmonary edema. EKG: Paced rhythm, left bundle branch block. HOSPITAL COURSE: 1. Cardiovascular: Pump: Patient with Class IV CHF admitted with acute CHF exacerbation. At initial presentation in the ED, patient in acute respiratory distress, received Lasix with good diuresis, and subsequent improved respiratory status. He initially went to the floor, where he was weaned down to 4 liters nasal cannula of oxygen. However, the day following admission, patient developed worsening respiratory distress and was markedly tachypneic with decreased urine output and abdominal pain. He was then transferred to the MICU for closer monitoring. Upon arrival in the MICU, there was concern that patient might be intervascularly dry given his hypernatremia, acute renal failure, and free water deficit, and low CVPs. He received several free water and normal saline boluses. Although his chest x-ray did show bilateral pleural effusions, these were thought to be chronic. However, on [**10-4**], the patient continued to have significant respiratory distress and difficulty weaning off the ventilator. A CAT scan was obtained, which showed bilateral layering effusions, pulmonary edema, and patient was thought to be in CHF. At this point, he was then diuresed with Zaroxolyn and Bumex for several days without response. Cardiology was then consulted for evaluation of his CHF at which point he was started on a Natrecor drip. Initially, Bumex and Zaroxolyn were D/C'd. Patient had minimal diuresis. Review of the record showed patient has had multiple episodes of CHF refractory to diuresis. Bumex and Zaroxolyn were added back. In addition, patient was started on a Lasix drip. He did have an adequate diuretic response on this regimen. He also required the addition of dobutamine given his poor cardiac function. A Swan was placed to monitor patient's hemodynamics throughout this. Multiple attempts were made to wean him off of his drips, which were unsuccessful. After several days, his Lasix drip was stopped, and he was maintained on Natrecor and dobutamine. However, patient had significant ectopy with dobutamine, so this was slowly weaned down. The CHF service was also consulted, but no further progress was able to be made in the management of patient's CHF. Rhythm: Patient with biventricular pacer and defibrillator. He was V paced throughout the hospitalization. He was seen by EP and his pacer rate was increased to 95 in order to optimize his cardiac function given his severe CHF. He had marked ectopy on dobutamine drip, which had been added as per his CHF. Coronary: Patient had no active ischemia during the hospitalization. 2. ID: Patient admitted having just completed treatment for a pneumonia. He was started on Levaquin and Cipro on admission to cover for community acquired and aspiration pneumonia. When he was transferred to the MICU, his antibiotic coverage was brought in to ceftaz, Flagyl, and Vancomycin to cover for pneumonia. He was treated for seven days. Given his continued respiratory issues, patient was bronched with BAL cultures obtained. These grew out only sparse MRSA which was thought to be colonization. Patient remained off antibiotics for many days. He then subsequently developed a Pseudomonas UTI for which he was started on cefepime. 3. Pulmonary: Patient admitted with mild respiratory distress thought to be CHF exacerbation and pneumonia. Following diuresis, his respiratory status initially improved, but then upon day of transfer to the MICU, he was markedly tachypneic with abdominal pain and decreased urine output. In this setting, he was electively intubated to allow for better workup of his other issues. Following this, multiple attempts to wean him off the ventilator were unsuccessful. He was then started on an aggressive diuresis regimen. He was finally extubated on [**10-10**]. He had been intubated for a total of 12 days. He did well for several days following extubation, but in the setting of his worsening CHF, developed progressive respiratory distress. Following lengthy discussions with the patient and the family, decided that patient would not be reintubated. He was briefly placed on BiPAP, which he did not tolerate well and which had minimal effect on his respiratory distress. 4. Heme: Several days into admission, the patient developed left lower upper edema. An ultrasound showed a new left subclavian vein thrombus in addition to an old right IJ clot. Patient was then started on Heparin. Given patient's history of GAVE syndrome, GI was consulted prior to initiation of Heparin. There was also concern given a recent EGD, which showed gastritis and a few AVMs. Following lengthy discussion with the GI team, it was decided that the patient would benefit from Heparin. Serial hematocrits were followed on this regimen. Patient with baseline anemia due to chronic renal insufficiency, he was maintained on Epogen and iron per his outpatient regimen. 5. Renal: Patient with chronic renal insufficiency and baseline creatinine of approximately 2.2. His creatinine remained essentially stable. His medications were renally dosed. Patient did have symptoms with urinary obstruction. The day following admission, he developed acute abdominal pain. A CAT scan of the abdomen showed a distended bladder. Following catheterization, his abdominal pain resolved. Patient had multiple issues with Foley catheter placement thought to be due to his prostatectomy and unusual anatomy. Multiple episodes of Foley catheter clogging and with large bladder residuals measuring 100 cc. Urology was consulted, and several catheters were placed including finally a catheter placed under cystoscopy. Patient then had multiple blood clots and hematuria thought to be due to Foley catheter trauma in the setting of Heparin. He was briefly placed on continuous bowel irrigation and his symptoms resolved. 6. GI: Patient with dysphagia. He had a PEG tube placed and tube feeds were started, which he tolerated well. He has a history of GAVE syndrome for which GI followed him. He had no active exacerbations of this. 7. Fluids, electrolytes, and nutrition: Patient initially dry on admission and rehydrated. He subsequently developed a severe CHF exacerbation and was fluid restricted. His electrolytes were followed throughout the hospitalization and patient was started on tube feeds, which he tolerated well. A PEG was placed for tube feed delivery. 8. Disposition: Patient continued to have progressive CHF refractory to diuretic or other treatments. He developed progressive respiratory distress, but did not wish to be reintubated. Multiple discussions regarding codes and interventions were discussed with patient and his daughter. [**Name (NI) 227**] patient's extremely poor prognosis and medical futility treatment, it was decided that he would not benefit from intubation. Patient had progressive symptoms related to his CHF. He was briefly placed on BiPAP, which he did not tolerate. He was given Morphine to make him comfortable and in an attempt to facilitate BiPAP. Patient developed progressive respiratory distress and died secondary to cardiopulmonary failure on [**2115-10-20**] at 4:10 p.m. Patient's daughter was [**Name (NI) 653**] and made aware. She declined any postmortem examination. The patient was actually transferred to the CCU service with the attending, Dr. [**Last Name (STitle) **], although it is still listed in the computer under MICU, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], just as to clarify who the attending of record is to be. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932 Dictated By:[**Last Name (NamePattern1) 5212**] MEDQUIST36 D: [**2116-1-23**] 23:36 T: [**2116-1-24**] 12:10 JOB#: [**Job Number 96378**] cc:[**Last Name (NamePattern4) 96379**]

[ "427.31", "785.51", "453.8", "585", "599.0", "428.41", "276.0", "428.0", "518.84" ]

icd9cm

[ [ [] ] ]

[ "43.11", "89.64", "96.72", "99.04", "33.24", "38.93", "96.6", "89.45", "96.48", "00.13", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

2339, 2370

2811, 10640

158, 1212

2385, 2794

1234, 2152

2169, 2322

45,727

159,541

4214

Discharge summary

report

Admission Date: [**2104-10-20**] Discharge Date: [**2104-10-26**] Date of Birth: [**2040-8-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2782**] Chief Complaint: Dyspnea, OSH transfer for PE. Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo man with h/o COPD presented to OSH complaining of SOB on exertion that had started on Thursday evening. His breathing improved with rest, but he contined to have DOE over the weekend. Earlier in the day on Monday, he felt that he was unable to catch his breath even at rest and he decided to go to the ER. He also has noticed that his right ankle was swollen, the full time like on his ankle swelling is not clear, but he reports he first officially noticed it on Sunday. At the OSH, he was found to be tachycardia to the 120s with an o2 say of 88%. LENIs were reportedly negative. A CTA showed a "large saddle embolus, involving all lobes, likely small L lower lobe infarct." He was then started on a heparin gtt (80 mg/kg bolus, then 18 mg/kg drip; guaiac negative as per report) and transferred to [**Hospital1 18**]. VS on transfer were HR 115s, SBP 130-140 and stable, and O2 sat of 92% on 2L. . In the ED inital vitals were, T 98.1 HR 120 BP 96/57 RR 16 O2 sat 95% 6L NC. He denied current CP or SOB at rest, but continues to have DOE and desatted to the 80s. He denies recent trauma, travel or a decrease in ambulation. He has been afebrile, but has been endorsing a dry cough. A bedside echo was done which was significant for RV strain, with RA dilatation. His BP remained stable and he was admitted to the ICU. . On the floor, he is resting comfortably and in no acute distress. He continues to deny CP or current SOB. He denies recent pleuritic CP, F/C, N/V, abd pain, calf pain. No h/o clots in the past and no family history of clots. He reports a chronic cough productive of whitish sputum that is unchanged. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: COPD - dx following hernia repair surgery about 1.5 years prior. Anterior cervical disk excision and fusion, C6-7. ?Chronic HCV - reported was found to have positive Ab but negative VL, no bx, no treatment. Hernia repair ?Cirrhosis a/w history alcohol abuse Social History: - Tobacco: +2 ppd x50ish years - Alcohol: +self reported significant history of drinking, has cut back and now is slightly vauge, but appears to drink about once per week - Illicits: denies Family History: Colon Ca in both parents, around age 60. Physical Exam: On admission to ICU: Vitals: T: BP: 106/89 P: 105 R: 27 O2: 94-95% on 6L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated but limited exam due to body habitus, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, good air entry throughout, speaking comfortably in full sentances. 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 appreciated, +obesity GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, or cyanosis. Trace pedal edema slighlty greater on R>L. No calf tenderness b/l Pertinent Results: On admission: [**2104-10-20**] 10:37PM BLOOD WBC-7.2 RBC-5.10 Hgb-17.4 Hct-53.0* MCV-104*# MCH-34.1*# MCHC-32.9 RDW-17.2* Plt Ct-99* [**2104-10-20**] 10:37PM BLOOD Neuts-89.5* Lymphs-4.6* Monos-4.6 Eos-1.0 Baso-0.2 [**2104-10-20**] 10:37PM BLOOD PT-17.1* PTT-150* INR(PT)-1.5* [**2104-10-20**] 10:37PM BLOOD Glucose-244* UreaN-10 Creat-0.8 Na-139 K-3.8 Cl-102 HCO3-21* AnGap-20 [**2104-10-20**] 10:37PM BLOOD ALT-10 AST-22 LD(LDH)-257* AlkPhos-19* TotBili-0.3 [**2104-10-20**] 10:37PM BLOOD proBNP-1097* [**2104-10-20**] 10:37PM BLOOD cTropnT-<0.01 [**2104-10-20**] 10:37PM BLOOD Iron-27* [**2104-10-21**] 05:34AM BLOOD Albumin-3.2* Calcium-8.8 Phos-1.9* Mg-1.7 [**2104-10-20**] 10:37PM BLOOD calTIBC-247* Ferritn-746* TRF-190* [**2104-10-21**] 05:34AM BLOOD %HbA1c-5.9 eAG-123 [**2104-10-21**] 05:34AM BLOOD AFP-3.4 [**2104-10-20**] 11:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2104-10-20**] 11:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Report from OSH - CTA: Extensive b/l pulmonary emboli with large amount of clot noted within the distal R main pulmonary artery. Clot is noted in the pulmonary bifurcation c/w cell embolism. Faint opacity in the LLL may reprent small infarction. Minimal emphysematous changes b/l. Multiple tortuous vessels in the LUQ suggests varices. Focal area of low attenuation in the spleen. Report from OSH - R-LENI: negative for DVT . [**2104-10-24**] 08:18AM BLOOD WBC-6.9 RBC-4.51* Hgb-15.7 Hct-45.1 MCV-100* MCH-34.9* MCHC-34.9 RDW-17.9* Plt Ct-87* [**2104-10-23**] 07:55AM BLOOD WBC-7.2 RBC-4.74 Hgb-16.4 Hct-47.8 MCV-101* MCH-34.6* MCHC-34.3 RDW-17.9* Plt Ct-100* [**2104-10-22**] 05:01AM BLOOD WBC-9.5 RBC-4.66 Hgb-16.4 Hct-46.7 MCV-100* MCH-35.2* MCHC-35.1* RDW-18.0* Plt Ct-87* [**2104-10-21**] 05:34AM BLOOD WBC-7.2 RBC-4.51* Hgb-15.6 Hct-43.1 MCV-96# MCH-34.6* MCHC-36.2*# RDW-17.7* Plt Ct-89* [**2104-10-20**] 10:37PM BLOOD WBC-7.2 RBC-5.10 Hgb-17.4 Hct-53.0* MCV-104*# MCH-34.1*# MCHC-32.9 RDW-17.2* Plt Ct-99* [**2104-10-21**] 05:34AM BLOOD Neuts-88.0* Lymphs-7.5* Monos-3.7 Eos-0.8 Baso-0.1 [**2104-10-20**] 10:37PM BLOOD Neuts-89.5* Lymphs-4.6* Monos-4.6 Eos-1.0 Baso-0.2 [**2104-10-23**] 07:55AM BLOOD PT-14.2* PTT-30.8 INR(PT)-1.2* [**2104-10-22**] 05:01AM BLOOD PT-12.9 PTT-29.6 INR(PT)-1.1 [**2104-10-20**] 10:37PM BLOOD PT-17.1* PTT-150* INR(PT)-1.5* [**2104-10-24**] 08:18AM BLOOD Glucose-115* UreaN-10 Creat-0.8 Na-140 K-3.3 Cl-105 HCO3-28 AnGap-10 [**2104-10-23**] 07:55AM BLOOD Glucose-191* UreaN-16 Creat-0.8 Na-139 K-3.5 Cl-101 HCO3-29 AnGap-13 [**2104-10-22**] 05:01AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-142 K-4.0 Cl-108 HCO3-26 AnGap-12 [**2104-10-24**] 08:18AM BLOOD ALT-56* AST-67* AlkPhos-84 TotBili-1.3 [**2104-10-20**] 10:37PM BLOOD ALT-10 AST-22 LD(LDH)-257* AlkPhos-19* TotBili-0.3 [**2104-10-20**] 10:37PM BLOOD cTropnT-<0.01 [**2104-10-20**] 10:37PM BLOOD proBNP-1097* [**2104-10-20**] 10:37PM BLOOD calTIBC-247* Ferritn-746* TRF-190* [**2104-10-21**] 05:34AM BLOOD %HbA1c-5.9 eAG-123 [**2104-10-21**] 05:34AM BLOOD AFP-3.4 . CXR [**10-20**]: IMPRESSION: No acute intrathoracic process . ECHO [**10-21**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Agitated saline contrast study is consistent with the presence of an intracardiac shunt (likely stretched patent formamen ovale or small atrial septal defect). . [**10-21**] RUQ u/s: IMPRESSION: 1. 2.6 x 2.9 x 4.3 cm left hepatic lobe mass, equivocally seen on the single-phase reference CT examination from [**2104-10-20**]. An abdominal MR examination is recommended for further evaluation of this lesion. 2. Coarse liver echotexture, which may represent fatty infiltration or cirrhosis/fibrosis. 3. Splenomegaly. . MRI abdomen: IMPRESSION: 1. The lesion identified on the recent ultrasound corresponds to a hemangioma posteriorly in segment II of the liver. 2. Splenic infarct in the lower pole of the spleen. 3. Heterogenous signal intensity in the liver with varices seen in the left upper quadrant suggests the presence of chronic liver disease. Correlate clinically, and with liver function tests and biopsy as indicated. 4. 5mm cyst in the tail of the pancreas, given the patient's age, recommend follow-up with repeat MRCP in 1 year. 5. 7mm indeterminate right adrenal nodule. Brief Hospital Course: This is a 64 yo M with h/o COPD presented to OSH c/o RLE swelling x2 days and SOB. He was found to have a large saddle PE and transfered to [**Hospital1 18**] on a heparin drip for futher management. # Pulmonary embolism: He presented from OSH with CTA showing extensive b/l pulmonary emboli with large amount of clot in distal R main pulmonary artery. He was started on a heparin gtt bridge with coumadin. Heparin gtt was then noted to be infiltrated into left arm, resulting in swelling in left arm which improved with warm compresses. Heparin gtt was switched to lovenox injections [**Hospital1 **] on [**2104-10-21**]. Oxygen saturation remained mid 90s on 6L nasal cannula initially; he was weaned to 5L by time of transfer to floor. EKG did not show evidence of right heart strain. TTE showed normal EF >55%, mildly dilated right ventricle with normal free wall contractility, mildly dilated aortic root, as well as intracardiac shunt (likely patent formamen ovale or small atrial septal defect). Of note, OSH CTA also showed splenic infarct. Per history, he did not have known precipitating factors for pulmonary embolism (no personal or family history, hx of malignancy, recent prolonged travel). Hypercoagulability work-up was deferred for outpatient. He remained on therapeutic lovenox till the morning of [**10-26**] as his INR was 2.0 on [**10-25**] and [**10-26**] it was 2.2 with a dose of 5mg coumadin. He will be discharged on 5mg coumadin daily with planned anti-coagulation monitoring through his pcp's office. He was not hypoxic at rest but with activity such as walking his saturation was in the mid 80s. He was discharged with supplemental 02 (2l NC) with activity. . # Hepatic mass/hemangioma: As per old records, patient worked up for possible HCV due to ?positive Ab testing. Work up was negative including HCV viral load. Patient denied knowledge of HCV history but did recall being told that liver was damaged from alcohol. LFTs were normal, albumin 3.2. INR was elevated to 1.5 prior to initiation of coumadin, albumin was normal. However, platelets were low at 70-90K. Per OSH records, pt had longstanding history of thrombocytopenia with platelets in this range. RUQ was obtained that showed ill defined hepatic lobe mass and coarse liver echotexture concerning for fatty infiltration or cirrhosis/fibrosis. MRI of the liver was obtained to further evaluate that showed cirrhosis and hemangioma #Pancreatic Tail Cyst: found incidentally on MRI of liver --recommended to have repeat MRCP in 1 year #Incidentally found R adrenal nodule (7mm) found on MRI of liver --defer further workup to PCP as an outpatient #Splenic infarct-Pt was found to have a small ASD vs. stretched PFO on echo. This could have been due to an embolus. Pt is being anticoagulated as above. He will need continued evaluation in the outpatient setting. . #Cirrhosis-likely due to ETOH. ?Hep C history but review of prior notes suggest +ab but negative VL. +varices seen on MRI of the abdomen. LFTs normal. Did not appear to have evidence of any clinical decompensated cirrhosis during admission. Discussed importance of continued alcohol abstinence with patient. He was advised to follow up with hepatology for continued care an surveillance after discharge. . #Erythrocytosis-on admit. Appears chronic as per the few old data points available. Most likely secondary to smoking. Iron was low at 27, ferritin high at 746. Can have further outpatient heme workup. # Thrombocytopenia Etiology unclear, but appears to be a chronic process as thrombocytopenia dated back several years. Per OSH records, platelets had always been low. He did not have evidence of active bleeding. Work-up included RUQ ultrasound and liver MRI per above. Platelet count remained stable despite heparin products making HIT unlikely. *recommend outpatient hematology followup. # COPD No interventions at this time. Patient has an rx for spiriva but does not take regularly at home. This may also be a reason he desaturates with activity. # Tobacco use Pt received nicotine patch. He was counseled regarding smoking cessation and would like to continue on nicotine patch as an outpatient. # Hyperglycemia Pt did not have hx of diabetes. Pt initially had random blood glucose of 235 and he was started on a sliding scale. This was further evaluated with a hemoglobin A1c was 5.9. Transient hyperglycemia may have been [**2-13**] stress response from large PE; insulin was discontinued. Discharge Medications: 1. home oxygen therapy 2L NC with ambulation to keep saturation above 88% indication: hypoxia below 88% with ambulation (low of 84 with activity) 2. warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation three times a day as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 5. Outpatient Lab Work INR please forward result to patient's PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 18323**] fax [**Telephone/Fax (1) 18324**] Discharge Disposition: Home Discharge Diagnosis: acute saddle pulmonary embolus ETOH cirrhosis splenic infarct thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred from another hospital for continued evaluation and management of a large pulmonary embolus (blood clot). For this, you were started on a blood thinning medication (lovenox and coumadin) and you will need to continue this coumadin for at least [**3-16**] month's time. You will need regular blood tests to monitor your INR (how thin your blood is) and the goal should be between 2 to 3. Please call your doctor to arrange these blood tests and adjustment of your coumadin dose. In addition, it is important that you see your PCP after discharge to have age appropriate cancer screening such as colonoscopy and consideration of prostate evaluation. In addition, we discussed the importance of smoking cessation and abstinence from alcohol. . You would benefit from continued evaluation of a liver specialist as well. . Medication changes: 1.start coumadin 2.nicotine patch Please take all of your medications as prescribed and follow up with the appointment below. TRANSITIONAL ISSUES: 1) Recommend repeat MRCP in one year to evaluate 5mm cyst found in tail of pancreas 2)management of anticoagulation 3)evaluation by hepatologist for possible cirrhosis and varices 4)evaluation by hematologist for possible hypercoag workup. 5)evaluation of 7mm indeterminate R adrenal nodule Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**] at [**Telephone/Fax (1) 18325**] to schedule a follow up within 1 weeks of discharge. You will also need to talk with him about setting up anticoagulation management for your coumadin and for your INR lab tests. Please ask your doctor to refer you to a hematologist to review possible hypercoagulable conditions and also a referral to a hepatologist (liver specialist) to review the condition of your liver.

[ "287.5", "415.13", "571.2", "305.1", "289.59", "790.29", "577.2", "496", "228.04" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14055, 14061

8741, 13236

336, 343

14184, 14184

3741, 3741

15659, 16196

2931, 2974

13259, 14032

14082, 14163

14335, 15175

2989, 3722

15344, 15636

2021, 2421

15195, 15323

267, 298

371, 2002

3755, 8718

14199, 14311

2443, 2704

2720, 2915

10,134

156,534

13475

Discharge summary

report

Admission Date: [**2142-6-2**] Discharge Date: [**2142-6-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: bleeding, hypotension Major Surgical or Invasive Procedure: Intubation History of Present Illness: 85F h/o ESRD on HD, CAD, CHF (EF 35%), on HD for ESRD presenting to ED this morning after awakening covered in blood, with displacement of right chest hemodialysis line. Pressure was applied to the wound, and EMS was activated. Upon arrival to the ED VS=97.8 103 [**11-23**] 16 95%, however she quickly dropped to 70/p, although her right chest wound was no longer oozing. Left cordis was placed, and pt received 3U PRBCs with HCT improving from 33->30->38. BP remained low, and pt was started on levophed gtt with increase in SBP to 100s/60s, and HR to 110s. She was intubated [**1-29**] increased confusion, though initial CXR reveals right main stem intubation, which by report was corrected. FAST USN revealed no acute intrabominal bleeding. ECG revealed afib, and old lbbb vs ivcd. She is admitted to the MICU for management of presumed hypovelemic shock. She received 3U PRBCs and 1L NS in the ED. Her access includes L cordis and right PIVx1. Per family, she was in her USOH until presenting this morning. No fevers, chills, CP, SOB, N/V, ABD PAIN, rash, medication changes. Past Medical History: 1. HTN 2. CHF (EF 50-60%) 3. CAD s/p CABG ([**2118**]; LIMA->LAD, SVG->OM1, SVG->RCA), most recent cath in [**2133**], 3VD with patient LIMA-LAD 4. s/p MI ([**2105**]) 5. DM2 6. bilateral RAS s/p stents ([**2134**]) 7. right carotid stenosis 8. s/p appendectomy ([**2105**]) 9. s/p cholecystectomy ([**2104**]) 10. Spinal stenosis; s/p surgery ([**2134**]) 11. Chronic renal insufficiency (baseline Cre 2.3) 12. Bilateral cataracts 13. s/p colonoscopy ([**2135**]) 14. h/o atrial flutter 15. h/o chronic anemia (baseline Hct 30-32) 16. PVD s/p aortobifemoral bypass Social History: Former tobacco- + 30-pack-year smoking history. She denies alcohol. Family History: NC Physical Exam: General: intubated, sedated. HEENT: PERRL, gag intact, no LAD. Lungs: Clear to auscultation anteriorly, +bronchial breath sounds CV: irregular, tachycardic, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, +bowel sounds present, no rebound tenderness or guarding, ventral hernia. Ext: cool extremities, dopplerable LE pulses, dusky, blue/purple toes bilaterally. 2+ B LE edema. L LE ~3cm erythematous, wound with central ulcer. Pertinent Results: [**2142-6-2**] 08:52PM GLUCOSE-207* UREA N-61* CREAT-6.3* SODIUM-132* POTASSIUM-5.0 CHLORIDE-94* TOTAL CO2-22 ANION GAP-21* [**2142-6-2**] 08:52PM CALCIUM-9.2 PHOSPHATE-7.1* MAGNESIUM-1.8 [**2142-6-2**] 04:17PM TYPE-ART TEMP-37.2 RATES-16/ TIDAL VOL-450 PEEP-5 O2-40 PO2-147* PCO2-45 PH-7.34* TOTAL CO2-25 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED [**2142-6-2**] 03:53PM GLUCOSE-213* UREA N-61* CREAT-6.3* SODIUM-134 POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-22 ANION GAP-22* [**2142-6-2**] 03:53PM CALCIUM-9.5 PHOSPHATE-7.0* MAGNESIUM-1.8 [**2142-6-2**] 03:53PM PT-14.2* PTT-27.2 INR(PT)-1.2* [**2142-6-2**] 10:31AM HCT-37.7 [**2142-6-2**] 09:23AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2142-6-2**] 09:23AM URINE RBC-3* WBC-4 BACTERIA-NONE YEAST-NONE EPI-<1 [**2142-6-2**] 07:50AM TYPE-ART TEMP-36.8 TIDAL VOL-450 PEEP-5 O2-40 PO2-160* PCO2-41 PH-7.34* TOTAL CO2-23 BASE XS--3 [**2142-6-2**] 07:40AM GLUCOSE-189* UREA N-55* CREAT-5.9*# SODIUM-134 POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-21* ANION GAP-23* [**2142-6-2**] 07:40AM ALT(SGPT)-24 AST(SGOT)-86* ALK PHOS-171* [**2142-6-2**] 07:40AM ALBUMIN-3.6 CALCIUM-8.8 PHOSPHATE-7.4* MAGNESIUM-1.8 [**2142-6-2**] 07:40AM WBC-11.2* RBC-3.85* HGB-12.6 HCT-38.9 MCV-101* MCH-32.7* MCHC-32.4 RDW-22.4* [**2142-6-2**] 07:40AM PLT COUNT-133* [**2142-6-2**] 07:40AM PT-14.7* PTT-27.3 INR(PT)-1.3* Brief Hospital Course: /[**6-5**] CXR: right mainstem intubation, cordis in place. [**2142-6-2**] EGG: afib 104 bpm, LAD, LBBB (old), no STE (sgarbossa). # hypotension - Was worked up for hypovolemic shock with blood transfusions and serial hcts. no acute GIB found. Underwent TTE which showed worsened CHF. Hypotension did require pressors however as patient's family eventually changed goals of care to comfort measures this was weaned off. she passed away after a few days in the hospital. # respiratory failure - pt intubated in the setting of prolonged hypotension, resulting on altered mental status, and concern over patient's airway. pre-intubation ABG 7.35/46/340, consistent with good lung mechanics. She was quickly extubated and tolerated this well, although was clearly uncomfortable. After the family changed the goals of care she was kept comfortable with morphine PRN and passed away a few weeks later. # Code: Patient came in and family discussion resulted in changing from DNR to CMO if patient was extubated. she was eventually extubated and tolerated it well for a few days. She was transitioned to CMO. # Communication: With family. Husband [**Name (NI) 40815**]: [**Telephone/Fax (1) 40816**], [**Name2 (NI) 40817**] [**Last Name (NamePattern1) 40818**] (DTR): [**Telephone/Fax (1) 40819**] or [**Telephone/Fax (1) 7960**] Medications on Admission: (from family) Levothyroxine 112mcg daily Folic Acid 1mg daily Aspirin 81mg daily Omeprazole 40mg daily Neurontin 200mg QHS Niacin ER 500mg daily at night Metoprolol 12.5mg [**Hospital1 **] (not on HD days) Lipitor 40mg daily Ultram 100mg QAM, 50mg QPM Allopurinol 100mg daily NPH insulin 45units [**Hospital1 **] Humulin R insulin SS Senna PRN Ativan 1mg [**Hospital1 **] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2142-6-6**]

[ "250.00", "412", "996.73", "E878.1", "585.6", "V45.79", "V45.11", "366.8", "785.59", "285.1", "427.32", "V45.81", "518.81", "V58.67", "403.91", "433.10", "724.00", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5845, 5854

4063, 5394

282, 294

5905, 5914

2607, 4040

5970, 6007

2112, 2116

5816, 5822

5875, 5884

5420, 5793

5938, 5947

2131, 2588

221, 244

322, 1420

1442, 2010

2026, 2096

51,797

104,616

12561

Discharge summary

report

Admission Date: [**2194-1-28**] Discharge Date: [**2194-2-5**] Date of Birth: [**2107-6-29**] Sex: F Service: MEDICINE Allergies: Scopolamine Attending:[**First Name3 (LF) 3565**] Chief Complaint: Malaise, weakness, reduced appetite . Reason for MICU transfer: cholangitis / pancreatitis / ARDS Major Surgical or Invasive Procedure: Intubation, mechanical ventilation ERCP with two stent placed Arterial lines X2 Right IJ line placement History of Present Illness: HPI gleaned from [**Hospital1 **] [**Location (un) 620**] notes and daugther since Pt is intubated. . Pt is a 86 year old female w/ PMH of hypertension, hyperlipidemia, and insulin-dependent diabetes mellitus who complains of generalized malaise and weakness. According to family she has had a six-month decline in her general function including mobility, ability to communicate and mental status. At baseline, she can transfer wheelchair to toilet with assistance and some walking at home with physical therapy, but is "quite confused". According to the family, 2 days ago she had an episode of hypoglycemia related to a insulin dose it was late in the evening administered by her husband. Shortly afterwards, she became combative and needed to be restrained by her son. They called 911 and EMS found her blood sugars to be in the 40s. Her mental status cleared after admin of D50 and glucagon. Since that episode, she has had increased lethargy and weakness. She has been refusing to get out of bed at all and she has been moaning. No vomiting, no diarrhea, no fever. She did have episode of incontinence however that was in the setting of not getting out of bed. She always is a poor eater reported to family however she's had much nothing to eat for the last 24 hours. Her husband states her blood sugars have been normal and has been giving her her insulin as usual the last couple of days. Pt was brought to [**Hospital1 **] [**Location (un) 620**] ED for evaluation by family for continued "moaning" and reduced responsiveness. At BIDN, initial vitals were Temp: 100.6 HR: 98 BP: 120/46 Resp: 20 O(2)Sat: 94. Pt complained of L chest pain and R wrist pain. Troponins were negative, no concerning ECG changes. Plain CXR did not show any fractures of the chest or R wrist. Pt's lipase was elevated to [**2122**] and Pt developed a fever to 102F. She had a CT abdomen w/ contrast, which showed a common bile duct dilated to 2.8 cm w/ multiple stones and a question of obstructing ampullary stone. Plan was made to transfer Pt to [**Hospital1 **] [**Location (un) 86**] for ERCP, and Pt received a dose of Zosyn. Before transport, the patient became unstable with SBP in 70's. She was given 2L IVF and her BP remained low, and she was started on peripheral levophed. [**Hospital1 **] [**Location (un) 620**] ED placed a R IJ without complications, however she developed hypoxia just afterwards and needed to be intubated for airway control. She was intubated on second attempt with a 7.0 ETT. Her ETT and CVL appear to be in correct position on CXR and [**Hospital1 **] [**Location (un) 620**] feels she may have developed ARDS. Pt was then transferred to [**Hospital1 **] [**Location (un) 86**] ED. . In the [**Hospital1 **] [**Name (NI) 86**] [**Name (NI) **], Pt was stable. CXR showed diffuse bilateral infiltrates R > L and blunting of R costophrenic angle, ?ARDS. Pt was on midaz/fent. On norepi 0.21. IJ + 2PIVs. Received a dose of Vanc. Vent settings on transfer were FiO2 50% TV 420 RR 20 PEEP 5. Vitals were 76, 107/49, 98%. Pt was finishing 6th liter of IVF. . On arrival to the ICU, Pt's vital signs were 37.2C, HR 73, BP 109/46, RR 17, Sat 100% on FiO2 50%, intubated and sedated. . Review of systems: Unable to confirm due to intubation. Per [**Hospital1 **] [**Location (un) 620**] records and daughter, Pt did not have fevers / chills. No nausea or vomiting. No diarrhea. Reports malaise and reduced appetite for several months, but especially so for the last two days. No urinary symptoms. Past Medical History: insulin-dependent diabetes hypertension hyperlipidemia benign stricture of the pylorus and duodenum s/p dilation [**2187**] ampullary stenosis s/p sphincertotomy in [**2187**] peptic ulcer disease rheumatic heart dz Mixed aortic valve disease (mild) Mixed mitral valve disease (mild) History of breast cancer; status post bilateral mastectomy osteoporosis chronic hip and leg pain peripheral neuropathy R hip "plate" L carotid artery stenosis ? TIA Social History: Former smoker, quit decades ago. Denies EtOH. She lives with her husband in their home. Has visiting PT 2x weekly. Family History: Alzheimer dementia in sisters Physical Exam: Vitals: 37.2C, HR 73, BP 109/46, RR 17, 100% on FiO2 50%. General: intubated elderly woman HEENT: pupils pinpoint, dry mucous membranes Neck: R IJ Lungs: Clear to auscultation bilaterally except for L base, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic and diastolic murmurs, no rubs Abdomen: soft, non-distended, bowel sounds present, no organomegaly GU: foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**1-28**] 1.45a ABG: 7.26/42/87/20 on FiO2 50%. [**1-27**] 11.50p Lactate 1.3 Lipase [**2122**] [**1-27**] CBC: WBC 10.6, Hct 40.9, Plt 174. [**1-27**] 4pm LFTs: AST 68, ALT 34, T bili 0.57, AP 82. [**1-27**] Chem7: 138, 4.6, 102, 26.1, 19, 0.8, 112, Lactate 1.4. [**1-27**] UA bland, troponin < 0.01 . [**2194-1-27**]: CXR showed diffuse bilateral infiltrates R > L and blunting of R costophrenic angle, ?ARDS [**2194-1-27**]: CT abdomen w/ contrast: common bile duct dilated to 2.8 cm w/ multiple stones and a question of obstructing ampullary stone. L1 impression fracture of uncertain age. Small right upper lobe opacity consistent with resolving infection. . EKG: no prior available. NSR, normal axis, normal intervals, no PQ or ST changes, T waves tall. Brief Hospital Course: 86 yo F w/ PMH diabetes, hypertension, ampullary stenosis s/p sphincterotomy who presented with increasing lethargy, fevers, and hypotension, found to have septic [**Month/Day/Year **] from likely cholangitis and gallstone pancreatitis. She initially appeared to respond well to ERCP and antibiotics, initially coming down on pressors and appeared close to extubation. Then, however, her pressures began to drop and she was put back on pressors. Her mental status was poor, even off sedation, and she persistently failed her spontaneous breathing trials. Leukocytosis and fevers increased, and it appeared her sepsis and overall clinical status was worsening. At this point, her family felt that she would not want to continue with this level of treatment if it did not appear she would return to her baseline. After a meeting with the entire family (including daughter/HCP [**Doctor First Name 4134**], Dr. [**Last Name (STitle) **], and the rest of the ICU team, her care was transitioned to comfort focused care. Her pressors and antibiotics were stopped on [**2-4**], but she remained intubated and ventillated, as the family did not want her to feel air hunger. She passed away peacefully with family at her side at 4:05pm on [**2194-2-5**]. Please see below for more detailed summary of main hospital problems. PRIMARY PROBLEMS: # [**Name2 (NI) 21020**]: Thought to be septic in nature [**2-27**] cholangitis. Echo showed significant multi-valve dysfunction, however there was no evidence of cardiogenic component. Patient was intubated and started on norepinephrine on arrival in the ICU. For source control, she was sent to ERCP (see below) and started on empiric vancomycin and zosyn. Blood pressure was originally reasonably responsive to fluids, so patient was intermittently bolused and weaned off pressors after 3 days. She then, however, began to drop her pressures again requiring uptitration with pressors. Leukocytosis increased and she developed new fevers, raising concern for worsening of sepsis. No new source identified, nothing grew on blood or urine cultures. UOP decreased despite maintenance of MAPs. She began developing pleural effusions due to administered fluid and leaky capillaries, worsening her respiratory status. Given her overall worsening septic picture despite aggressive interventions, her family decided to focus on comfort and stop the antibiotics and pressors. # Respiratory distress: Pt was intubated for hypoxia and dyspnea at [**Hospital1 **] [**Location (un) 620**]. She initially met criteria for ARDS w/ acute onset, bilateral infiltrates, PaO2:FiO2 of 174 on admission. Likely cause was acute infectious process cholangitis vs pancreatitis. Patient was difficult to extubate due to poor gag, AMS and agitation as well as subsequent volume overload with fluid administration which did not resolve with diuresis. She continued to fail her SBTs daily and ultimately could not be extubated. # Cholangitis: OSH CT abdomen showed common bile duct dilated to 2.8cm w/ multiple stones. Given her presentation with fevers and hypotension, it was thought that she developed septic [**Location (un) **] from cholangitis or possibly gallstone pancreatitis (see below), although LFTs were never singificantly elevated. Started on vancomycin and zosyn. ERCP on [**2194-1-28**] showed 2 strictures, both dilated, and an 8mm irregular stone which was not evacuated. 2 stents were placed. Initially she seemed to be improving after this intervention and antibiotics, with WBC count and fever coming down, weaned off pressors. After 5 days, however, her leukocytosis and fevers began to climb again while on seemingly adequate coverage with vanco/zosyn. # Gallstone pancreatitis: Pt's lipase elevated to [**2122**] by report at OSH, now down in the 100s. Given presence of multiple stones in CBD, pancreatitis thought to be very likely due to gallstones. ERCP done with stents placed in CBD, stone was not removed. Serum TG 68. Given IVFs given aggressively and bowel rest initially. Patient started on tube feeding several days into ICU stay, however she did not tolerate these. # Arrhythmias: On the morning of admission, she went into numerous runs of ventricular tachycardia, which were sustained for [**11-7**] secs but spontaneously resolved without intervention. Later in her course, she developed atrial fibrillation with RVR that was not responsive to control with diltiazem 5mg x 2, metoprolol 5mg x2 plus 10mg x1. Started amiodarone drip w/ bolus. Hemodynamically unstable requiring increased pressor dose at that time. After about one day, spontaneously converted back to sinus after changing pressor to neosynephrine from levophed. Amio drip was stopped. Remained in normal sinus after that until she passed away. # Myoclonus: On the morning of admission, started having twitching of left shoulder and leg concerning for seizure activity. Neuro consulted and felt abnormal movements were not seizure activity, believes it is more consistent with myoclonus. EEG according to neuro shows no signs of seizure (even during marked periods of movements), just diffuse slowing consistent with encephalopathy Medications on Admission: Atenolol 12.5 mg daily Aggrenox 1 tablet twice a day calcium 600 mg daily vitamin D 1000 units a day. Insulin - 70/30, 10 units before supper B12 1000mcg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Septic [**Month/Year (2) **] Cholangitis Gallstone pancreatitis Hypoxic respiratory failure Atrial fibrillation with RVR Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "401.9", "785.52", "518.81", "537.3", "574.51", "424.0", "V58.67", "427.1", "428.0", "576.1", "272.4", "537.0", "433.10", "348.30", "333.2", "357.2", "733.00", "V10.3", "038.9", "577.0", "427.31", "428.21", "995.92", "250.60" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "44.22", "51.87", "46.85" ]

icd9pcs

[ [ [] ] ]

11388, 11397

5967, 11145

371, 476

11561, 11570

5181, 5944

11626, 11636

4643, 4674

11356, 11365

11418, 11540

11171, 11333

11594, 11603

4689, 5162

3727, 4021

232, 333

504, 3707

4043, 4494

4510, 4627

57,637

174,877

48801

Discharge summary

report

Admission Date: [**2113-4-7**] Discharge Date: [**2113-4-19**] Date of Birth: [**2039-4-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2712**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: intubation History of Present Illness: 73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on HAART), COPD, dCHF, a fib, PE on coumadin presents with 4 days of increasing SOB and cough with green sputum. His symptoms have been going on for about 4 days. He denied any fevers, chills, sweats. He also denied any chest pain, nausea, vomitting. He did report acute on chronic abdominal pain, which has had an extensive and negative outpatient work up. Of note, he was recently discharged from [**Hospital1 18**] in early [**2113-3-10**] for UTI, superficial ulcer. Because his symptoms worsened over time, he developed . In the ED, the patient presented with the following vital signs: 96.8 147/70 94 34 96%12L NRB. He was thought to be initially with acute COPD was given 500cc NS and duonebs when he became acutely dyspneic and was thought to have acute pulmonary edema. He was given nitro SL to no avail. He was given nitro paste again with no significant help. He then was given lasix 20mg IV ONCE but made no urine from this. He then was given nitro gtt, which per ED resident seemed to help him, as did bipap. He was given morphine for abdominal pain and respiratory distress. He was also given levofloxacin 750mg IV ONCE, azithromycin 500mg PO ONCE, ceftriaxone 1gm IV ONCE. His last set of vitals were 67 111/76 21 98% on CPAP FIO2 60, PEEP of 10. Past Medical History: # HIV disease, dx [**9-15**] likely secondary to heterosexual transmission. ATRIPLA started [**12-17**]. Self-d/c meds due to side effects. Last CD4 count [**2112-9-9**] was 123. # Chronic kidney disease (baseline cr 1.0) # Atrial fibrillation - off coumadin due to GI bleed # Prostate cancer - Diagnosed 15 yrs ago, in remission s/p hormonal and radiation therapy # COPD, long ex-tobacco history, severe emphysema on radiography # Pumonary Nodule: 2mm LUL lung nodule detected on CT chest [**9-15**] # GERD # PUD, Had 'surgery' 40 yrs ago, likely a Billroth # Anemia # Lumbar radiculopathy, spinal stenosis # Left shoulder rotator cuff tear with repair in [**10/2105**] # Trichomonas # Gout # Hx of esophageal candidiasis # Chronic left-sided abdominal pain, follows with GI here, extensive negative workup as an outpatient # Infrarenal abdominal aneurysm, measuring 3.6 cm on [**2111-12-31**] Social History: (per OMR and patient) He lives with his wife in [**Location (un) 686**] at an [**Hospital3 **] and denies alcohol or drug use. He smoked for 60 years and quit recently. Family History: per OMR) No history of lung disease, cancer or CAD. Physical Exam: On admission: GEN: Elderly man in moderate distress, tachypneic, diaphoretic HEENT: anicteric, RESP: CTA b/l with good air movement throughout, scattered crackles, no wheezes CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, mild LUQ tenderness, no masses or hepatosplenomegaly EXT: no c/c 2+ edema bilaterally SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Pertinent Results: On admission: [**2113-4-7**] 07:05PM BLOOD WBC-9.7# RBC-3.43* Hgb-11.7* Hct-35.9* MCV-105* MCH-34.1* MCHC-32.6 RDW-16.5* Plt Ct-213 [**2113-4-7**] 07:05PM BLOOD Neuts-89.8* Lymphs-8.5* Monos-1.4* Eos-0.1 Baso-0.3 [**2113-4-7**] 07:05PM BLOOD PT-23.5* PTT-23.9 INR(PT)-2.2* [**2113-4-7**] 07:05PM BLOOD Glucose-127* UreaN-32* Creat-2.0* Na-138 K-4.9 Cl-105 HCO3-22 AnGap-16 [**2113-4-8**] 02:25AM BLOOD Glucose-165* UreaN-38* Creat-2.5* Na-136 K-5.4* Cl-106 HCO3-19* AnGap-16 [**2113-4-7**] 07:05PM BLOOD ALT-22 AST-21 LD(LDH)-397* AlkPhos-54 TotBili-0.5 [**2113-4-8**] 02:25AM BLOOD CK-MB-6 cTropnT-0.15* [**2113-4-7**] 10:51PM BLOOD Type-ART Temp-37.8 PEEP-8 FiO2-60 pO2-32* pCO2-51* pH-7.23* calTCO2-22 Base XS--7 Intubat-NOT INTUBA [**2113-4-8**] 12:10AM BLOOD Type-ART PEEP-10 pO2-77* pCO2-33* pH-7.36 calTCO2-19* Base XS--5 Intubat-NOT INTUBA Vent-SPONTANEOU [**2113-4-8**] 06:11AM BLOOD Type-ART pO2-83* pCO2-42 pH-7.29* calTCO2-21 Base XS--5 [**2113-4-7**] 07:53PM URINE RBC-50* WBC->182* Bacteri-MANY Yeast-NONE Epi-2 [**2113-4-7**] 07:53PM URINE CastGr-4* CastHy-21* CXR on admission: IMPRESSION: Given profound low lung volumes, it is difficult to definitively diagnose a superimposed acute process above the extensive linear reticular scarring seen at the lung bases. Conceivably, there may be a superimposed consolidation at the left lung base although this is not entirely clear. If clinical management is dependent on determination, consider repeat x-ray or CT for further characterization. INDICATION: History of HIV, intubated in ICU for respiratory failure. COMPARISON: CT available from [**2113-3-13**] and [**2112-12-22**]. TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were obtained without the use of IV contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. 1.25-mm axial reconstructions were also obtained for further evaluation of the pulmonary parenchyma. FINDINGS: Again seen is severe centrilobular emphysema with paraseptal blebs, the largest measuring 21 mm in diameter located at the right base (3:32). There is increased ground-glass opacity and atelectasis within the right upper and middle lobes, partially obscuring a right upper lobe mass (3:22) better seen on prior examinations. Increased septal thickening, predominantly at the lung bases (3:34) are reflective of mild-to-moderate pulmonary edema, worse since the [**2113-3-13**] examination. A left lower lobe consolidation (3:37) is new. Trace bilateral pleural effusions are present. The heart is mildly enlarged. There is no pericardial effusion. The great vessels are normal in caliber, re-demonstrating mild atherosclerotic calcifications. Crescentic narrowing of the trachea is reflective of tracheomalacia. Prominent prevascular nodes measure up to 9 mm in diameter (2:17), increased since the prior examination. Other scattered axillary lymph nodes do not meet CT criteria for lymphadenopathy. Included views of the upper abdomen demonstrate transesophageal catheter terminating within the stomach lumen. Non-contrast enhanced images of the liver, gallbladder, pancreas, kidneys, spleen, small splenule (2:43), and adrenal glands are normal. IMPRESSION: 1. Left lower lobe pneumonia. 2. Bilateral pleural effusions. 3. Increase in right upper and middle lobe atelectasis and diffuse mild-to-moderate pulmonary edema. 4. Spiculated right upper lobe nodule, obscured by neighboring atelectasis and edema, better appreciated on the [**2113-3-13**] examination, remains concerning for neoplasm. MICRO: URINE CULTURE (Final [**2113-4-11**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMIKACIN-------------- =>64 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 32 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 I MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- =>512 R PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R . Blood Cultures: [**4-7**] and [**4-8**]: negative . CRYPTOCOCCAL ANTIGEN (Final [**2113-4-8**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). . Legionella Urinary Antigen (Final [**2113-4-9**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . MRSA SCREEN (Final [**2113-4-10**]): No MRSA isolated. . Respiratory Viral Culture (Final [**2113-4-12**]): 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 [**2113-4-10**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Reported to and read back by DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**] [**2113-4-10**] AT 12:18. . BAL: GRAM STAIN (Final [**2113-4-8**]): RESPIRATORY CULTURE (Final [**2113-4-10**]): >100,000 ORGANISMS/ML. Commensal Respiratory Flora. YEAST. ~3000/ML. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. LEGIONELLA CULTURE (Final [**2113-4-15**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2113-4-8**]): 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 [**2113-4-9**]): NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2113-4-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. . STOOL: MICROSPORIDIA STAIN (Final [**2113-4-12**]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [**2113-4-12**]): NO CYCLOSPORA SEEN. FECAL CULTURE (Final [**2113-4-13**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2113-4-13**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2113-4-12**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. Cryptosporidium/Giardia (DFA) (Final [**2113-4-12**]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-4-12**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . Catheter tip CULTURE (Final [**2113-4-17**]): No significant growth. . BDGlucan and Galactomman: NEGATIVE . Labs on Discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2113-4-19**] 04:05 7.2 2.63* 9.2* 28.0* 106* 35.0* 32.9 17.5* 307 DIFFERENTIAL Neuts Bands Lymphs Monos Eos [**2113-4-19**] 04:05 87.1* 9.7* 2.4 0.7 0.1 BASIC COAGULATION PT PTT INR(PT) [**2113-4-19**] 04:05 21.0* 24.9 1.9* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2113-4-19**] 04:05 104*1 24* 1.3* 137 4.3 104 25 12 Brief Hospital Course: 73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on HAART), COPD, dCHF, a fib, PE on coumadin. . # Hypoxic respiratory failure: Patient presented with 4 days of increasing SOB and cough with green sputum and admitted to the MICU on a NRB. CXR appeared to have LLL infiltrate so he was empirically started on treatment for hospital acquired pneumonia with Vanc/Cefepime/levofloxacin. On the night of admission, he was intubated for clinically worsening respiratory failure. CT chest showed consolidation in the LLL and emphysematous changes throughout the rest of the lung. [**Last Name (un) **] and BAL was performed which revealed frank pus in the left lower lobe which was plugging the distal bronchioles. BAL sent for infectious organisms but did not grow any bacteria, it did grow yeast but B-glucan and galactomman were negative so this was felt to be a contaminant. PCP and viral cultures were negative. ESBL Klebsiella grew from the patient's urine (taken in the ED prior to antibiotics) and this was presumed to be the cause of his pneumonia as well. Therefore ABX were changed to Vanc/[**Last Name (un) **]/Levoflox and he completed an 8 day course. Patient was weaned from the vent and successfully extubated on HD #9. He did well post-extubation and was weaned down to 4L-5L 02 via NC by HD #12. He was continued on nebs post-extubation. -patient will require pulmonary rehab -patient will follow up with his outpatient pulmonologist as he missed an appointment in the hospital. -volume overload was contributing to his hypoxia in the hospital and he was diuresed with 40 IV lasix daily for several days. He appears to be more euvolemic now and has been restarted on his home lasix 20mg po daily but may require additional doses of 40 IV lasix for volume overload -Patient should remain on 1.5L Fluid restriction . #. UTI: Culture grew Klebsiella resistant to all ABX except meropenem. He completed 8 days of meropenem. . #. Acute Kidney injury: On admission, creatinine was 2.6. This resolved with IVF in the ICU and remained 1.1 to 1.3 for the rest of his stay. His lamivudine and valganciclovir were initially renally dosed and then changed back to full dose as his creatinine improved. -patient should have weekly chem7 particularly if he is requiring diuresis with IV lasix. . #. Atrial fibrillation: Patient was admitted in afib with rates <100. The patient developed a wide complex tachycardia and cardiology looked at his strips and felt it was consistent with Afib with RVR and abberence. He was started on diltiazem and his rate improved and he had no more wide complex tachycardia. When patient stabilized he was restarted on his home coumadin 1mg PO daily (restarted [**2113-4-18**]) -patient will need daily INRs until stabilized (INR on the day of discharge is 1.9) -patient should be monitored closely for bleeding as he developed hemoptysis in the ICU while on heparin. . # Hemoptysis: Patient was put on heparin gtt given his history of afib and PE. However he developed hemoptysis. Bronch did not reveal a source of bleeding. Heparin was held and the patient's hemoptysis slowly resolved. Patient was restarted on his home coumadin on HD 11 and he had no more hemoptysis. . # HIV: Patient was continued on his home HAART, initially dose adjusted Lamivudine for renal failure. Also continued on Bactrim prophylaxis and valgancyclovir for CMV prophylaxis. Patient's outpatient ID provider was [**Name (NI) 653**]. . # Depression: Patient's home fluoxetine and mirtazipine held due to his intubation. These medications were not initially restarted after extubation due to delerium. Mirtazipine and fluoxetine restarted on discharge. -can uptitrate fluoxetine as needed as an outpatient . # Hyperglycemia: Patient is not a known diabetic. He was intermittently hyperglycemic in the setting of acute illness and has required a small dose of sliding scale insulin with humalog. -He should be worked up for diabetes as an outpatient and may reqiore oral hypoglycemics. . # Thrush: Patient noted to have oral thrush. Given his immunocompromised status he was started on fluconazole for 14 days starting [**4-19**] -needs LFTs checked in 1 week -monitor INR very closely while patient on fluconazole Medications on Admission: 1. abacavir-lamivudine 600-300 mg Tablet Sig: One (1) Tablet PO once a day. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-11**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO at bedtime. 4. DILT-CD 120 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Capsule, Ext Release 24 hr(s) 5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 9. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty (20) mL PO QID (4 times a day). 15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H as needed for pain. 16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 18. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*16 Tablet(s)* Refills:*0* 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day. 3. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO once a day. 5. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR ([**Month/Day (2) 766**] -Wednesday-Friday). 8. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for SOB. 11. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for abdominal pain. 13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. insulin lispro 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous four times a day as needed for hyperglycemia: per sliding scale. 15. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day. 16. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 14 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Acute Respiratory Failure secondary to Pneumonia Afib w/RVR and abherency COPD HIV Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with difficulty breathing. We believe this was from pneumonia and we treated you with antibiotics. You required intubation and mechanical ventilation. You were able to wean off the ventilator. You also had a urinary tract infection that we also treated with antibiotics. . Please follow up with your doctors as below. Followup Instructions: Department: PULMONARY FUNCTION LAB When: THURSDAY [**2113-5-4**] at 4:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2113-5-4**] at 4:30 PM With: DR. [**Last Name (STitle) 11071**] / DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Hospital Ward Name **], [**Name8 (MD) **] MD Location: [**Hospital1 **] DIVISION OF INFECTIOUS DISEASE Address: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 457**] *Please call the above number to schedule an appointment to see Dr. [**Last Name (STitle) **] within 2 weeks. Completed by:[**2113-4-19**]

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54111

Discharge summary

report

Admission Date: [**2126-9-19**] Discharge Date: [**2126-10-25**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents Attending:[**First Name3 (LF) 398**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Right Wrist ORIF Right elbow external fixation Tracheostomy Change Percutaneous gastrostomy tube placement History of Present Illness: 53 yo m with hx of severe COPD, s/p trach, who presented today to the ER after a fall at his nursing home. He had a mechanical fall by slipping on an object on the floor. He fell on his right wrist resulting in severe pain and wrist deformity. He was give oxycodone 20mg at the NH and morphine 10mg PO by EMS enroute. . On presentation to the ER his VS were 98.6 122 129/93 22 100% 4 liters. He is on a baseline 2-3 liters oxgyen, with 92-94% sats at the rehab. CXR showed no acute change. On wrist xray he was found to have a radius and ulnar fracture. He was given an additional diluaudid 1mg x 3. Then he was too sleepy and was given 0.2 of narcan. Ortho reduced his wrist and placed a splint on it with plans for a likely operation. With the reduction he was given an additional dialudid 0.25 reduction. He remained tahcy to 120s to 130s with sinus tach on EKG. He was found to have pin point pulpils and again was given 0.2 narcan. Then his SOB worsen, with sats in 80s. ABG checked 7.15/129/ 50 (unclear if veinous). Respriatory was called and changed his trach to 6.0 cuff and vent was started with CMV 400 x 24, FIO2 100, PEEP 5. At tranfer to the MICU his HR was 125, BP was 131/87, and sats of 94-95%. Past Medical History: COPD with trach on O2 and prednisone, tracheomalacia, h/o tracheal stenosis Type II DM diastolic CHF mild pulmonary HTN osteoporosis s/p Mid-thoracic vertebral body fracture h/o nephrolithiasis h/o MRSA nasal swab, MRSA sputum Cx Hepatitis B h/o gastric and duodenal ulcers chronic LBP - pt reports compression fractures from osteoporosis Social History: Mr. [**Name13 (STitle) 14302**] lives in the [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home. He quit using heroin about eight years ago, but has an approximately 20 year history. He quit drinking more than seven years ago. He quit smoking approximately one to two years ago and has a 60 pack year history. He smoked two packs per day for many years. He tested HIV negative in the past. He used to work as a dog groomer. He did work in construction in the past, but does not know of any asbestos exposure. He denies TB exposure. Family History: Non-contributory. Physical Exam: Vitals: T:99 BP: 113/91 P: 120 R: 21 O2: 98% General: somluent, complaining of severe pain in wrist when awake HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, no LAD Lungs: rhonchi bilaterally CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild distention, non-tender, bowel sounds present Ext: warm, well perfused, 2+ pulses, erythema on lower extremities, 1+ edema to knees, venous statsis changes Pertinent Results: Initial labs: [**2126-9-19**] 03:30PM BLOOD WBC-11.8* RBC-4.57* Hgb-11.5* Hct-38.7* MCV-85 MCH-25.2* MCHC-29.7* RDW-14.9 Plt Ct-329 [**2126-10-21**] 04:36AM BLOOD WBC-10.9 RBC-3.25* Hgb-8.3* Hct-27.2* MCV-84 MCH-25.5* MCHC-30.5* RDW-15.0 Plt Ct-525* [**2126-9-19**] 03:30PM BLOOD PT-11.3 PTT-25.9 INR(PT)-0.9 [**2126-10-21**] 04:36AM BLOOD PT-12.9 PTT-28.4 INR(PT)-1.1 [**2126-10-21**] 04:36AM BLOOD Plt Ct-525* [**2126-9-19**] 03:30PM BLOOD Glucose-236* UreaN-16 Creat-0.8 Na-140 K-4.6 Cl-93* HCO3-41* AnGap-11 [**2126-9-20**] 03:25AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-144 K-4.2 Cl-97 HCO3-44* AnGap-7* [**2126-10-21**] 04:36AM BLOOD Glucose-133* UreaN-10 Creat-0.5 Na-143 K-4.4 Cl-103 HCO3-32 AnGap-12 [**2126-9-23**] 04:02AM BLOOD ALT-33 AST-50* AlkPhos-35* TotBili-0.2 [**2126-9-20**] 06:27AM BLOOD CK-MB-11* MB Indx-6.3* cTropnT-0.05* [**2126-9-24**] 06:45PM BLOOD CK-MB-8 cTropnT-0.03* [**2126-10-3**] 02:39AM BLOOD proBNP-41 [**2126-9-20**] 03:25AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8 [**2126-9-20**] 06:27AM BLOOD Calcium-8.1* Mg-1.7 [**2126-10-21**] 04:36AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8 [**2126-9-19**] 09:43PM BLOOD Type-ART pO2-50* pCO2-129* pH-7.15* calTCO2-48* Base XS-10 Intubat-NOT INTUBA [**2126-9-19**] 11:58PM BLOOD Type-ART pO2-105 pCO2-87* pH-7.29* calTCO2-44* Base XS-11 [**2126-10-9**] 01:48AM BLOOD Type-ART FiO2-40 pO2-49* pCO2-75* pH-7.42 calTCO2-50* Base XS-19 -ASSIST/CON Intubat-INTUBATED Comment-PS = 8 [**2126-10-9**] 06:23AM BLOOD Type-ART pO2-68* pCO2-70* pH-7.44 calTCO2-49* Base XS-18 [**2126-10-15**] 06:34PM BLOOD Type-ART pO2-66* pCO2-63* pH-7.44 calTCO2-44* Base XS-15 [**2126-9-20**] 04:07AM BLOOD Lactate-7.0* [**2126-9-20**] 04:18AM BLOOD Lactate-5.6* Na-141 K-4.2 [**2126-9-20**] 09:44AM BLOOD Lactate-2.0 [**2126-9-20**] 06:02PM BLOOD Lactate-1.7 [**2126-9-20**] 10:29PM BLOOD Lactate-1.2 [**2126-10-5**] 01:07PM BLOOD Glucose-146* Lactate-0.7 Na-143 K-4.9 Cl-86* [**2126-10-3**] 06:24PM BLOOD LEVETIRACETAM (KEPPRA)-Test [**2126-10-12**] 05:05PM BLOOD B-GLUCAN-Test [**2126-10-12**] 05:05PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [**2126-9-27**] 03:00PM URINE RBC-[**6-19**]* WBC-0 Bacteri-RARE Yeast-NONE Epi-0-2 [**2126-10-12**] 09:45AM URINE CaOxalX-OCC [**2126-10-11**] 12:45PM URINE CaOxalX-MOD [**2126-9-27**] 11:28AM URINE Hours-RANDOM UreaN-446 Creat-54 Na-101 K-31 Cl-97 Discharge labs: 8.1 13.5 >-----< 447 25.8 . 143 100 7 -------------------< 99 4.1 40 0.5 . MICRO: [**2126-9-20**] 4:04 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2126-9-24**]** GRAM STAIN (Final [**2126-9-20**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2126-9-24**]): ~5000/ML OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM------------- 4 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ <=1 S [**2126-9-29**] 1:33 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2126-9-30**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2126-9-30**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2053**] @ 3:56A [**2126-9-30**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. [**2126-9-27**] 3:00 pm BLOOD CULTURE Source: Line-A-line. **FINAL REPORT [**2126-10-3**]** Blood Culture, Routine (Final [**2126-10-3**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. PSEUDOMONAS AERUGINOSA. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], #[**Numeric Identifier 26242**] [**2126-9-30**] 11:00AM. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. PSEUDOMONAS AERUGINOSA. 2ND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 2 S 2 S MEROPENEM------------- 4 S 8 I PIPERACILLIN---------- =>128 R =>128 R PIPERACILLIN/TAZO----- R =>128 R TOBRAMYCIN------------ <=1 S <=1 S [**2126-10-16**] 5:26 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2126-10-16**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2126-10-18**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110911**] [**2126-10-12**]. POTASSIUM HYDROXIDE PREPARATION (Final [**2126-10-17**]): 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). FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2126-10-17**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2126-10-22**] 2:42 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2126-10-22**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. GRAM NEGATIVE ROD(S). HEAVY GROWTH. [**2126-10-22**] 2:42 pm URINE Source: Catheter. **FINAL REPORT [**2126-10-25**]** URINE CULTURE (Final [**2126-10-25**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R RADIOLOGY: [**10-23**] CXR: FINDINGS: Lung volumes remain low. Increased opacification within the left lower chest is likely subsegmental atelectasis. The lateral aspect of the right chest is excluded from this examination, however, moderate right pleural effusion and right base segmental atelectasis appear unchanged, and a small left pleural effusion is unchanged. A tracheostomy tube is in the standard position. A left PICC line terminates at the junction of the brachiocephalic veins. There is no pneumothorax. The heart size is normal. IMPRESSION: Interval increase in subsegmental left lower lobe atelectasis. Stable bilateral pleural effusions and right basilar atelectasis. [**10-22**] Elbow xray: FINDINGS: In comparison with the study of [**10-21**], external fixation device remains in place. The alignment of structures around the elbow appears to be quite well maintained. [**10-21**] CT head: NON-CONTRAST HEAD CT: Imaging was repeated using helical mode due to patient motion. No evidence of acute intracranial hemorrhage, edema, mass, mass effect, hydrocephalus, or large vascular territory infarction is seen. Vascular calcifications are noted particularly in the right carotid siphon. On a couple of images only, the basilar artery (6:12) and the left vertebral artery (6:9) appears dense, similar in appearance to [**2126-9-20**]; with this vessel seen to enhance normally on subsequent MRI. There is also increased attneuation in the prepontine cistern on this image, likely artifactual. Thus this probably represents artifact rather than thrombosis. The soft tissues, orbits and skull appear intact. A left nasogastric tube is in place. There is partial opacification of ethmoid air cells as well as mucosal thickening within the sphenoid and maxillary sinuses. Partial opacification of the mastoid air cells was also previously present. IMPRESSIONS: No acute traumatic injury seen. Slightly dense appearanc eof the Basilar artery focally, is likely artifactual. Attention can be paid to this on f/u study. [**10-18**] EEG: SPIKE DETECTION PROGRAMS: There were 1,000 entries in these files. These contained movement and electrode artifact. There were no epileptiform discharges. SEIZURE DETECTION PROGRAMS: There were four entries in these files. These showed movement and electrode artifact. There were no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were three entries in these files. The first pushbutton was pressed by a nurse due to paroxysmal bilateral elevation of the arms. There is no obvious change in the EEG from interictal background activity. The next pushbutton is pressed for abrupt elevation of the right arm on video. There is no visualization of the left arm on this part of the video monitoring. Likewise, there is no change in EEG from background interictal activity. The last pushbutton is pressed for unclear reasons and the patient is not visualized on video; however, there again is no obvious change in EEG from interictal background activity. AUTOMATED TIME SAMPLES: There were 82 entries in these files. There was a low voltage and mixed theta/delta frequency slowing of the background. There was no focal slowing or epileptiform discharges. SLEEP: No morphologies in sleep were seen during this study. CARDIAC MONITOR: Showed normal sinus rhythm in a single EKG channel. IMPRESSION: This is an abnormal video EEG due to low voltage and slowing of the background activity. There were no epileptiform discharges or electrographic seizures. This telemetry captured three pushbutton activations, two involving sudden elevation of the arm(s) without obvious EEG correlate. These findings are consistent with a moderate to severe encephalopathy secondary to anoxic injury. On video, abrupt episode of bilateral arm elevation with sustained elevation for a couple of seconds suggests frontal seizure activity that may not be detected on current study. Clinical correlation is recommended. Compared to EEG from prior 24 hours, this study is unchanged. CTA chest: FINDINGS: Quality of vascular opacification allows to exclude acute pulmonary embolism in the central pulmonary arteries and several well-perfused right lower lobar segmental pulmonary arteries. The left lower lobar and segmental pulmonary arteries show lesser perfusion due to the presence of atelectasis and small pleural effusion. An apparent filling defect on image 30 on series #3 is most likely caused by partial volume averaging, resulting from increased lymphatic tissue. The pulmonary arteries are borderline in size. In addition to left lower lobar atelectasis and effusions, there is atelectasis in the right lower lobe. Small pleural effusion on the left is new and atelectasis has minimally increased. Dependent atelectasis adjacent to the left fissure is also seen, increased from the prior. Otherwise, there is no change from the prior study, with indwelling tracheostomy tube, prominent by number but not enlarged by size, mediastinal and bilateral hilar lymph nodes. Again seen is centrilobular and paraseptal emphysema with upper lobe predominance. Coronary artery calcifications involve left anterior descending, left main and right coronary arteries. This study is not optimized for subdiaphragmatic evaluation, except to note nasogastric tube, coursing in the stomach, with the tip not in the field of view. Note is again made of infrarenal IVC filter. There is a tiny calcification in the mid pole of the left kidney, which may represent a vascular calcification versus non-obstructing calculus. Stable degree of significant kyphotic angulation is noted at at T8-9 level. IMPRESSION: 1. No evidence of PE in the central and some segmental pulmonary arteries. 2. Development of small left pleural effusions, and mild increase in bibasilar consolidations, right lower lobe consistent with atelectasis and more heterogeneous appearance of the left lower lobe, but likely also due to atelectasis. Brief Hospital Course: The patient initially presented to [**Hospital1 18**] after a fall at his nursing home, during which he sustained fractures to his right wrist (radius and ulna) and elbow. He was in a significant amount of pain for which he was medicated with hydromorphone. He had tachycardia that was progressive to the 120s and had progressive shortness of breath. He was admitted to the medical ICU where he went into cardiac arrest, thought to be driven by hypoxia. His medical course has been notable for prolonged tracheostomy dependence, ventilator associated pseudomonal pneumonia and pseudomonal bacteremia, seizures, and prolonged altered mental status and agitation. # Cardiac Arrest (Pulseless Electrical Activity) Mr. [**Known lastname 110907**] was started on the arctic sun cooling protocol and had continuous EEG monitoring during a time which seizure activity was suspected. After undergoing a tracheostomy change for an MRI-compatible trach, he had a head MRI/MRA which showed no evidence of anoxic brain injury. However, his mental status has been labile and has improved on lower narcotic doses and sedation. # Hypercarbic Respiratory Failure: This was felt to be a combination of VAP and COPD exacerbation as described below. He is trach-dependent. # Chronic Obstructive Lung Disease: He was started on IV steroids and quickly tapered to prednisone 10 mg daily. He is on steroids chronically. # Ventilator Associated Pneumonia: He was treated with a 14 day course of meropenam/tobramycin, ended [**10-13**]. Last bronchoscopy on [**10-16**] still had sputum culture growing pseudomona, felt to be colonization at this point. He was also noted to have positive B-glucan but negative galactomanna. BAL grew yeast, bcxs were negative for fungus. He was not treated for fungal pneumonia. He had repeat fevers on [**10-22**] and was started on a 8 day course of cefepime and gent for presumed recurrent pseudomonas VAP. Sputum cultures show heavy GNR growth, speciation adn sensitivities pending. # UTI: Patient was found to have MDR. He needs 1 week course of nitrofurotoin starting [**10-25**]. # Altered Mental Status: This was felted to be due to anoxic brain injury from PEA arrest and ICU delirium worsened by narcotics. His mental status improved with decreasing dose of narcotic regimen. He was also started on clonidine for agitation, which is now being tapered off. By discharge, he was able to communicate (via mouthing words) appropriately. # Seizure: Neurology was consulted and felt that the patient had clinical seizures although his EEG did not show any epileptiform activity. He was started on Keppra. # C. difficle colitis: Patient was treated with po vancomycin, projected end date to be 1 week past last dose of antibiotics. # Right Wrist/Elbow Fracture: Patient underwent ex-fix and PRIF on R elbow and wrist on [**10-7**] by Orthopedics. His pain was controlled with fentanyl patch and oxycodone for breakthrough pain. He was started on calcium and vitamin D and was recommended to start a bisphosphonate as an outpatient. # Fungal rash on back: He is on antifungal creams as well as fluconzole to complete 14 day oral course. # Diabetes: He was continued on his home ISS. # Iron deficiency anemia: Pt was continued on iron supplements. # Nutrition: PEG was placed on [**10-22**]. Patient is on tube feeds. Medications on Admission: Tums 500mg TID Iron 325mg Qday Celexa 20mg Qday Bactrim DS MWF SSI Combivent 2 puffs Q4H PRN Mylanta 30ml Q6H PRN Mag Citrate Qweekly PRN constipation Lactulose 30ml Q6H PRN Miralax MWF Tyelnol 650mg Q6H PRN Arovent Q4H PRN Duoneb 2 puffs PRN Senokot [**Hospital1 **] PRN Oxycodone 10mg Q6H PRN Oxygen 2liters NC Lotrisone cream [**Hospital1 **] Miconazole Nitrate powder [**Hospital1 **] to groin Prednisone 15mg alternating with 20mg Qday ASA 325mg Colace 100mg [**Hospital1 **] Omeprazole 20mg [**Hospital1 **] Vancomycin completed coures on [**9-18**] Lasix 40mg [**Hospital1 **] KCL 20meq [**Hospital1 **] Mirapex 0.25mg HS Cipro 500mg [**Hospital1 **] for 7 days, completed [**2126-9-17**] Discharge Medications: 1. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: 0-12 units Subcutaneous ASDIR (AS DIRECTED): Pls see sliding scale. 2. Gentamicin 40 mg/mL Solution [**Month/Day/Year **]: Four [**Age over 90 1230**]y (450) mg Injection Q24H (every 24 hours) for 4 days: Until [**2126-10-29**]. 3. Nitrofurantoin (Macrocryst25%) 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2 times a day) for 7 days. 4. Cefepime 2 gram Recon Soln [**Month/Day/Year **]: Two (2) gram Intravenous twice a day for 4 days: Until [**2126-10-29**]. 5. Fluconazole 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 6. Fentanyl 25 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: One (1) PO every 6-8 hours as needed for pain. 8. Fondaparinux 2.5 mg/0.5 mL Syringe [**Month/Day/Year **]: One (1) Subcutaneous DAILY (Daily). 9. Vancomycin 125 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q6H (every 6 hours) for 14 days. 10. Prednisone 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day). 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 14. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Age over 90 **]: 4-8 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 15. Miconazole Nitrate 2 % Powder [**Age over 90 **]: One (1) Appl Topical TID (3 times a day) as needed for groin rash. 16. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Age over 90 **]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eye. 17. Colace 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg PO twice a day. 18. Senna 8.8 mg/5 mL Syrup [**Age over 90 **]: One (1) Tablet PO BID (2 times a day). 19. Lactulose 10 gram/15 mL Syrup [**Age over 90 **]: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 20. Polyethylene Glycol 3350 17 gram/dose Powder [**Age over 90 **]: One (1) PO DAILY (Daily) as needed for constipation. 21. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Age over 90 **]: 2.5 Tablets PO DAILY (Daily). 22. Calcium Carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension [**Age over 90 **]: Five Hundred (500) mg PO TID (3 times a day). 23. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Age over 90 **]: Three Hundred (300) mg PO DAILY (Daily). 24. Aspirin 325 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 25. Cortisone 1 % Cream [**Age over 90 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash on face. 26. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 1000 (1000) mg PO q8 hr. 27. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed for mouth care. 28. Terbinafine 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 29. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical TID (3 times a day). 30. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): Please titrate off over 1 week. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Right radial and ulnar fracture Pulseless electrical activity arrest Respiratory failure Anoxic brain injury Secondary: Ventilator associated pneumonia Chronic obstructive pulmonary disease exacerbation C. difficile colitis Urinary tract infection Diabetes mellitus type 2 Fungal rash Delirium Discharge Condition: Stable oxygenation on PS, afebrile x 48 hours Discharge Instructions: You were admitted for a wrist fracture of the right arm, which has been fixed by Orthopedics. During your hospitalization, your heart stopped (PEA arrest) and you have recovered from this. Your respiratory status worsened from a combination of your COPD and pneumonia. Both have been treated and you have improved. You are being discharged to [**Hospital 100**] Rehab MACU. Followup Instructions: Please follow up with orthopedics 1 week after discharge from MACU with Dr. [**Last Name (STitle) 1005**]. His clinic number is [**Telephone/Fax (1) 1228**]. Please follow up with your pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**] 2 weeks after your discharge from MACU. His clinic number is ([**Telephone/Fax (1) 514**]. Please also follow up with Neurology regarding your seizure activity. The clinic number is ([**Telephone/Fax (1) 58666**].

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icd9cm

[ [ [] ] ]

[ "97.23", "33.21", "43.11", "79.02", "79.32", "38.93", "78.12", "79.01", "96.72", "99.60" ]

icd9pcs

[ [ [] ] ]

24725, 24791

17103, 19229

344, 452

25139, 25187

3172, 5515

25613, 26108

2662, 2681

21222, 24702

24812, 25118

20501, 21199

25211, 25590

5538, 9288

2696, 3153

9470, 9684

9324, 9436

9725, 12040

284, 306

480, 1694

12049, 12062

12071, 17080

19245, 20475

1716, 2058

2074, 2646

79,952

135,279

4571

Discharge summary

report

Admission Date: [**2127-5-25**] Discharge Date: [**2127-6-2**] Date of Birth: [**2085-3-22**] Sex: M Service: SURGERY Allergies: Motrin / Haldol / Catapres-Tts 1 Attending:[**First Name3 (LF) 598**] Chief Complaint: Stab wound to abdomen Major Surgical or Invasive Procedure: Exploratory laparotomy Central venous acess Arterial line placement History of Present Illness: 42M stabbed by another resident in group home with a screw driver into epigastrum. Initally with abdominal and right sided scapular pain. Past Medical History: HTN, Schizophrenia, 1* aldosteronism, asthma, chronic constipation Social History: Born in [**Country 2045**], moved to US in [**2112**]. Has been living in group home for seven years, is independent. Family History: Noncontributory Physical Exam: On Admission: 97.2 132 110/84 20 98%RA NAD, mild discomfort AT/NC, PERRL CTA b/l RRR 3mm penetrating wound to epigastrum, ttp LUQ 1 cm puncture near R scapula 2+ pulses, MAE Pertinent Results: [**2127-5-25**] 06:14PM BLOOD WBC-14.3* RBC-4.72 Hgb-14.1 Hct-41.1 MCV-87 MCH-29.9 MCHC-34.3 RDW-13.3 Plt Ct-378 [**2127-5-25**] 06:14PM BLOOD PT-11.9 PTT-25.0 INR(PT)-1.0 [**2127-5-25**] 06:14PM BLOOD UreaN-9 Creat-1.4* [**2127-5-27**] 06:51PM BLOOD ALT-26 AST-21 AlkPhos-82 Amylase-17 TotBili-0.7 [**2127-5-25**] 06:14PM BLOOD Lipase-25 [**2127-5-26**] 06:35AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8 [**2127-5-25**] 06:11PM BLOOD Glucose-112* Lactate-10.5* Na-140 K-4.2 Cl-97* calHCO3-19* Imaging [**5-25**] CXR - No acute cardiopulmonary process [**5-27**] CT head - No acute intracranial process Brief Hospital Course: 42M s/p stab wound to epigastrum in the ER was hemodynamically stable with negative FAST. Wound explored in trauma bay and penetration of anterior fascia was noted, therefore patient was taken to the OR for an exploratory laparotomy and admitted to the trauma service. Small bleeding was noted from a gastric artery, which was ligated, otherwise no additional injuries were found. Please see op note for further details. Patient was transferred to the floor where on post-op day one his nasogatric tube was pulled and he was put on a clear diet, which he tolerated well. His foley was also pulled, however he was unable to void and his foley was replaced. Pain was well controlled with a dilaudid PCA. On hosptial day 3, patient was evaluated in the morning and appeared to be doing well, however later was found with decreased mental status and a code blue was called. Patient was hypotensive to 80s/40s but maintained a pulse and adequate respirations. He was given narcan and IV fluid and mental status improved slightly. He was transferred to the TSICU in stable condition. Central venous access was obtained as well as peripheral arterial access. His hematocrit was stable and abd nontender. His mental status continued to be clouded and he had a CT head which was negative. Eventually, his mental status improved without specific intervention. Ultimately, the etiology of this incident was not determined. Patient then was stable for transfer to the floor, however developed an ileus. Pt was kept NPO and eventually was able to tolerate a regular diet and had normal bowel movements at the time of discharge. Medications on Admission: geodon (ziprasidone)80', lamictal 150'', tylenol 325 q6h PRN, visine eye drops 2 drops q6h PRN, microzide 25', senna 187', tofranil (imipramine)10', klonopin 0.5'', clozaril (clozapine) 200', desyel (trazodone)150', colace, mom, zantac 150'', aldactone 25', zestril (lisinopril)20', enablex (overactivebladder)15', toprolol 50' Discharge Medications: 1. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Trazodone 100 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed for sleep. 5. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Stab wound to abdomen Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after getting stabbed in your belly with a screwdriver. You had an operation to look for damage from this injury and were only found to have a small bleeding vessel that was repaired. You had an episode where your mental status was decreased and your blood pressure was low and therefore you were transfered to the ICU overnight. You were given some fluids and you improved without any intervention. During this time you had a central venous line and arterial line placed for better monitoring of your status, which were then removed when you returned to the floor. Your abdominal distention slowly resolved and at the time of discharge you were having normal bowel movements and were able to eat normally. Your staples were removed and steristrips were placed over your wound. You can leave these in place until your follow-up or until they fall off on their own. Your metoprolol was increased to 75mg from 50mg, which you should take every day. If you start having dizziness when you stand or have problems with fainting you should call your regular doctor to discuss your medications. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in trauma clinic in 2 weeks. Call [**Telephone/Fax (1) 6429**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

[ "348.30", "V64.41", "401.9", "780.2", "879.2", "493.90", "E966", "458.29", "293.0", "560.1", "902.21", "295.62", "255.10", "427.89", "876.0" ]

icd9cm

[ [ [] ] ]

[ "38.86" ]

icd9pcs

[ [ [] ] ]

4727, 4733

1639, 3272

312, 381

4799, 4799

1017, 1616

6105, 6325

791, 808

3650, 4704

4754, 4778

3298, 3627

4950, 6082

823, 823

251, 274

409, 549

837, 998

4814, 4926

571, 639

655, 775

11,825

125,195

6940

Discharge summary

report

Admission Date: [**2179-11-4**] Discharge Date: [**2180-3-21**] Date of Birth: [**2136-2-6**] Sex: M Service: SURGERY Allergies: Imipenem/Cilastatin Sodium Attending:[**First Name3 (LF) 1384**] Chief Complaint: Elevated lfts, abdominal pain Major Surgical or Invasive Procedure: Hepaticojejunostomy, Exploratory Lap x2 Alloderm graft to abd wound, failed Hepatic artery bleed with stenting Hepatic artery erosion [**2180-2-17**], re-bleed with angio s/transjugular biopsies on [**2180-1-24**],[**2180-2-4**], [**2180-2-28**], and on [**2180-3-14**] Endoscopy [**2180-2-29**] Picc line placements [**2180-1-27**], [**2-2**], [**2180-2-7**] L chest tube [**2-18**]. removed [**2180-2-20**] History of Present Illness: 43M well known to the transplant service w/ ESLD secondary to Hepatitis C cirrhosis s/p OLT [**2178-12-2**] c/b recurrent Hepatitis C sp second OLT [**2179-10-23**] which was complicated by bile duct necrosis. Pt then underwent hepaticojejunostomy [**2179-11-9**] for distal CBD necrosis and ex-lap, abdominal washout and wound closure [**11-13**]. This was complicated by wound dehiscence and the pt underwent ex lap & repair of recipient bile duct leak on [**11-18**] which was c/b hepatic artery bleed s/p stent [**1-9**]. Past Medical History: ESLD secondary to Hepatitis C cirrhosis h/o acute/chronic rejection sp Orthotopic liver transplant # 1 on [**2178-12-2**] c/b recurrent hepatitis C sp Ex lap and repair of IVC bleed [**2178-12-5**] sp Ex lap and evacuation of intra abdominal hematoma [**2178-12-8**] sp Orthotopic liver transplant # 2 on [**2179-10-23**] secondary to recurrent Hepatits C c/b distal CBD necrosis s/p hepaticojejunostomy secondary to distal bile duct necrosis on [**2179-11-10**] s/p Ex-lap, abdominal washout, abdominal closure [**2179-11-14**] s/p Ex lap & repair of recipient bile duct leak/closure of bile duct stump [**11-18**] c/b hepatic artery bleed s/p stent [**12-28**] Abdominal wound dehiscence Entero-cutaneous fistula history of VRE bacteremia [**4-29**] history of thrombocytopenia history of polysubstance abuse 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. Family History: Mother - healthy at age 63 Father - healthy at age 69 Grandfather - diabetes Physical Exam: PE on admission: Pertinent Results: ADMISSION LABS: [**2179-11-4**] 09:45PM GLUCOSE-215* UREA N-39* CREAT-1.4* SODIUM-132* POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-27 ANION GAP-17 [**2179-11-4**] 09:45PM ALT(SGPT)-19 AST(SGOT)-13 ALK PHOS-185* AMYLASE-27 TOT BILI-2.5* [**2179-11-4**] 09:45PM LIPASE-23 [**2179-11-4**] 09:45PM WBC-4.6 RBC-3.25* HGB-9.9* HCT-30.3* MCV-93 MCH-30.6 MCHC-32.8 RDW-16.0* [**2179-11-4**] 09:45PM PLT COUNT-52* 12/09/048.8 3.19* 9.7* 30.3* 95 30.4 32.0 22.6* 50*1 [**2180-1-20**] 06:30AM BLOOD WBC-8.9 RBC-3.05* Hgb-9.2* Hct-27.8* MCV-91 MCH-30.0 MCHC-32.9 RDW-21.7* Plt Ct-38* [**2180-1-20**] 06:30AM BLOOD PT-13.6 PTT-33.3 INR(PT)-1.2 [**2180-1-20**] 06:30AM BLOOD PT-13.6 PTT-33.3 INR(PT)-1.2 [**2180-1-20**] 06:30AM BLOOD Plt Ct-38* [**2180-1-24**] 05:40AM BLOOD Glucose-101 UreaN-42* Creat-1.8* Na-131* K-4.6 Cl-100 HCO3-21* AnGap-15 [**2180-1-20**] 06:30AM BLOOD ALT-125* AST-120* AlkPhos-226* TotBili-7.1* [**2180-2-18**] 02:52AM BLOOD WBC-4.6# RBC-3.81* Hgb-11.6* Hct-32.5* MCV-85 MCH-30.4 MCHC-35.7* RDW-18.4* Plt Ct-75*# [**2180-2-18**] 01:20PM BLOOD PT-14.6* PTT-33.5 INR(PT)-1.4 [**2180-2-18**] 06:30PM BLOOD Glucose-94 UreaN-61* Creat-2.0* Na-142 K-4.6 Cl-107 HCO3-25 AnGap-15 [**2180-2-18**] 06:30PM BLOOD ALT-94* AST-116* AlkPhos-203* Amylase-25 TotBili-17.3* [**2180-3-21**] 06:25AM BLOOD WBC-3.8* RBC-2.32* Hgb-7.7* Hct-25.0* MCV-108* MCH-33.2* MCHC-30.8* RDW-22.4* Plt Ct-33* [**2180-3-21**] 06:25AM BLOOD Glucose-108* UreaN-74* Creat-2.0* Na-135 K-4.2 Cl-101 HCO3-26 AnGap-12 [**2180-3-21**] 06:25AM BLOOD ALT-116* AST-92* AlkPhos-261* TotBili-14.9* [**2180-3-20**] 05:40AM BLOOD FK506-16.3 [**2180-3-19**] 07:07AM BLOOD FK506-6.9 [**2180-3-18**] 10:13AM BLOOD FK506-7.7 [**2180-3-17**] 07:30AM BLOOD FK506-8.3 [**2180-3-16**] 06:00AM BLOOD FK506-10.1 [**2180-2-26**] 07:00AM BLOOD FK506-4.1* [**2180-2-20**] 07:15AM BLOOD FK506-21.0* [**2180-2-18**] 07:23AM BLOOD FK506-4.2* [**2180-2-4**] 06:15AM BLOOD FK506-23.5* [**2180-1-16**] 06:30AM BLOOD FK506-4.0* [**2179-12-7**] 06:00AM BLOOD FK506-26.3* [**2179-11-26**] 06:53AM BLOOD FK506-4.3* [**2179-11-22**] 06:10AM BLOOD FK506-4.9* [**2179-11-21**] 07:04AM BLOOD FK506-3.7* Brief Hospital Course: Summary of Hospital Course: Mr [**Known lastname 6359**] is a 43 yr old male with hepatitis c related cirrhosis that underwent liver transplant [**2178-12-1**]. His post-op course was significant for recurrent hepatic c as well as repeat acute cellular rejection episodes. He eventually developed chronic rejection with progressive cholestasis (AST 400, alt 200, t Bili 35, alk Phos 2628). He was re-listed for liver transplantation. On [**2179-10-23**] he underwent repeat OLT. His post op course has been complicated by hepatic artery stenosis, biliary ischemia and Roux -en-y Hepaticojejunostomy, native bile duct stump leak, open abdomen, break down of jejuno-jejunostomy with fistula formation, and hepatic arterial bleed and stenting. His most recent hospital course has also been complicated by both recurrent hepatitis c and recurrent ACR treated by increasing immunosuppression. After his second OLT ([**10-22**]) he did well until [**11-9**] when he developed severe neutropenia and a large biloma. He was taken to OR. His biloma was evacuated, the liver was viable with Doppler signals but there was a clear bile leak at the bile duct anastomosis. A Roux hepaticojejunostomy was performed and his abdomen was irrigated and closed temporarily. He returned to the OR on [**11-13**] for abdominal washout and closure. An arteriogram on [**11-14**] demonstrated hepatic artery stenosis and he was stented. On [**11-18**] he drained succus entericus from his wound and he returned to the OR. He was leaking from his native CBD, which was oversewn, and his fascia closed with a biosynthetic mesh. He developed a controlled duodenal leak that eventually sealed with conservative measures. He developed a small bile leak from the Roux that healed with PTC placement. He developed ([**1-5**]) break down and fistula formation from his jejunojejunostomy of his Roux that is being controlled with wound management, TPN with hepatamine and daily fat infusion. On [**1-9**] he developed arterial bleeding from the upper portion of his wound c/w an hepatic arterial bleed which was controlled in Angio with stenting. Finally, he also has recurrent hep C with high viremia and he is being treated for recurrent acute cellular rejection. [**2180-1-24**] Patient had a liver biopsy due to elevated LFT's which demonstrated mild acute cellular rejection, and mod cholestasis. Patient was treated for rejection. Blue surgery team was consulted for assistance with wound management and recommended whistle tip drains with suction which improved the abdominal wound. Patient had complained of left sciatic pain with fevers, and MRI obtained demonstrating a Disc protrusion at L5-S1 with narrowing of the left neuroforaminal at L5-S1 level. No evidence of intraspinal abscess. PT had been re-consulted and has been working with Mr. [**Known lastname 6359**]. Patient had another transjugular biopsy on [**2180-2-4**] demonstrating resolving acute ceullar rejection, mod. centrilobular cholestasis , and lobular mononuclear inflammation with apoptotic hepatocytes consistent with recurrent hepatitis C infection, On [**2180-2-17**] Patient had a decrease HCT along with hematemesis and melenic stools. Patient transferred to SICU.Patient intubated. Acute abdominal bleeding with concern for hepatic artery was the source. Patient brought to the Cardiac Cath lab emergently for diagnosis and treatment after giving him multiple blood products. It was discovered that patient had hepatic artery pseudo aneurysms with acute bleeding, and central HTN. Successful thrombosis of the hepatic artery and cessation of bleeding was performed and successful treatment of hepatic artery origin with balloon angioplasty was also performed. Patient had a chest tube in the CSICU secondary to a left pneumothorax from line placement which was removed on [**2180-2-21**]. Patient was started on Imipenem and completed a 15 day course. Patient extubated and transferred to [**Hospital Ward Name 121**] 10. PT/OT was re-consulted. Patient continued on TPN, and Wound care nursing team continued to follow patient for his abdominal wound. On [**2180-2-28**] another TJ liver biopsy performed demonstrating mild acute rejection. An EGD was performed which was normal on [**2180-2-29**]. Because there was a slow rise in Mr. [**Known lastname 6362**] LFT, another transjugular biopsy was performed on [**2180-3-14**] which demonstrated cholestasis, bile duct proliferation,Hepatitis C, without acute rejection. Patient's LFTs have been stable with no acute elevations. His platelets have been relatively low but stable in the 30's. Patient has had multiple transfusions during this hospitalization and needed a transfusion today, [**2180-3-21**] for a HCT of 25 Patient continues with TPN, with Fat emulsion 20% 250 ml IV daily. Patient's abdominal wound with fistula drainage is granulating. The wound measures 9x175.cm x 2.5 cm depth. There is greenish/yellow drainage. The wound bed is predominantly beefy-red in color. The wound care nurses have been working closely with the Transplant team and have done an excellent job with managing his abdominal wound with a large wound drainage pouch to gravity drainage. He has been draining approximately 800cc of greenish/brown fluid. He has only been allowed to drink clear fluids with a total intake restriction of 500ml/day ordered. Generally, he will have am nausea just after taking po medications. This has responded to IV Anzemet fairly well. Intermittently, he received IV phenergan as well. He has had intermittent episodes of vomiting approximately 50-150ml of clear watery to light bilious emesis once a day. He has had small loose-liquid bowel movements. During this stay [**Doctor First Name **] was followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from psychiatry for management of depression. Remeron was started and increased to 15mg qhs. This has recently been reevaluated. This dose is appropriate at this time. In addition, abdominal pain has been managed with a Duragesic patch and prn IV dilaudid. This was converted to dilaudid po prn. He will usually request prn po dilaudid prior to his abdominal wound pouch change. Patient is ready for rehab, and is expected to be discharged to [**Hospital1 **] on [**2180-3-21**] with weekly follow up visits with Dr.[**First Name (STitle) **]. He will require twice weekly labs with results fax'd to the transplant center. Medications on Admission: Prednisone, MMF, Tacrolimus, Bactrim SS, Zolpidem, Percocet, Protonix, Colace, Ursodiol, Lasix, Valgancyclovir Glargine, Humulog SS Stentplasty hepatic artery [**11-23**]- revealed 50% stenosis proximal to stent Discharge Medications: . Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 4. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 5. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 6. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 7. Promethazine HCl 25 mg/mL Solution Sig: 6.25 Injection Q6H (every 6 hours) as needed. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Albuterol Sulfate 0.083 % Solution Sig: [**11-28**] Inhalation Q6H (every 6 hours) as needed. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 15. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO BID (2 times a day) for 2 doses. 17. Fat Emulsion 20 % Emulsion Sig: One (1) ML Intravenous once a day for 1 doses. 18. Hydromorphone HCl 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed. 19. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig: 5mg Recon Solns Injection Q24H (every 24 hours). 20. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 21. Sodium Chloride 0.9 % Parenteral Solution Sig: 3ml MLs Intravenous DAILY (Daily) as needed: FLUSH 3ML IV DAILY PRN-INSPECT SITE EVERY SHIFT. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p Orthotopic liver transplant x2, s/p hepaticojejunostomy, s/p exploratory laparotomy x2 for bile leak Neutropenia Duodenal fistula, npo Hepatic artery pseudoaneurysms Malnutrition r/t bowel rest. tx'd with TPN left sciatica Discharge Condition: stable Discharge Instructions: Call Transplant Office [**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, inability to take medicines, abd pain, increased wound drainage or jaundice Wound drainage pouch change twice a week. see printed instructions Patient needs labs every Monday and Thursday in which CBC, CHEM 7, ALT, AST, ALK PHOSP, ALBUMIN, T. BILI, AND PROGRAF LEVEL NEEDS TO BE ORDERED. PLEASE FAX THE RESULTS IMMEDIATELY TO [**Telephone/Fax (1) 697**] Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Call to schedule appointment Completed by:[**2180-3-21**]

[ "569.81", "998.59", "998.31", "997.4", "442.84", "447.1", "576.8", "996.82", "722.10", "512.1", "284.8", "070.54" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.14", "39.90", "45.13", "86.67", "39.50", "51.59", "87.54", "50.11", "34.04", "88.14", "51.79", "51.37", "54.11", "99.15" ]

icd9pcs

[ [ [] ] ]

13365, 13444

4611, 4611

315, 727

13715, 13723

2439, 2439

14223, 14390

2307, 2386

11354, 13342

13465, 13694

11117, 11331

13750, 14200

2401, 2404

4639, 11091

246, 277

755, 1285

2455, 4588

2420, 2420

1307, 2119

2135, 2291

74,817

192,449

9167

Discharge summary

report

Admission Date: [**2179-8-13**] Discharge Date: [**2179-8-24**] Date of Birth: [**2131-10-15**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Azathioprine Attending:[**First Name3 (LF) 5893**] Chief Complaint: Anemia on routine labs, dermatomyositis exacerbation Major Surgical or Invasive Procedure: R IJ CVL placement L IJ pheresis catheter placement NG tube placement Pericardiocentesis History of Present Illness: This is a 47 year old male with a history of dermatomyositis who is currently on steroids, MTX, recently recieved rituximab ([**Month (only) 958**]), and who recently underwent 1 week of treatment for H. pylori, who was recently admitted after being found to have a hct of 14 on routine labs (prior: 33 two months prior). He is being admitted after being found to have guaiac positive stool at rehab facility so he is being admitted for further work-up. . Patient was recently admitted in [**5-/2179**] with anemia, which was thought to be due to medications (MTX, rituxan). He had an EGD in [**3-/2179**], which showed mild gastritis and a scope in [**9-6**] diverticulosis of sigmoid colon. He has had occasional dark stool in recent weeks but denies any BRPBR, nausea, vomiting, or abdominal pain. Also denies chest pain, shortness of breath, dyspnea on exertion, cough or any other respiratory symptoms. . In the ED, initial vs were: T- 96.3, HR- 81, BP- 107/56, RR- 16, SaO2- 98% on RA. Stool was found to be guaiac positive. NG lavage was negative. Hct stable from previous admission. The patient was seen by GI who recommended EGD in the morning. He had central line placed. CXR checked for confirmation but incidentally showed collapse of left lobe. CT scan showed secretions/debris in the left main stem that seemed to have caused the collapse of the left lung. Patient denied any respiratory symptoms and was satting well. . On the floor, the patient feels well. He denies any current N/V, abd pain, diarrhea, melena, BRBPR, fatigue, SOB, dizziness or CP. . Review of sytems: (+) Per HPI (-) Denies, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -dermatomyositis- currently on no treatment, has been on medrol most recently and methotrexate, tapered off, no treatment for 1 month. In past on prednisone, methotrexate, IVIG x 6, rituxan x 2 -H. Pylori positive, gastritis - s/p triple therapy -Elevated BP without Dx of HTN -atypical chest pain -anemia- iron def and chronic disease Social History: tobacco: denies alcohol: denies drugs: denies Lives [**Location (un) 6409**]. Divorced. Works as a computer systems engineer. Family History: Mother - HTN Father - [**Name (NI) **] [**Name2 (NI) **] - siblings with HTN Physical Exam: Expired Admission Physical Exam: Vitals: T: 95.8 BP: 111/56 P: 86 R: 14 O2: 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, no JVD, no LAD. Right IJ in place Lungs: Clear to auscultation bilaterally. Decreased breath sounds on left. No wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: (in ED- guaiac positive) Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. +2 pitting edema of b/l LE Pertinent Results: [**2179-8-24**] 09:01PM BLOOD WBC-16.4* RBC-2.88* Hgb-8.8* Hct-25.7* MCV-89 MCH-30.7 MCHC-34.4 RDW-17.8* Plt Ct-54* [**2179-8-24**] 06:48AM BLOOD WBC-17.1* RBC-2.61* Hgb-7.6* Hct-23.4* MCV-90 MCH-28.6 MCHC-32.3 RDW-18.2* Plt Ct-111*# [**2179-8-23**] 01:47PM BLOOD WBC-16.6* RBC-2.51* Hgb-7.1* Hct-22.7* MCV-91 MCH-28.2 MCHC-31.4 RDW-19.1* Plt Ct-63* [**2179-8-22**] 09:42PM BLOOD WBC-17.5* RBC-3.02* Hgb-9.2* Hct-25.8* MCV-86 MCH-30.4 MCHC-35.5* RDW-18.8* Plt Ct-29* [**2179-8-22**] 05:26AM BLOOD WBC-19.7* RBC-3.33* Hgb-9.7* Hct-28.0* MCV-84 MCH-29.2 MCHC-34.6 RDW-19.2* Plt Ct-44* [**2179-8-21**] 03:44PM BLOOD WBC-13.4* RBC-2.63*# Hgb-7.3*# Hct-22.9*# MCV-87 MCH-27.7 MCHC-31.9 RDW-20.5* Plt Ct-16* [**2179-8-20**] 02:21PM BLOOD WBC-17.4* RBC-2.70* Hgb-7.1* Hct-22.0* MCV-81* MCH-26.3* MCHC-32.3 RDW-23.7* Plt Ct-35* [**2179-8-19**] 05:36PM BLOOD WBC-11.0 RBC-2.68* Hgb-6.8* Hct-21.7* MCV-81* MCH-25.2* MCHC-31.2 RDW-23.7* Plt Ct-37* [**2179-8-17**] 06:34PM BLOOD Hgb-7.8* [**2179-8-16**] 04:59PM BLOOD WBC-6.6# RBC-3.13* Hgb-7.7* Hct-24.2* MCV-77* MCH-24.7* MCHC-32.0 RDW-21.5* Plt Ct-71* [**2179-8-14**] 04:35AM BLOOD WBC-7.6 RBC-3.19* Hgb-7.9* Hct-25.5* MCV-80* MCH-24.7* MCHC-30.9* RDW-21.2* Plt Ct-78* [**2179-8-13**] 06:10PM BLOOD WBC-9.6# RBC-3.34* Hgb-8.4* Hct-25.6* MCV-77* MCH-25.2* MCHC-32.9 RDW-21.0* Plt Ct-41*# [**2179-8-23**] 06:06AM BLOOD Neuts-98* Bands-1 Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-7* [**2179-8-20**] 06:20AM BLOOD Neuts-94* Bands-1 Lymphs-1* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-27* [**2179-8-24**] 09:01PM BLOOD Plt Ct-54* [**2179-8-24**] 09:01PM BLOOD PT-20.5* INR(PT)-1.9* [**2179-8-24**] 06:48AM BLOOD Plt Ct-111*# [**2179-8-24**] 06:48AM BLOOD PT-19.3* PTT-55.0* INR(PT)-1.8* [**2179-8-23**] 10:50AM BLOOD Plt Ct-68* [**2179-8-23**] 10:50AM BLOOD PT-18.7* PTT-54.1* INR(PT)-1.7* [**2179-8-21**] 05:38PM BLOOD Plt Ct-143*# [**2179-8-21**] 03:44PM BLOOD PT-25.1* PTT-88.8* INR(PT)-2.4* [**2179-8-17**] 06:34PM BLOOD QG6PD-17.0* [**2179-8-18**] 12:30PM BLOOD ESR-31* [**2179-8-24**] 06:48AM BLOOD ESR-30* [**2179-8-24**] 06:48AM BLOOD Glucose-175* UreaN-66* Creat-0.5 Na-146* K-3.9 Cl-121* HCO3-11* AnGap-18 [**2179-8-23**] 06:06AM BLOOD Glucose-299* UreaN-66* Creat-0.5 Na-142 K-5.0 Cl-118* HCO3-18* AnGap-11 [**2179-8-20**] 06:20AM BLOOD Glucose-156* UreaN-34* Creat-0.4* Na-141 K-4.0 Cl-104 HCO3-24 AnGap-17 [**2179-8-16**] 04:59PM BLOOD Glucose-94 UreaN-18 Creat-0.3* Na-137 K-4.0 Cl-104 HCO3-26 AnGap-11 Brief Hospital Course: 47M with dermatomyositis (on steroids, MTX, rituximab) who was found to have a anemia and thrombocytopenia, L lung collapse, and new anasarca. . This patient was initially admitted for anemia and possible GI bleed. Incidentally, the patient was found to have a complete left lung collapse, despite having not being hypoxic. Bronchoscopy x 2 was completed to attempt to re-expand the lung, however no mucus plug was found. Eventually, with several respiratory maneuvers, his lung started to re-expand. While he was in the [**Hospital Unit Name 153**], it was noticed that the patient had anemia and thrombocytopenia was concerning for a TTP like picture. His anemia and thrombocytopenia persisted despite aggressive transfusion measures. Plasmapheresis was attempted to treat the TTP-like picture. However anemia and thrombocytopenia persisted. While in the ICU patient also developed anasarca from severe nephrosis which thought to be [**3-2**] TTP or acute exacerbation of dermatomyositis along with severe malnutrition. Patient was started TPN for nutrition as he did not tolerate tube feeds. Patient also developed as result of malnutrition and nephrosis, severe scrotal and penile edema requiring foley placement. Patient was called out to the floor when he was stable and when he no longer needed ICU care. On the floor patient became hypotensive and was sent back to the ICU. In the ICU patient was intubated for hypercarbic respiratory failure thought to be [**3-2**] to extreme muscle weakness from his dermatomyositis. While intubated, patient developed rapid atrial fibrillation with rapid ventricular response. Patient was rate controlled. EKG's were noticed to be low voltage. In the setting of a hypotension, an ECHO was completed showing a pericardial effusion with early tamponade physiology. A pericardiocentesis was completed and a drain placed to help drain the fluid. Serosanginous fluid continued drain from the pericardial drain. Patient became increasingly hypotensive with no clear etiology for shock. There was no clear infectious etiology. Patient was severely acidemic with increased lactate. Cytoxan was administered the patient as recommended by Rheumatology. Despite these aggressive measures, the patient was persistently hypotensive with severe lactic acidosis. Patient had large amount of blood evacuating from anus, suggesting bowel infarction. Given poor prognosis, goals of care discussion occurred with patient's family and HCP. When third BP supporting medication was added and patient continued to be hypotensive, patient was made DNR. Shortly thereafter, patient died. Medications on Admission: Medications: Medications on admission: Calcium 600 with Vitamin D3 600 mg Omeprazole 20 mg Cap [**1-30**] Capsule(s) by mouth daily Atovaquone 750 mg/5 mL Oral Susp Oral Daily Alendronate 70 mg Tab Oral saturdays Vitamin D-3 400 unit Cap Oral 2 Capsule(s) Once Daily Methylprednisolone 20 mg [**Hospital1 **] Colace 100 mg Cap Oral 1 Capsule(s) Twice Daily Senna 8.6 mg Cap Oral 1 Capsule(s) Twice Daily Ferrous Sulfate 325 mg Tab Oral 1 Tablet(s) Twice Daily Maalox Advanced Zofran 4 mg Tab Oral Twice Daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2179-10-13**]

[ "285.29", "507.0", "261", "584.9", "562.10", "283.0", "287.5", "427.31", "518.0", "518.81", "578.0", "570", "283.19", "288.4", "428.0", "578.1", "581.9", "428.21", "285.1", "458.9", "710.3", "560.1", "280.9", "286.6", "423.3", "276.2", "038.9", "787.20", "511.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "99.14", "37.0", "99.71", "96.71", "96.04", "99.15", "96.6", "38.93", "99.25" ]

icd9pcs

[ [ [] ] ]

9395, 9404

6194, 8803

344, 434

9455, 9464

3689, 6171

9520, 9559

2942, 3020

9363, 9372

9425, 9434

8868, 9340

9488, 9497

3069, 3670

252, 306

2048, 2422

462, 2030

2444, 2782

2798, 2926

31,630

141,993

31339

Discharge summary

report

Admission Date: [**2129-7-12**] Discharge Date:[**2129-9-15**] Date of Birth: [**2129-7-12**] Sex: F Service: NB HISTORY: Baby girl [**Known lastname 73886**] was the 1.3 kg product of a 29- [**3-12**]-week gestation born to a 17-year-old G1 mother. Prenatal screens: O positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, GBS positive, chlamydia negative, GC negative. PAST MEDICAL HISTORY: Remarkable for exercise induced asthma treated with albuterol. INTRAPARTUM: Unremarkable until 4 days prior to delivery with development of preterm labor and given betamethasone. Intrapartum remarkable for fetal tachycardia and maternal fever to 99.8. Received antibiotics intrapartum. Normal spontaneous vaginal delivery with Apgar's of 8 and 8. SOCIAL HISTORY: Lives with parents. Father of baby involved. PHYSICAL EXAMINATION: On admission baby weighed 1305grsams, HC 27 cm and length 40 cms all appropriate for GA. HOSPITAL COURSE: RESPIRATORY: Infant was admitted to newborn intensive care unit and has been stable in room air since admission. She had occasional apnea with bradycardia of prematurity, not requiring caffeine therapy. She has been free of any episodes for several weeks prior to discharge. She was intubated for PDA ligation and extubated 4 days later. She has remained in room air since that time. CARDIOVASCULAR: She has been treated with indomethacin on [**2129-7-18**] for a patent ductus. Her most recent echocardiogram on [**2129-7-25**] revealed a a small 1 mm patent ductus arteriosus with continuous left-to-right flow. Decision at that time was to watch the infant clinically, as she was in room air and stable. She did have ongoing intermittant episodes of tachypnea and a chest film was obtained on [**8-16**] for increased incidence of tachypnea and increased work of breathing with oral feedings. This revealed increased heart size since the previous film and some pulmonary congestion. Cardiology was reconsulted , and an echocardiogram was done on [**8-17**] which showed a 3 mm PDA with L>R shunting/dilated L atrium and R ventricular hypertension.In view of her clinical status of failure and the results of the ECHO she went to CHMC on [**8-18**] for ligation of her ductus. She has done well post surgey and currently no murmur is audible. FLUID AND NUTRITION: Initially started on day of life 1. Was made NPO for indomethacin treatment. Was restarted on enteral feedings on [**7-22**] and was on full enteral feedings on [**7-30**] without issue. She is currently on Enfacare 24 cals per ounce and her discharge weight is 2775. GI: Peak bilirubin was 7.5/0.7. She has required phototherapy and her last rebound bilirubin level was 6.8/0.8 on [**8-2**]. HEMATOLOGY: Hematocrit on admission was 43.5. She required 1 split packed red blood cell transfusion at 20 cc/kg on [**8-10**] for a hematocrit of 23 and retic count of 2.6. She received a second packed RBC transfusion on [**8-20**] post surgery for a hematocrit of 26. Her last hematocrit on [**9-6**] was 32 with a reticulocyte count of 1.8. She is on ferrous sulfate. State screen revealed she has sickle cell trait. INFECTIOUS DISEASE: CBC and blood culture obtained on admission: CBC was benign, blood cultures remained negative at 48 hours at which time ampicillin and gentamycin were discontinued. Infant received a total of 3 doses of oxacillin for a infectious lesion on the left foot secondary to an IV placement. NEURO: Infant has been appropriate for gestational age. Head ultrasounds on day of life number 7 and 29 were normal. Hearing screening passed on [**9-14**]. Ophthalmology Was mature on [**8-24**]. Immunizations: Hepatitis B vaccine given on [**8-15**]. Pediarix , Hemophilus B and Pneumococcal vaccines on [**9-11**]. MEDICATIONS: Ferrous sulfate 0.2cc PO q day DISCHARGE PLANS: F/U AT HAVMA/CAM/Dr.[**First Name (STitle) 17470**] on [**9-20**]. Early Intervention Referral VNA to come to home day post discharge. Discharge Diagnosis: Premature female 29 [**3-12**] S/P Apnea of Prematurity PDA treated with indocin and ligated on [**8-18**] S/P Anemia S/P Hyperbilirubinemia S/P immature feeding [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**] MEDQUIST36 D: [**2129-9-15**] 22:33:15 T: [**2129-9-15**] 06:27:01 Job#: [**Job Number 73887**]

[ "747.0", "779.89", "997.3", "770.82", "776.6", "V30.00", "779.3", "765.15", "779.81", "276.2", "518.0", "765.25", "774.2" ]

icd9cm

[ [ [] ] ]

[ "38.85", "38.92", "99.04", "99.83", "96.6", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

4064, 4556

989, 4043

881, 971

445, 796

813, 859

32,628

126,898

52524

Discharge summary

report

Admission Date: [**2184-1-6**] Discharge Date: [**2184-1-9**] Date of Birth: [**2103-1-26**] Sex: M Service: MEDICINE Allergies: Lovastatin Attending:[**First Name3 (LF) 2745**] Chief Complaint: [**First Name3 (LF) **], afib with rvr Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 80 yo cantonese man with pmhx significant for DMII, ESRD on HD, HTN, CAD, PAF with multiple recent hospitalizations for enterococcus urosepsis ([**11-21**])and [**Month/Day (4) **] of unknown source ([**12-1**]) who presents today with [**Month/Year (2) **], chills, nausea, vomiting and diarrhea. Patient was first hospitalized with enterococcus UTI in early [**Month (only) **] and was treated with 7 days of augmentin. He then returned a week later with [**Month (only) **] and chills and had negative w/u including LP, head ct, abd/pelvic ct, Mycotic culture, mycobacteria culture, urine culture, sputum culture, c.diff and blood cultures were all negative. Thin/thick smear was negative for parasites. Additionally, U/S negative for abscess/fluid collection at fistula site, CXR which showed a questionable right middle lobe pneumonia, however CT chest showed no evidence of pneumonia, and TTE which showed no evidence of endocarditis. Patient was given 4 days of antibiotics in total and then monitored. Patient did not have [**Month (only) **] thereafter and was discharged. Patient was in his usual state of health until this am when he woke up with chills, weakness and some mild respiratory distress without cough. Initial vs in the ED were T 100.4-->102.3 rectally, HR 122-150, BP 162/66, 93% RA. In the ED, he had episode of non-bloody emesis and brown guaic negative diarrhea. Otherwise, patient denies dizziness, headache, neck stiffness, cough, sob, cp, abd pain, muscle/joint pain or diarrhea or vomiting at home. Patient was also noted to have petechial [**Month (only) **] on his right arm which was thought to be old per his nephrologist who knows the patient. Prior to this knowledge there was concern that the [**Month (only) **] could be sign of meningococcemia and he was given a dose of vancomycin and ceftriaxone. Patient also had afib with rvr to 140s in the ED during the time when he was vomiting and nurses were trying to place IV access. He did not receive av nodal blocking agents but his hr came down to low 100s with IVF x 2.5 liters in total. Patient also received 2 grams of magnesium. Renal consulted in ED and plan to dialyze patient today. On presentation to ICU, intial vs were: T 99.1, BP 106/49, HR 91, O2 sat 100% on 3 liters. Patient reported feeling weak and tired but otherwise had no complaints. Past Medical History: 1. CAD - reported as single vessel disease s/p catheterization in [**5-20**] following ETT-MIBI demonstrating an inferolateral perfusion defect. Mid LCX was stented with a Drug Eluting Stent with successful rescue of the OM1 with balloon angioplasty. 2. Diabetes Mellitus Type II - for more than 30 years. Has nephropathy and proteinuria, as well as mild distal neuropathy. 3. Atrial fibrillation - paroxysmal atrial fibrillation diagnosed in [**2170**]. On long-term anticoagulation. 4. Hypertension 5. History of GI bleed - History of gastric ulcers. Presumed lower GI bleed on [**1-20**]. 6. Chronic renal insufficiency - Probable diabetic nephropathy. 7. Sleep apnea 8. Musculoskeletal problems: (a) Bilateral severe carpel tunnel (b) Polyneuropathy of hands (c) Right flexor tendon nodules/ contracture (d) OA of DIPs, PIPs, and 1st CMC (e) Gout - recent admission in [**2-19**] for gout flair. (f) Pseudogout. (g) osteopenia Social History: Mr. [**Known lastname **] is Cantonese speaking. He lives at home with his wife. [**Name (NI) **] has a remote 20-year history of tobacco smoking. He quit 20 years ago. No alcohol or illicit drug use Family History: Both parents deceased. Father had diabetes. He has 2 children who are well and no siblings. . Physical Exam: VS: Temp 99.1 : BP: 106/49 HR: 91 RR: 16 O2sat 100% on 3 liters NC GEN: sleepy but easily arousable and appropriately answering questions, pleasant, comfortable, NAD HEENT: NCAT, PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, jvp 7-8 cm, no carotid bruits, no thyromegaly or thyroid nodules, neck supple w/ no pain on movement in all directions or cervical spine tenderness RESP: bibasilar crackles, no wheezes or rhonchi CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: right arm- non-blanching macular [**Last Name (LF) **], [**First Name3 (LF) **] red, non-tender NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: guaic negative in ED Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2184-1-9**] 07:40AM 10.3 3.75* 12.2* 37.5* 100* 32.6* 32.5 15.0 170 [**2184-1-8**] 06:25AM 11.2* 3.54* 11.5* 35.7* 101* 32.5* 32.2 14.2 155 [**2184-1-6**] 11:21PM 11.8* 3.57* 11.4* 35.5* 99* 32.0 32.2 14.7 157 [**2184-1-6**] 08:50AM 14.5* 3.98* 12.7* 39.5* 99* 32.0 32.3 15.5 222 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2184-1-9**] 07:40AM 140* 36* 2.9* 138 4.6 100 29 [**2184-1-8**] 06:25AM 136* 43* 3.3* 143 4.2 104 29 [**2184-1-7**] 11:36AM 234* 29* 2.7* 141 4.6 105 26 [**2184-1-6**] 11:21PM 80 21* 2.3* 144 4.2 108 29 [**2184-1-6**] 08:50AM 144* 49* 4.0* 142 5.2*1 105 25 . [**2184-1-8**] 8:40 am Influenza A/B by DFA Source: Nasopharyngeal aspirate. **FINAL REPORT [**2184-1-9**]**: NEGATIVE FOR INFLUENZA A & B VIRAL ANTIGEN . [**2184-1-6**] No growth on blood cultures x 2 [**2184-1-6**] No growth on urine culture . Legionella Urinary Antigen (Final [**2184-1-7**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN Brief Hospital Course: ASSESSEMENT/PLAN: Pt is an 80 yo man with pmhx CAD, ESRD on HD, DM2, HTN, PAF admitted with fevers, developed vomiting in the ED, now with no further episodes of fevers. . # [**Month/Day/Year **]: Pt with history of [**Month/Day/Year **] without known source despite extensive workup in [**11/2183**], also in 2 other times during [**2182**]. Admitted with a significant [**Year (4 digits) **], however no further episodes during hospitalization. Had a one day stay in the MICU due to ?sepsis. Pt did not develop any localizing signs without growth on blood or urine cultures, influenza & legionella antigens negative. ?Drug [**Year (4 digits) **] with allopurinol, also no evidence of malignancy on imaging done. Possibility that fevers may be related to dialysis as they started soon after initiation of HD, although no evidence of infection at AV graft site. Pt received an empiric course of antibiotics including vancomycin, flagyl & levaquin for a total of 3 days. Pt did not have any further episodes of fevers during hospitalization. . # Afib with RVR: Episode of RVR on admission which resolved with single dose of metoprolol 5mg IV; also repeat episode in association with hypoglycemia and resolve with correction of metabolic derangement. Uptitrated metoprolol dosing from 37.5mg [**Hospital1 **] to 50mg TID during hospitalizaton. Pt also on coumadin, although INR slightly subtherapeutic at discharge. . # CAD: No evidence of ischemia per EKG, pt without symptoms of chestpain or shortness of breath. Continued aspirin, atorvastatin and increased metoprolol as above. Held isosorbide mononitrate on admission but restarted prior to d/c. . # ESRD: Pt had 2 sessions of hemodialysis while on admission. Usually with HD tues/thurs/sat. Nephrology followed closely, continued pt on nephrocaps. . # h/o gout: Significant gout, closely followed by rheumatology outpt. Pt was continued on home regimen allopurinol and methylprednisolone. No acute issues while in house. . # DM: Was labile initially during admission with an episode of hypoglycemia overnight on lantus 6U and sliding scale humalog. FSG AC & HS, diabetic diet. Pt was changed to home regimen of Levemir & Novolog prior to discharge. . Pt reached maximal hospital benefit and was discharged home to follow up with PCP. Medications on Admission: 1. Isosorbide Mononitrate 30 mg QD 2. Allopurinol 200 mg Tablet QD 3. Metoprolol Tartrate 37.5 mg Tablet [**Hospital1 **] 4. Methylprednisolone 8 mg QD 5. Levothyroxine 75 mcg QD 6. Folic Acid 1 mg QD 7. Atorvastatin 10 mg QD 8. Aspirin 81 mg QD 9. Protonix 40 mg QD 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO 2days/week: Take 2.5mg 2days per week. 11. Coumadin 2.5 mg Tablet Sig: 0.5 Tablet PO once a day: Please take 1.25mg 5 days per week. 12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual up to 3 times as needed for chest pain: place under tongue for chest pain as needed. 13. Levemir 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 14. Novolog 100 unit/mL Solution Sig: per sliding scale Subcutaneous refer to sliding scale three days per day. 15. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Methylprednisolone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**12-18**] tablet Sublingual AS directed as needed for chest pain. 12. Levemir 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 13. Novolog 100 unit/mL Solution Sig: One (1) units Subcutaneous Before meals & at bedtime: Per sliding scale. 14. Warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO 5X/WEEK (MO,TU,WE,FR,SA). 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK ([**Doctor First Name **],TH). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, [**Doctor First Name **]. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 18. Bacitracin 500 unit/g Ointment Sig: One (1) tube Topical twice a day: Apply thin layer of ointment over affected area. Disp:*1 tube* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: [**Hospital **] of unknown origin Atrial fibrillation Diabetes II Hypertension Gout Discharge Condition: Stable, afebrile 96.8F Discharge Instructions: You were admitted with high fevers which resolved after admission. We did not find the source of your fevers. You received antibiotics for 3 days. You developed a very fast heart rate, we increased your metoprolol to control your HR. . We have made some changes to your medications. Please increase your metoprolol to 50mg three times daily. You may continue to take your other medications as prescribed. . Please call or come to the ED if you develop chestpains, shortness of breath, high fevers or any other worrisome concerns. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2184-1-16**] 11:10 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2184-3-18**] 8:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2184-3-26**] 10:40

[ "780.6", "427.31", "V58.67", "V45.1", "585.6", "715.90", "274.9", "250.40", "414.01", "V58.61", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

10879, 10937

5936, 8225

308, 315

11065, 11090

4859, 5913

11668, 12062

3892, 3988

9138, 10856

10958, 11044

8251, 9115

11114, 11645

4003, 4840

230, 270

343, 2701

2723, 3659

3675, 3876

62,479

115,251

36964

Discharge summary

report

Admission Date: [**2134-5-31**] Discharge Date: [**2134-6-9**] Date of Birth: [**2077-9-3**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 3705**] Chief Complaint: OSH transfer for seizure Major Surgical or Invasive Procedure: intubation History of Present Illness: 56 y.o. male w/ Hep. C c/b cryoglobulinemia, ESRD on HD, s/p MVC with slight trauma to the head some weeks ago, who woke up this morning complaining of a HA after which he was found seizing in bed. According to the patient's son, he was in a car accident approximately 3 weeks ago after which he began experiencing "migraines" again. He reportedly has a history of migraines that had long resolved. He additionally had been complaining of "kaleidoscope vision" saying specifically that his vision was blurry, similar to looking through a kaleidoscope. He was also reportedly unstable on his feet, but never noted to fall. He does not have a prior history of seizures, does not consume alcohol, use illicit drugs or smoke. He had been taking Benadryl in excess because of his headaches. He ordinarily takes Benadryl to sleep. He has been chronically ill for many years, but sees doctors [**Name5 (PTitle) 83371**]. Of note, patient had been taking Alka-Seltzer for the past 3 days and has a history of a severe, but unknown allergy to aspirin. Patient was taken to [**Hospital6 302**] where additional history raised the possibility of Benadryl ingestion and ? TCA ingestion. Given a QRS of 116, he was started on bicarb drip. Additionally, because of a fever to 102.7 and a WBC of 22 in the setting of these neurological symptoms, Ceftriaxone and Vancomycin were started empirically and he was intubated to protect his airway after seizing two additional times (given Ativan) prior to being transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ER, Acyclovir was added prior to performing an LP, which was unremarkable for infection. CT head and spine were unremarkable and neuro and toxicology were consulted. Past Medical History: Hepatitis C c/b by cryoglobulinemia ESRD on HD (last on HD one year ago, reportedly told he no longer needed it) Migraines Social History: lives in [**Location (un) 5503**] with son, remote smoking history, no alcohol or illicits. Family History: NC Physical Exam: Vitals: T: 102.6, BP: 139/81 P: 109 R:21 O2: 100% AC 500/20/.50/5 General: Sedated, intubated HEENT: NC/AT; pupils small, but equally round and reactive to light, sclera anicteric; OG with bloody secretions Neck: Supple, no LAD Lungs: CTAB CV: S1, S2 nl, no m/r/g appreciated 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 Neuro: Limited due to sedation, but notable for clonus b/l and equivocal babinksi. Patient does not follow commands Skin: No rash, no jaundice Pertinent Results: [**2134-5-31**] WBC-20.4* RBC-4.14* Hgb-12.8* Hct-37.6* Plt Ct-170 [**2134-6-1**] WBC-13.4* Hct-30.4* Plt Ct-148* [**2134-6-2**] WBC-12.3* RBC-3.80* Hgb-11.8* Hct-34.6* Plt Ct-142* [**2134-6-5**] WBC-8.3 RBC-3.86* Hgb-12.1* Hct-35.1*31.3 Plt Ct-151 [**2134-6-6**] WBC-6.7 RBC-4.03* Hgb-12.4* Hct-36.4* Plt Ct-151 [**2134-6-8**] WBC-5.2 RBC-3.81* Hgb-11.7* Hct-34.8* Plt Ct-180 [**2134-6-9**] WBC-5.2 RBC-3.79* Hgb-11.6* Hct-34.2* Plt Ct-189 [**2134-5-31**] Glucose-347* UreaN-38* Creat-3.6* Na-139 K-5.0 Cl-103 HCO3-18* [**2134-6-2**] Glucose-141* UreaN-32* Creat-3.7* Na-142 K-4.0 Cl-106 HCO3-22 [**2134-6-3**] Glucose-105 UreaN-32* Creat-4.2* Na-139 K-4.1 Cl-108 HCO3-22 [**2134-6-4**] Glucose-113* UreaN-32* Creat-4.0* Na-146* K-3.8 Cl-111* HCO3-21* [**2134-6-5**] Glucose-109* UreaN-33* Creat-3.5* Na-142 K-3.4 Cl-108 HCO3-17* [**2134-6-6**] Glucose-105 UreaN-35* Creat-3.4* Na-143 K-3.4 Cl-109* HCO3-20* [**2134-6-8**] Glucose-131* UreaN-41* Creat-3.4* Na-142 K-3.8 Cl-108 HCO3-22 [**2134-6-9**] Glucose-99 UreaN-42* Creat-3.3* Na-141 K-3.9 Cl-108 [**2134-5-31**] ALT-18 AST-38 CK(CPK)-147 AlkPhos-71 TotBili-0.2 [**2134-6-1**] ALT-15 AST-36 LD(LDH)-274* CK(CPK)-284* AlkPhos-56 TotBili-0.3 [**2134-6-6**] LD(LDH)-250 CK(CPK)-151 [**2134-5-31**] CK-MB-4 cTropnT-0.03* [**2134-6-1**] CK-MB-6 cTropnT-0.05* [**2134-5-31**] Lipase-106* [**2134-6-6**] Lipase-37 [**2134-6-6**] calTIBC-309 VitB12-324 Folate-11.0 Ferritn-162 TRF-238 [**2134-6-1**] Phenyto-4.7* [**2134-6-3**] Phenyto-12.6 [**2134-6-6**] Phenyto-<0.6* [**2134-6-6**] Phenyto-1.8* [**2134-6-7**] Phenyto-1.2* [**2134-5-31**] Lactate-2.4* [**2134-6-1**] Lactate-0.8 Brief Hospital Course: Patient was admitted as a transfer to the ICU. Seizure: Seizure was of unclear etiology and patient without a known history of seizures. Differential would include brain trauma s/p MVA, acute bleed, infection, intracranial mass and toxic/metabolic derrangement. Patient underwent a lumbar puncture that was negative. Patient had head imaging that revealed as fluid collection at C2 which after serial imaging was felt to be a hematoma. The patient loaded intially started on Keppra, renally dosed. Attempt was made to switch patient to dilantin given renal clearance of Keppra, but depsite several loads, dilantin level stayed subtherapeutic. Patient was finally transitioned to keppra monotherapy. Patient was on morphine for pain control for his neck pain attributed to the C2 lesion. He was discharged then on Valium as needed and oxycontin twice daily for pain. C2 Hematoma: Secondary to fall, confirmed on MRI. Pain control as above. Toxic Ingestion: Per report, patient may have taken Benadryl or TCAs. Tox screen negative up transfer to ED. EKG with QRS of 116 initially. Patient was briefly on a bicarbonate drip. Toxicology felt it was inconclusive and that whatever ingestion may have occured the patient had recovered. Leukocytosis: With initially elevated lactate, suggestive of infection. CNS was of obvious concern for source given seizure, but LP is negative. Other culture data was negative. Patient is was initially on Ceftriaxone, Vancomycin and Acyclovir for empiric coverage intially, he was briefly off antibiotics, but when a question of the fluid collection at C2 being an abscess the patient was restarted on vancomycin and ceftazidime that were discontinued [**2134-6-7**] when the fluid collection was concluded to be hematoma on MRI ([**2134-5-27**]). Mental status. A+Ox3, but unclear about details and slow to respond and complained of poor memory. Patient reports that memory is improving, and much improved on discharge. Depression: restarted home sertraline, avoided home triazolam due to altering effect. Held amitryptiline on discharge as well. HTN: increased home amlodipine dose of 5mg to 10mg daily, and continued this on discharge. Patient initially on labetolol in unit but transitioned to home diovan on the floor. Hyperglycemia: Mild, on ISS in the hospital, by end of hospital course, no longer requiring. Respiratory Failure: Intubated in the setting of seizing to protect airway. Patient was able to be rapidly extubated. CKD Stage IV: Previously been on HD. Currently with good urine output. Patient maintained on his nephrocaps. Medications renally dosed. Hepatitis C: Unclear status of liver disease. Stable LFTS and good synthetic function during this hospitalization Elevated Troponin: EKG with non-specific changes and troponin elevated in the setting of renal failure. Patient ruled out for myocardial infarction. The patient was FULL CODE during this admission. Medications on Admission: Per PCP's office: amtriptyline 50 qhs amlodipine 5 mg qhs valsartan 80 qday nephrocaps parvocet prn triazolam 0.25 mg qhs sertraline 100 qday Discharge Medications: 1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for muscle pain. Disp:*90 Tablet(s)* Refills:*0* 6. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*200 Tablet(s)* Refills:*0* 8. OxyContin 15 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Spine hematoma Seizures Secondary: Discharge Condition: stable Discharge Instructions: You were admitted to hospital after having a seizure. You had neck pain and imaging of your spine show a blood collection in your cervical spine. This blood collection should clear slowly on its own. The seizure is likely secondary to either the blood collection or trauma from the motor vehicle accident you were in several weeks ago. You should also take precautions given that you have new seizures. This would mean, that you should NOT drive, operate machinery, or bathe alone. The following were made your medication regimen: 1. Amlodipine (for blood pressure) was increased from 5mg to 10mg daily. Continue to take Diovan as well. 2. Keppra 500mg twice a day was started for seizures. 3. For pain, you should take 1gm of tylenol up to 4 times a day. 4. For muscle spasms, take [**1-8**] pills of Valium as needed, up to 3 times a day. 5. For pain you should take Oxycontin 15mg twice a day. If you still have pain, you can take percocet 2 pills up to 4 times a day. You should discuss tapering this with your primary care doctor, as your pain should decrease as the blood collection in your neck resolves 6. Do not take Triazalam and Amitriptyline. You can discuss the need for these with your Primary care doctor Please call your doctor or return to the hospital if you have fevers, chills, numbness or tingling in your fingers or legs, increased severity of neck pain or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 71087**] on [**2134-6-24**] at 130Pm. ([**Telephone/Fax (1) 50234**] Dr. [**First Name (STitle) **], the neurologist, on [**2134-7-8**] at 9am. She is located [**Location (un) **], the [**Hospital Ward Name 23**] building, [**Location (un) **]. [**Telephone/Fax (1) 83372**]. Completed by:[**2134-7-3**]

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Discharge summary

report

Admission Date: [**2120-1-12**] Discharge Date: [**2120-1-17**] Date of Birth: [**2040-4-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2610**] Chief Complaint: Tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 79 y/o female with advanced dementia recently discharged from [**Hospital3 **] s/p admission for PNA and PEG placement. At the [**Hospital 228**] nursing home she was noted to have repspiratory rate elevation that did not improve with morphine. Vitals at the NH noted to be 123/68, 93, 33, 99.6, 91-92% on RA. . In the ED intial vital signs were 98.5, 145/89, 57, 34, 100% A. She was noted to have abdominal pain and distension. A CT of the abdomen was performed for concern of SBO and the patient was evaluated by surgery. She had dilated loops of bowel, but the overall exam and imaging was felt to be most consistent with constipation. Disimpaction was recommended. . A UA with positive WBC, bacteria. Patient was given levofloxacin, clindamycin, and vancomycin for coverage of both PNA and UTI. The emergency room spoke to the son who reversed her DNR/DNI with the thought of possible intubation if she has a short-term process. The patient was admitted to the ICU for further evaluation. . Review of systems: Patient unable to provide. Past Medical History: Hypernatremia, History of dehydation Dementia Aspiration pnumonia, Bipolar disorder. hip fracture with contraction fracture history of PE x 2 during the surgery Osteomyelitis and ferquent UTI Social History: Lives in [**Hospital 745**] [**Hospital **] Nursing home. Son [**Name (NI) **]. Family History: Noncontributory Physical Exam: On Admission: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . On Discharge: Vitals: Tm/c: 97.9/97.5, BP: 132/62 (110-132/52-62), HR: 87 (82-87), RR: 22, O2: 97%RA GA: Pt lying in bed, verbally responsive HEENT: MMM. no LAD. neck supple. Cards: No RVH. [**2-25**] holosystolic murmur heard best at the right upper sternal, loud S1, soft S2. Pulm: fine crackles at the bases bilaterally Abd: soft, NT, +BS. no g/rt. Extremities: 1+ radial pulses bilaterally, lower extremity pulses difficult to palpate secondary to edema. Lower extremity edema bilaterally, with soft fluffy skin around patella bilaterally, PICC line on the left. Skin: pt has bilateral heel blisters. The blister on the left is intact and the one on the right is popped and skin peeling. The patient also has a stage 2 right lateral malleolus ulcer with clean borders. A well healing scar at the inferior border and otherwise pink granulation tissue Neuro/Psych: Answers questions appropriately Pertinent Results: [**2120-1-12**] 02:45PM BLOOD WBC-8.6# RBC-3.57* Hgb-10.6* Hct-32.7* MCV-92 MCH-29.7 MCHC-32.4 RDW-15.8* Plt Ct-211 [**2120-1-14**] 07:05AM BLOOD WBC-4.4# RBC-3.39* Hgb-9.8* Hct-31.2* MCV-92 MCH-28.9 MCHC-31.3 RDW-15.9* Plt Ct-203 [**2120-1-17**] 05:25AM BLOOD WBC-6.3 RBC-3.26* Hgb-9.4* Hct-29.4* MCV-90 MCH-28.8 MCHC-32.0 RDW-15.6* Plt Ct-276 [**2120-1-12**] 02:45PM BLOOD PT-13.8* PTT-22.5 INR(PT)-1.2* [**2120-1-13**] 04:01AM BLOOD PT-16.5* PTT-23.2 INR(PT)-1.5* [**2120-1-12**] 02:45PM BLOOD Glucose-147* UreaN-21* Creat-0.3* Na-138 K-4.5 Cl-102 HCO3-30 AnGap-11 [**2120-1-17**] 05:25AM BLOOD Glucose-126* UreaN-12 Creat-0.4 Na-137 K-4.4 Cl-104 HCO3-28 AnGap-9 [**2120-1-12**] 02:45PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0 [**2120-1-15**] 04:50AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.2 [**2120-1-17**] 05:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 . CT [**2119-1-12**]: Extensive venous thrombus extending inferiorly from the IVC filter to involve at least the common femoral veins with the left extending further, off of imaged field. . Cecum in abnormal location in the right upper quadrant though non-dilated measuring up to 5.0cm with no wall thickening. Contrast from prior procedure seen distal to this point. Top-normal measured loops of small bowel measuring just up to 3.0cm with focal areas of narrowing though no transition. Air is still in colon, ?Ileus versus early partial obstruction. Rectal wall thickening with fecal impaction, ?stercoral colitis. Focal fluid in the left pelvis. . [**2120-1-15**] [**Month/Day/Year **] 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. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). The aortic valve leaflets are mildly thickened (?#). No discrete vegetation is seen (cannot exclude). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild bileaflet leaflet mitral valve prolapse. A small 5-6cm mobile echodensity is seenon the left atrial side of the valve (clip [**Clip Number (Radiology) **]), near the coaptation point of the leaflets, c/w a vegetation. An eccentric, anterior and posteriorly directely jets of severe (4+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2117-6-21**], the mobile mitral leaflet echodensity is new and c/w a vegetation. The severity of mitral regurgitation is markedly increased as well. . [**2120-1-15**] MRI Ankle FINDINGS: Evaluation of the bone marrow demonstrates edema in the distal 5 cm of the fibula, and cortical irregularity at the lateral aspect of the distal lateral malleolus. With an overlying soft tissue ulcer, these findings are consistent with osteomyelitis. There is no discrete fluid collection. There is no bone marrow edema elsewhere. There is trace fluid in the calcaneocuboid and talonavicular joints. The tibiotalar joint is intact. The sinus tarsi contains fat. The Achilles tendon is intact, however there is significant subcutaneous fluid posterior to it. Marked edema is seen at the dorsal aspect of the foot. There is mild edema at the plantar fascia, which is suboptimally evaluated in absence of sagittal views, as well as mild edema in the plantar foot muscles. The deltoid and spring ligaments are grossly intact. The anterior tibiofibular, posterior tibiofibular, calcaneofibular, and posterior talofibular ligaments are intact. The anterior talofibular ligament is torn. There is mild tenosynovitis of the peroneus longus and brevis tendons, but the intrinsic signal intensity of the tendons is normal. Posterior tibialis tendon, flexor hallucis longus tendon, and flexor digitorum longus tendon are intact. The extensor tendons are intact. IMPRESSION: 1. Deep soft tissue ulcer, extending to the lateral aspect of the lateral malleolus, associated with cortical irregularity and bone marrow edema in the distal fibula, most consistent with osteomyelitis. No abscess. 2. Marked circumferential ankle edema, most pronounced in the dorsal aspect of the foot. 3. Edema in the plantar foot muscles,nonspecific myositis, the differential diagnosis is broad and includes infectious or inflammatory or neurogenic etiologies. 4. Mild peroneal tenosynovitis. 5. Tear of the anterior talofibular ligament, likely chronic. . [**2120-1-17**] CXR PICC placement FINDINGS: A left PICC catheter has been reinserted and is now positioned more centrally with the tip in the mid-to-upper SVC. Lung volumes remain with left basilar atelectasis. No pneumothorax is present. An IVC filter and catheter projecting over the upper abdomen are unchanged. IMPRESSION: Left PICC tip in the mid-to-upper SVC. No complications. Brief Hospital Course: 79 y/o female with tachypnea, tachycardia, abdominal pain and distentsion. . # Tachypnea: The patient came in with rapid breathing but overnight her RR improved to the mid-20's. Her oxygen saturation was maintained, and there was no evidence of PNA on CT. Given this clinical picture tachypnea was thought to be a response to pain from her distended abdomen or from restrictive physiology due to abdominal distension. Abdominal distention was treated as below, with improvement in respiratory symptoms. She remained slightly tachypneic and it was found that she was bacteremic. Her tachypnea could be secondary to infection as well as pain in addition to her underlying fecal impaction. Her respiratory status should be followed, but she is breathing comfortably at the time of discharge. . # Abdominal Distension/Pain: CT with evidence of significant constipation, likely in context of morphine use. There is no evidence of abdominal pathology requiring surgical intervention per ACS. The patient cleared out rectally following fleet and soap suds enema but still has considerable amount of stool throughout her colon. Started on lactulose/miralax from above. The patient began moving her bowels well and, in fact started having very loose stools. We pulled back on her bowel regiment and made most of her medications PRN with the instructions to give them if she does not have a bowel movement in 2 days. . # Urinary Tract Infection: Patient with history of E Coli, Enterococcus, and Morganella all sensitive to ciprofloxacin. Started on cipro/vanc. Culture sent. The patient was growing klebsiella from her urine and she was started on cipro as she had UTI's all sensitive to cipro on the past. This UTI was resistent to cipro and she was switched to Bactrim. She will complete a 7 day course of Bactrim for her UTI. . # Bacteremia: Blood cultures from the ICU grew GPC and was empirically started on vancomycin. Ultimately it speciated as coag negative staph and she patient was switch from vancomycin to daptomycin because of a reaction to vancomycin that she has had in the past. She was clinically improving on daptomycin and serial cultures were all negative. Suspicion for source was the right hip which had been infected in the past and her right ankle that had a lateral malleolus stage III ulcer. [**Month/Day/Year **] showed a 3-5mm vegetation on the mitral valve and worsening MR [**First Name (Titles) **] [**Last Name (Titles) **] compared to [**2116**]. She also had an MRI of the right ankle as suspicion for osteomyelitis was high with an overlying stage III ulcer in the region. Initial [**Location (un) 1131**] of the MRI was highly suspicious for osteomyelitis, likely the source for her bacteremia. A PICC line was placed and she will be continued on daptomycin for 6 weeks. Weekly CBC with Differential, BMP, Ca, Mg, Phos, CK, LFTs will be faxed to [**Telephone/Fax (1) 457**]. [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] will follow the results and follow up with the patient in [**Hospital **] clinic. . # Goals of care: After goals of care discussion with the son it was decided not to be more agressive with washout of the right hip to assess if the fluid collection was infectious. He also decided not to consult surgery regarding valve replacement. Ms [**Known lastname 109139**] will be continued on IV Abx and follow up in outpatient clinic as described above. . # Dementia: Continued on Namenda, Aricept, Remeron, with zyprexa PRN for agitation. Medications on Admission: Robitussin Ativan for insomnia Tylenol for pain/Tempterature Miralax Colace Tramadol Roxanol [**Last Name (un) 39705**] Namenda 5 [**Hospital1 **] Vitamin C 250 Zyprexa 6mg Aricept 10 Daily Senna ASA 9am daily ASA Remeron Discharge Medications: 1. Fibersource HN Liquid [**Hospital1 **]: full strength PO continuous: Tubefeeding: Fibersource HN Full strength; Starting rate: 50 ml/hr; Do not advance rate Residual Check: q4h Hold feeding for residual >= : 200 ml give 150cc bolus water every 8 hours. 2. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours). 3. Robitussin Cough & Cold 2-15 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO every six (6) hours as needed for cough. 4. Ativan 0.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO QHS as needed for insomnia. 5. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours as needed for pain, temp>101. 6. Miralax 17 gram Powder in Packet [**Hospital1 **]: One (1) PO once a day as needed for constipation: please give if no BM in greater than 48hrs. 7. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 8. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) for 4 days. 9. daptomycin 500 mg Recon Soln [**Hospital1 **]: 0.8 Recon Soln Intravenous Q24H (every 24 hours) for 6 weeks. 10. tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO every eight (8) hours as needed for pain. 11. roxanol [**Hospital1 **]: Five (5) mg every four (4) hours as needed for shortness of breath or wheezing. 12. memantine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 13. Vitamin C 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 14. olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 15. Vitamin D 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a month. 16. donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 17. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 19. Remeron 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 20. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2 times a day) as needed for constipation: if no bowel movement for three days. 21. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO DAILY (Daily) as needed for constipation. 22. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for increased secretions. 23. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for rash. 24. famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours). 25. Outpatient Lab Work weekly CBC with Differential, BMP, Ca, Mg, Phos, CK, LFTs. Please fax these results to [**Telephone/Fax (1) 457**]. Fax results att: [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Endocarditis Osteomyelitis Bacteremia UTI Fecal impaction . Secondary Diagnosis: Hypernatremia, History of dehydation Dementia Aspiration pnumonia, Bipolar disorder. hip fracture with contraction fracture history of PE x 2 during the surgery Osteomyelitis and ferquent UTI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were admitted to the hosptial and found to have a lot of stool in your rectum. You were admitted to the ICU for fast breathing and once they were able to move your bowels, your breathing decreased. However, your blood was found to have an infection that was thought to be coming from your right ankle ulcer and infection of the underlying bone. You also were found to have a urinary tract infection with a different antibiotic. An ultrasound of the heart also showed that you have an infection on your heart valve. You were started on the appropriate anitbiotics and your cognitive state greatly improved. At this time, we will treat you with long term IV antibiotics to treat the blood infection and the infection on the heart valve. . The following medication was started: Daptomycin 400 mg IV every 24hours for Bactrim DS 1 tab Daily for 5 days . Please take you other medications as prescribed. Followup Instructions: You will follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 719**], while you are at your nursing home. You will also be followed by the nurses, NP and physicians there. Department: INFECTIOUS DISEASE When: MONDAY [**2120-1-29**] at 10:10 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: THURSDAY [**2120-2-22**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2121-11-10**] Discharge Date: [**2121-12-1**] Date of Birth: [**2060-10-19**] Sex: M Service: MEDICINE Allergies: Azithromycin / Keflex Attending:[**First Name3 (LF) 1190**] Chief Complaint: right heel ulcer Major Surgical or Invasive Procedure: I+D and vac placement [**2121-11-15**] History of Present Illness: This is a 61 year old male with a history of RLE cellulitis, dementia, CVA, and CHF who presented [**2121-11-10**] with recurrent cellulitis of the right lower extremity. He is s/p a recent hospitalization for this at the end of [**Month (only) 359**]. At that time, he had a large RLE cellulitis/ulceration which failed treated with po Augmentin. He was admitted and placed on Unasyn, and underwent a bedside debridement at that time. He was discharged back to his nursing home on Unasyn. He was readmitted [**11-10**], with continued cellulitis and fevers. Past Medical History: 1) Recurrent RLE cellulitis 2) CHF, no documented EF 3) Etoh abuse 4) Vascular vs etoh dementia 5) CVA with resultant R hemiparesis 6) Dermatitis 7) Constipation Social History: History of etoh abuse. Resident of [**Location (un) **] NH. Has brother [**Name (NI) **] who is HCP, very involved. Family History: Unable to obtain. Physical Exam: Tc: 98.1 P: 86 BP: 88 by doppler R: 16 O2 sat 97% on RA Gen: alert male, appears in no distress, answering questions appropriately HEENT: mild L facial droop Neck: supple, no lympadenopathy CV: regular rate and rhythm, no murmurs, rubs, or gallops. nl s1, s2. Lungs: CTA bilaterally Abd: nondistended, nontender, good bowel sounds. Ext: R thigh with xerofoam dressing applied to skin donor site, no surrounding erythema (drsg [**Name5 (PTitle) **] in [**Name5 (PTitle) **] per podiatry instructions) R medial foot wound appears healthy, no surrounding erythema/exudate. bilateral toes with bluish discoloration c/w chronic venous stasis Neuro: L facial droop, strength LLE [**2-28**] (can lift against gravity), LUE contracted with increased tone Pertinent Results: Admission labs: [**2121-11-10**] 09:06PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2121-11-10**] 09:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2121-11-10**] 04:07PM PT-22.4* PTT-38.8* INR(PT)-3.2 [**2121-11-10**] 03:40PM LACTATE-1.8 [**2121-11-10**] 03:25PM GLUCOSE-152* UREA N-8 CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-11 [**2121-11-10**] 03:25PM WBC-11.7* RBC-3.61*# HGB-12.4* HCT-35.5* MCV-98 MCH-34.3* MCHC-34.9 RDW-14.3 [**2121-11-10**] 03:25PM NEUTS-68.3 LYMPHS-22.2 MONOS-5.3 EOS-3.9 BASOS-0.4 [**2121-11-10**] 03:25PM MACROCYT-1+ [**2121-11-10**] 03:25PM PLT COUNT-637* Transfer labs: [**2121-11-26**] 03:15AM BLOOD WBC-16.0* RBC-2.59* Hgb-8.6* Hct-26.0* MCV-100* MCH-33.2* MCHC-33.2 RDW-15.5 Plt Ct-354 [**2121-11-26**] 03:15AM BLOOD PT-15.8* PTT-40.4* INR(PT)-1.6 [**2121-11-26**] 03:15AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-136 K-2.8* Cl-107 HCO3-22 AnGap-10 [**2121-11-24**] 05:30AM BLOOD ALT-9 AST-16 CK(CPK)-24* AlkPhos-53 TotBili-0.3 [**2121-11-24**] 05:40PM BLOOD ALT-10 AST-16 CK(CPK)-312* AlkPhos-60 TotBili-0.4 [**2121-11-25**] 12:16AM BLOOD ALT-10 AST-21 CK(CPK)-634* AlkPhos-48 TotBili-0.5 [**2121-11-26**] 03:15AM BLOOD CK(CPK)-520* [**2121-11-25**] 12:16AM BLOOD CK-MB-4 cTropnT-<0.01 [**2121-11-26**] 03:15AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.0 [**2121-11-24**] 10:10PM BLOOD Cortsol-27.0* [**2121-11-24**] 10:40PM BLOOD Cortsol-27.9* [**2121-11-24**] 11:18PM BLOOD Cortsol-29.0* [**2121-11-24**] 05:40PM BLOOD CRP-3.05* [**2121-11-10**] 03:40PM BLOOD Lactate-1.8 [**2121-11-24**] 04:46PM BLOOD Lactate-3.1* [**2121-11-24**] 09:33PM BLOOD Lactate-2.7* [**2121-11-25**] 08:05AM BLOOD Lactate-1.1 Discharge labs: [**2121-12-1**] 06:30AM BLOOD WBC-7.8 RBC-3.46* Hgb-11.2* Hct-34.4* MCV-99* MCH-32.3* MCHC-32.5 RDW-16.8* Plt Ct-508* [**2121-12-1**] 06:30AM BLOOD PT-14.4* PTT-31.7 INR(PT)-1.3 [**2121-11-30**] 06:30AM BLOOD ESR-75* [**2121-12-1**] 06:30AM BLOOD Glucose-129* UreaN-6 Creat-0.8 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 [**2121-11-28**] 05:25AM BLOOD ALT-9 AST-17 AlkPhos-42 TotBili-0.3 [**2121-11-27**] 09:21PM BLOOD CK(CPK)-138 [**2121-11-26**] 03:15AM BLOOD CK(CPK)-520* [**2121-11-25**] 12:16AM BLOOD ALT-10 AST-21 CK(CPK)-634* AlkPhos-48 TotBili-0.5 [**2121-11-24**] 05:40PM BLOOD ALT-10 AST-16 CK(CPK)-312* AlkPhos-60 TotBili-0.4 [**2121-11-24**] 05:30AM BLOOD ALT-9 AST-16 CK(CPK)-24* AlkPhos-53 TotBili-0.3 [**2121-11-28**] 05:25AM BLOOD cTropnT-<0.01 [**2121-11-27**] 09:21PM BLOOD CK-MB-1 cTropnT-<0.01 [**2121-11-25**] 12:16AM BLOOD CK-MB-4 cTropnT-<0.01 [**2121-12-1**] 06:30AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0 [**2121-11-27**] 06:06AM BLOOD VitB12-267 Folate-17.0 CXR [**2121-11-29**] No evidence for pneumonia or CHF. Echo [**2121-11-27**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The 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. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. L knee xray [**2121-11-28**]: There is likely a small joint effusion. No acute fracture or dislocation identified. There are mild degenerative changes consisting of spurring of the tibial spines. Brief Hospital Course: 1. ID: (reiteration of course until transfer to floor): Pt was admitted, cultures taken and pt put on vancomycin, levaquin, and flagyl. He had a CT scan of his lower extremity, which revealed subcutaneous collections with enhancing rims involving the dorsum of the foot, and the medial and lateral ankles which are quite extensive in length. He was taken to the OR on [**11-14**] where his wound was again debrided. They also placed VAC dressing at this time. Podiatry performed a split thickness skin graft on [**2121-11-24**] (R thigh to R foot). On [**2121-11-24**] he was transferred to the MICU for hypotension (80's/40's) and fevers up to 105 after his split thickness skin graft procedure. His lactate was 3.1 and he was tachycardic so he was placed on the sepsis protocol. He was fluid rescusitated and his BP quickly improved to 110-120/40-50. He developed diarrhea on [**2121-11-25**]. Given that he had been on clindamycin for treatment of his foot infection, it was felt that he likely had C Diff and was begun on po flagyl. He was also empirically placed back on vancomycin and levaquin, as his only culture that was positive was a wound swab from admission that grew coag negative staph (rare; no sensitivities performed.) On 11/31 he was transferred to the floor. His [**Last Name **] problem on the floor was persistent hypotension in the 80s-90s. He was asymptomatic throughout. His blood pressure would bump occasionally with IV fluid boluses, but eventually these were stopped because his hypotension was asymptomatic and he would just diurese all of the fluid on his own. He initially was febrile and tachycardic with these low blood pressures, but both of those resolved and his BP remained low. He had numerous studies in terms of an infectious workup, including numerous negative CXR's, blood cultures, stools cultures (including CDiff neg x2, 3rd pending to date), and negative urine cultures - although he did have one urine cx with E.coli that was felt by ID to not be the source of his fevers, as on repeat UA it was negative. He did receive a couple doses of Macrobid for this UTI. At one point his left knee was mildly swollen, and a tap of this effusion revealed normal joint fluid with no evidence of infection. He was discharged home to finish one more week of vancomycin and on d/c he had been afebrile x 3 days. His levaquin and flagyl were discontinued as no source was identified. 2. Hyperthermia, resolved. Although this occurred directly after his operation, it was felt not to be due to malignant hyperthermia but was related to infection. 3. Cardiac hx: He had a reported history of CHF, but had an Echo that was essentially normal with an EFof 60%. He did not develop any pulmonary edema or lower extremity edema with the IVF he received. It was not felt that his hypotension was cardiogenic in origin given his EF. He had a normal EKG and cardiac enzymes were all negative in the setting of his tachycardia (mildly elevated CK but negative MB and negative troponins). 4. s/p R foot debridement: Followed by Podiatry. Wound instructions as per d/c instructions. He will follow up in Podiatry on the 14th. His wound looked excellent per them. 5. GI: His diarrhea was initially trace guaiac positive with a subsequent Hct drop, as low as 26. This was felt to possibly be dilutional secondary to his fluid resuscitation. He was transfused 1 unit PRBCs and his hematocrit remained stable (34 on d/c). His B12 and folate were normal. Numerous repeat stools were guaiac negative. He may require colonoscopy as outpatient. He was placed on Lansoprazole as his Prilosec was not on formulary. 6. Neuro: His warfarin was increased to attain a goal INR [**1-28**], which was difficult. Initially his warfarin was increased to 2 mg qhs, and on d/c he was ordered to have a bolus nighttime dose of 5 mg and change to a daily dose of 3 mg qhs. Medications on Admission: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). ml 9. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day). Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 4. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram Intravenous twice a day for 7 days. 5. Prilosec 10 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO once a day. Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once for 1 doses: Take tonight [**2121-12-1**]. Disp:*1 Tablet(s)* Refills:*0* 7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO at bedtime: Begin this dose [**2121-12-2**]. Disp:*90 Tablet(s)* Refills:*2* 8. boots Patient need multipolus boots bilaterally Discharge Disposition: Extended Care Facility: [**Hospital6 16166**] Facility - [**Location (un) 538**] Discharge Diagnosis: Ulcer right medial foot Discharge Condition: Good Discharge Instructions: Please return to see Dr. [**Last Name (STitle) **] in [**12-27**] weeks. Please call or return to clinic if you experience fevers, lightheadedness, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, worsening diarrhea, or increased redness/warmth/drainage from your foot. In terms of your coumadin, you need to take 5 mg tonight, and 3 mg every night after that. This is because your INR is too low. Your INR should be checked every 2-3 days while this is being adjusted. Followup Instructions: Podiatry: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 23305**] [**Name (STitle) **] Where: CC-2 PODIATRY UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2121-12-9**] 9:30 Dr. [**Last Name (STitle) **] at [**Hospital3 4262**] Group in [**12-27**] weeks Vascular Surgery: Dr. [**Last Name (STitle) 1391**] in 3 weeks call office for appointment

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icd9cm

[ [ [] ] ]

[ "99.07", "81.91", "93.56", "38.93", "88.48", "88.49", "86.69", "38.91", "99.04", "86.22" ]

icd9pcs

[ [ [] ] ]

11570, 11653

5822, 9725

301, 342

11721, 11727

2083, 2083

12278, 12661

1272, 1291

10562, 11547

11674, 11700

9751, 10539

11751, 12255

3870, 5799

1306, 2064

245, 263

370, 936

2100, 3853

958, 1121

1137, 1256

7,178

128,485

14764+14765+56578

Discharge summary

report+report+addendum

Admission Date: [**2146-1-27**] Discharge Date: [**2146-1-31**] Date of Birth: [**2100-6-23**] Sex: M Service: Cardiothoracic. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43433**] is a 45-year-old patient of Dr. [**Last Name (STitle) **] [**Name (STitle) **]. In [**2145-3-8**], the patient began experiencing dyspnea with minimal activities. Stress test was done in [**2145-6-7**] and positive for 2 to 3 mm inferolateral down sloping of the ST segment. Cardiac catheterization was performed. The results are as follows: LDEF 74%, No MR, diffusely narrowed left anterior descending, 6 beats of 70% stenosis at the circumflex, 6 beats of 70% proximal stenosis of the RCA and 80% stenosis of the distal RCA. He underwent percutaneous transluminal coronary angioplasty with stenting to the RCA at the [**Hospital1 **]. He has done well since. The patient was scheduled for endoscopy and required cardiac clearance. Prior to procedure, a cardiac catheterization was performed at an outside hospital on [**2145-12-8**] and the results are as followed: Left main diffusely narrowed, 50 to 60% stenosis at the mid circumflex, see report for full details. The patient was referred to the [**Hospital6 2018**] for cardiothoracic surgical consult. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Gastroesophageal reflux disease. 4. Increased cholesterol. 5. Diverticulitis. 6. Status post head injury two years ago. 7. Intermittent left face and arm paresthesias. SOCIAL HISTORY: Married with three children, works as a mortgage broker, smokes half pack of cigarettes a day and alcohol is about 5 drinks per week. ALLERGIES: No known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Ecotrin 325 q.d. 2. Atenolol 50 mg q.d. 3. altace 10 mg q.d. 4. Prilosec 40 mg q.d. 5. Lipitor 40 mg q.d. LABORATORY DATA: Prior to admission, white blood cell count was 11.4, hematocrit 39, platelets 289, PT-T 25.6, INR is 1.0, sodium 141, potassium 4.3, chloride 101, CO2 20, BUN 16, creatinine 1.0, glucose 106, liver function tests are normal. Carotid series was done for the intermittent left face and arm paresthesias. There were no significant abnormalities in the carotid or vertebral arteries in the neck noted. Chest x-ray no significant findings. Electrocardiogram revealed a normal sinus rhythm and nonspecific ST-T wave abnormalities in the inferior leads. This was consistent with an old electrocardiogram done in [**2145-6-7**]. PHYSICAL EXAMINATION: At the time of admission, vital signs revealed heart rate of 60, blood pressure was 135/82, Respiratory rate is 18. height is 6 feet and 3 inches. Weight is 108.7 kilograms. The patient is alert and oriented times 3. Pupils, equal, regular, and react to light and accommodation. Cranial nerves II-XII are grossly intact. Neck was supple with no jugular venous distention noted. Lungs were clear to auscultation. Cardiovascular has a regular rate and rhythm. S1 and S2. No murmurs, rubs or gallops. Abdomen with positive bowel sounds, soft and nontender and nondistended. Extremities has no cyanosis, clubbing or edema. 2+ pulses radial and femoral dorsalis tibial and posterior tibia bilaterally. HOSPITAL COURSE: On [**2146-1-28**], the patient was taken to the Operating Room where he underwent a coronary artery bypass graft times 3, a LIMA to the left anterior descending and SVG to the OM1 and OM2 sequential graft. A Transesophageal echocardiogram was done in the Operating Room and showed good biventricular systolic function and mildly thickened mitral valve leaflets, trace MR, trace TR, no AI. See report for full details. There were no intraoperative complications. The patient was recovered in the Intensive Care Unit and he was weaned from all cardioactive drugs. Anesthesia was revered and weaned from the ventilator and successfully extubated on postoperative day 0. The patient continued to do well. He was transferred to the floor on postoperative day #2 for continued postoperative care and cardiac rehabilitation. The patient was evaluated by PT and deemed to be safe for discharge to home. The patient has done well ambulating independently and full strength bilaterally in upper and lower extremities and eating well. The patient has remained stable and is ready for discharge on postoperative day #4. Physical examination on discharge revealed vital signs of a temperature of 98.4, sinus rhythm was in the 80's, blood pressure was 117/58 and 95% on room air. Alert and oriented times 3. The lungs are clear, but decreased in left lower base. Regular rate and rhythm. S1 and S2. No gallops, rubs or murmurs. Abdomen: Soft and nontender and nondistended. Full strength in upper and lower extremities bilaterally. No cyanosis, clubbing or edema. Incision is clean and dry, open to air. Postoperative weight is 107 kilograms. LABORATORY DATA: At the time of discharge, white blood cell count of 11.8, hematocrit 28.7, platelets 308, sodium 141, potassium 3.5 for which he received 40 mEq of KayCiel p.o. times 1, chloride 103, CO2 27, BUN 12, creatinine 0.7, sugar 107. DISCHARGE MEDICATIONS: 1. Toprol 37.5 mg p.o. b.i.d. 2. Atorvistatin 50 mg p.o. q.d. 3. Pantoprazole 40 mg p.o. times 1. 4. Enteric coated aspirin 325 mg p.o. times 1. 5. Percocet 1 to 3 tabs p.o. q. 4 to 6 p.r.n. DISPOSITION: Stable. Discharged to home. FO[**Last Name (STitle) 996**]P: Return to wound clinic in two weeks and follow up with Dr. [**Last Name (Prefixes) **] in four weeks and follow up with primary medical doctor in four weeks as well. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 43434**] MEDQUIST36 D: [**2146-1-31**] 12:17 T: [**2146-1-31**] 12:56 JOB#: [**Job Number 43435**] Admission Date: [**2146-1-27**] Discharge Date: [**2146-1-31**] Date of Birth: [**2100-6-23**] Sex: M Service: ADDENDUM: Discharge medications, Lasix 20 mg b.i.d. times seven days followed by 20 mg q day times one week. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 43436**] MEDQUIST36 D: [**2146-1-31**] 12:29 T: [**2146-1-31**] 13:07 JOB#: [**Job Number 26298**] Name: [**Known lastname 7924**], [**Known firstname 126**] Unit No: [**Numeric Identifier 7925**] Admission Date: [**2146-1-27**] Discharge Date: [**2146-2-1**] Date of Birth: [**2100-6-23**] Sex: M Service: On postoperative day four the patient continued to have low room air sats between 91 and 95%. Repeat chest x-ray was done and showed persistent left lower lobe effusion. Thoracentesis was performed on postoperative day five and drained approximately 300 cc of sanguinous material. Repeat chest x-ray showed improvement of effusion with no pneumothorax and patient was discharged on postoperative day five. DISCHARGE MEDICATIONS: Patient went home on metoprolol 50 mg p.o. b.i.d. [**Last Name (STitle) 1383**] DR.[**Last Name (Prefixes) **],[**First Name3 (LF) **] 02-351 Dictated By:[**Last Name (NamePattern1) 7926**] MEDQUIST36 D: [**2146-2-1**] 13:49 T: [**2146-2-1**] 13:02 JOB#: [**Job Number 7927**]

[ "530.81", "V45.82", "511.9", "414.01", "272.0", "401.9", "305.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "34.91", "36.15", "88.72", "39.61" ]

icd9pcs

[ [ [] ] ]

7057, 7361

3249, 5145

1743, 2501

2524, 3230

177, 1275

1297, 1521

1538, 1711

12,761

171,718

30993

Discharge summary

report

Admission Date: [**2117-6-1**] Discharge Date: [**2117-6-21**] Date of Birth: [**2063-2-15**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Flu like symtoms Major Surgical or Invasive Procedure: [**2117-6-2**] Debridement of abdominal wall and application of Wound VAC History of Present Illness: 54 year-old female who noticed a tenderness and indurated area on her abdominal wall on the [**6-22**]. This progressed to the point that her family noted a severe, foul smell coming from the patient. She presented to an area hospital where she was evaluated and found to be septic with gangrene of the anterior abdominal wall. She was then transferred emergently to the [**Hospital1 827**] where she was quickly evaluated and found to have necrotizing fasciitis of the anterior abdominal wall, for which emergent surgery would be needed. Past Medical History: Morbidly obese Osteoarthritis both knees, s/p knee surgery in past Multiple D & C's secondary to recurrent SAB's Social History: Married Family History: Noncontributory Pertinent Results: Upon admission: [**2117-6-1**] 04:08PM WBC-24.5* RBC-3.66* HGB-11.1* HCT-31.3* MCV-86 MCH-30.3 MCHC-35.4* RDW-15.4 [**2117-6-1**] 09:56AM GLUCOSE-120* UREA N-53* CREAT-0.9 SODIUM-143 POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14 [**2117-6-1**] 09:56AM CALCIUM-7.3* PHOSPHATE-3.9# MAGNESIUM-2.2 [**2117-6-1**] 09:56AM PLT COUNT-245 [**2117-6-1**] 09:56AM PT-15.1* PTT-28.7 INR(PT)-1.4* [**2117-6-1**] 11:54PM TYPE-ART PO2-160* PCO2-27* PH-7.45 TOTAL CO2-19* BASE XS--2 CHEST (PORTABLE AP) Reason: Assess fluid/disease progression [**Hospital 93**] MEDICAL CONDITION: 54 year old woman with sepsis, ARDS REASON FOR THIS EXAMINATION: Assess fluid/disease progression PORTABLE CHEST X-RAY, [**2117-6-7**]. COMPARISON: [**2117-6-5**]. INDICATION: Sepsis and ARDS. Endotracheal tube terminates about 6.5 cm above the carina, not significantly changed. Nasogastric tube continues to terminate below the diaphragm and central venous catheter remains in standard position in the superior vena cava. Cardiac and mediastinal contours are stable allowing for marked patient rotation. Previously identified diffuse areas of alveolar consolidation on radiographs of [**6-3**] and [**2117-6-4**] have markedly improved and nearly resolved. Diffuse haziness throughout the right hemithorax may be due to technical factors related to patient rotation and lack of centering, but layering right pleural effusion or diffuse hazy lung parenchymal process cannot be excluded and repeat radiograph with non-rotated position would be helpful in this regard. Cardiology Report ECHO Study Date of [**2117-6-3**] Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. OPERATIVE REPORT Date: [**2117-6-2**] PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis of the abdominal wall. POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis of the abdominal wall. PROCEDURE: Debridement of abdominal wall. ASSISTANT: [**Name8 (MD) 33863**], M.D. ANESTHESIA: General endotracheal anesthesia. IV FLUIDS: The patient required 3 liters of crystalloid during the operation. URINE OUTPUT: 200 cc. ESTIMATED BLOOD LOSS: None. INDICATIONS: This is a 54-year-old female who had a previous debridement 2 days ago for necrotizing fasciitis who is coming to the operating room today for debridement and placement of VAC dressing. PROCEDURE: After induction of the anesthesia, the patient's abdomen was prepped and draped under a sterile manner. She had Betadine soap wash and then Betadine solution on top. The patient was placed in supine position. The area was washed with the pulse irrigation and there were 2 small areas of necrosis identified under the pannus on the right side that were sharply debrided. After adequate debridement was obtained from the abdominal wall, the abdominal wall was washed with 2 liters of normal saline and it was clean. An extra large sponge was placed on the wound and it was secured with 2 large Ioban. The VAC was put under suction with no complications from this and the patient was transferred back to the intensive care unit. She tolerated this procedure well. She was intubated when she came to the operating room and was sent to the ICU intubated as well. No complications of this procedure. Brief Hospital Course: She was admitted to the Surgical Service and taken to the operating room for radical abdominal wall debridement; there were no introperative complications. She was taken back to the operating room on the following day for further debridement and application of a VAC dressing. Postoepratively she required ICU care as she remained intubated; was initially difficult to wean but was eventually extubated. She remained on enteral feedings until evaluated by Speech & Swallow. She was not found to be an apsiration risk and so her diet was advanced. She is currently tolerating a regular diet. OB/GYN were consulted for a vaginal mass noted on CT imaging. It is being recommended that she undergo further workup and pelvic ultrasound as an outpatient. Medications on Admission: Aleve PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to breast folds. 3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 5. Regular Insulin Sliding Scale Sig: One (1) dose four times a day as needed for per sliding scale: See attached sliding scale. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for cpnstipation. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Miconazole Nitrate 100 mg Suppository Sig: One (1) Vaginal HS (at bedtime) for 2 days. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Necrotizing fascitis abdominal wall Discharge Condition: Stable Discharge Instructions: Please call physician or return to ED if any of the following occur: 1. Fever >101.5 2. Increased pain not controlled with medication 3. Difficulty breathing 4. Increased drainage/redness/swelling from wound 5. Any other concerning symptoms Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] next week for wound check, please call [**Telephone/Fax (1) 600**] for an appointment. You will need to follow up with GYN following discharge from rehab for a pelvic ultraound as continuing workup of your pelvic mass. If you choose to you may follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 69**] by calling [**Telephone/Fax (1) 73251**] for an appointment. Completed by:[**2117-6-21**]

[ "250.00", "V58.67", "785.52", "401.9", "038.9", "785.4", "627.1", "728.86", "995.92", "278.01", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "54.3", "96.04", "99.04", "99.07", "33.22", "86.22" ]

icd9pcs

[ [ [] ] ]

7208, 7281

4983, 5734

330, 406

7361, 7370

1192, 1194

7659, 8148

1156, 1173

5794, 7185

1781, 1817

7302, 7340

5760, 5771

7394, 7636

274, 292

1846, 4960

434, 979

1209, 1744

1001, 1115

1131, 1140

59,922

131,251

36346

Discharge summary

report

Admission Date: [**2118-3-15**] Discharge Date: [**2118-3-19**] Date of Birth: [**2097-5-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain and Right foot pain after MVC Major Surgical or Invasive Procedure: s/p exploratory laparotomy, small bowel resection ([**2118-3-16**]) splinting of Right calcaneal fracture [**2118-3-15**] History of Present Illness: 20M s/p MVC with devascularized ileum (ripped from mesentery) and deserosalized cecum; now s/p exlap, sm bowel resxn, and primary anastamosis by Dr. [**Last Name (STitle) **]. Past Medical History: none Social History: + EtOH - social drinker + tobacco - intermittent Family History: denies Physical Exam: Afebrile, AVSS RRR no MRG CTA B/L no RRW soft, appropriately tender, non distended, wound C/D/I Right calcaneal fracture splinted, FROM Pertinent Results: Imaging: [**3-15**] Ct C spine No fracture or dislocation [**3-15**] Ct head: No acute IC process [**3-15**] Ct torso: Blood around liver , spleen, right paracolic, and pelvis; Hemoperitoneum No obvious solid organ lacs / injury Bowel bathed in fluid can r/o bowel injury although no obvious rent or pneumoperitoneum --> Perihepatic blood does not appear to be subcapsular but liver, less likely, bowel remain possible sources of this hemorrhage. [**3-15**] CT R foot: comminuted fracture of the right calcaneus which extends to the articular surface at the posterior subtalar joint. Also, equivocal lucent line through the left calcaneus, ? fracture. [**3-15**] repeat abd Ct: small-bowel wall non-enhancement and thinning with fecalization of the bowel contents within this loop is concerning for small-bowel infarction/ischemia [**3-17**] CTA: No PE. HCT: 39.5>32.7>32.8>31.3 Brief Hospital Course: Admitted on [**2118-3-15**] s/p MVC. At the time patient had films which were significant for Right calcaneal comminuted fracture which was non operative. There was also a question of Left calcaneal fracture but no clinical correlation was ascribed. Patient was seen by orthopedic surgery who splinted his Right heel and scheduled patient for outpatient follow up. Regarding his abdomen, on initial presentation he had a seat-belt sign on his lower abdomen. A CT abd/pel was perforemd on admission, but showed no acute injury, just bowel wasll thickineing and small amount of free fluid on the pelvis. Due to clinical exam, a CT was re-done 6 hours later and there was increased concern for bowel injury. Taken urgently to OR around 11 pm for exploratory laparotomy. A small amount of jejunum was ischemic and had a avulsion of its mesentery, this was resected and primarily anastomosed via jejuno-jejunostomy. He was tachypneic post operatively and a CTA of his chest showed no PE. He improved steadily and by POD 2 he had a bowel movement and was passing flatus. He was seen by physical therapy who agreed with orthopedic recommendations for home with supervision, and he understood his limitations which included non-weightbearing on the right side. He was on a CIWA scale for the duration of his admission. He was cleared for discharge home with follow up on [**2118-3-19**]. Medications on Admission: none 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ischemic small bowel Free fluid in pelvis/hemoperitoneum Comminuted fracture of the right calcaneus Discharge Condition: Good Discharge Instructions: Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from your incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Other instructions: * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. Followup Instructions: 1. Follow-up with Dr. [**Last Name (STitle) **] in [**12-3**] weeks. Call the office at [**Telephone/Fax (1) 2359**] to schedule an appointment. 2. Follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] (orthopedics) in [**12-3**] weeks. Call his office at [**Telephone/Fax (1) 1228**] to schedule an appointment.

[ "305.01", "789.59", "557.1", "863.29", "825.0", "868.03", "863.89", "E812.0" ]

icd9cm

[ [ [] ] ]

[ "45.62", "93.54", "54.11", "46.79" ]

icd9pcs

[ [ [] ] ]

3713, 3719

1881, 3274

358, 482

3863, 3870

976, 1045

4728, 5061

797, 805

3329, 3690

3740, 3842

3300, 3306

3894, 4705

820, 957

274, 320

510, 687

1054, 1858

709, 715

731, 781

82,179

195,465

48747

Discharge summary

report

Admission Date: [**2174-3-12**] Discharge Date: [**2174-3-15**] Date of Birth: [**2102-9-24**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 10593**] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: 71F history atrial fibrillation, ablation x2 with the most recent being in [**2173-11-30**], presents one week following a head injury, states she was getting out of bed, hit her head on the headboard, no loss of consciousness, no acute symptoms at that time. She says the cause of her sitting up was a nightmare which she normally has on the amiodarone she is taking. She has had persistent headache, which has gotten progressively worse, and now is a 10 / 10. Has also developed nausea but no vomiting. She denies any focal weakness, numbness, tingling. No bowel or bladder incontinence. She denies any other trauma. No changes in vision, no chest pain or shortness of breath. She denies any palpitations. INR was 6. She was given 10mg IV vitamin K x1 and seen by neurosurgery. Due to her complex medical history she was admitted to the MICU for q2hour meuro checks. Past Medical History: Atrial Fibrillation s/p cardioversion x 2 and PVI [**6-9**] Colon CA [**75**] years ago with resection (no chemo or radiation) Cataract Surgery Left Breast Cyst/Atypical Cells D & C with polypectomy TIA 7 + years ago-before on Coumadin Mild Arthritis Hypothyroidism Right thigh numbness Chronic UTI Chronic bladder prolapse Hyperlipidemia CKD (baseline Cr 1.5-1.7) Elevated LFT's Tick bite [**6-10**]; treated with antibiotics Social History: No tobacco, EtOH, or illicit drug use. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: T 97.1 HR 78 BP 151/72 O2 91% RA RR 14 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, PERRL, JVD to angle of jaw, large 15cm diameter ecchymosis over the left brow. Nother hematomas or echymoses CV: Regular rate and rhythm, normal S1 + S2, + S3 Lungs: Bibasilar crackles Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred. DISCHARGE PHYSICAL EXAM: Vitals: 98.0F, BP 127/74, HR 65, 18, 96% RA General: awake, alert, NAD HEENT: Sclera anicteric, EOMi, mucous membrane dry, Neck: supple, JVP 6-7 today, no LAD Lungs: minimal bibasilar crackles, no wheeze or rhonchi, poor inspiratory effort CV: regular, normal S1 and S2, no obvious m/r/g 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 Neuro: oriented X3, CN II-XII without focal findings. UE/LE strength 5/5, 2+ DTR in the biceps/brachioradialis, does finger-nose-finger without issue bilaterally today Pertinent Results: ADMISSION LABS [**2174-3-13**] 12:00AM GLUCOSE-145* UREA N-21* CREAT-1.2* SODIUM-137 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2174-3-13**] 12:00AM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-1.8 IRON-53 [**2174-3-13**] 12:00AM calTIBC-393 VIT B12-482 FOLATE-12.2 FERRITIN-108 TRF-302 [**2174-3-13**] 12:00AM WBC-8.1 RBC-3.79* HGB-10.4* HCT-32.1* MCV-85 MCH-27.5 MCHC-32.5 RDW-13.8 [**2174-3-13**] 12:00AM NEUTS-91.0* LYMPHS-7.4* MONOS-1.5* EOS-0 BASOS-0.1 [**2174-3-13**] 12:00AM PLT COUNT-227 [**2174-3-13**] 12:00AM PT-17.6* PTT-36.0 INR(PT)-1.7* [**2174-3-13**] 12:00AM RET AUT-1.1* [**2174-3-12**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2174-3-12**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2174-3-12**] 05:10PM GLUCOSE-130* UREA N-28* CREAT-1.5* SODIUM-135 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16 [**2174-3-12**] 05:10PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2174-3-12**] 05:10PM WBC-8.3 RBC-4.37 HGB-12.1 HCT-36.9 MCV-85 MCH-27.8 MCHC-32.8 RDW-13.8 [**2174-3-12**] 05:10PM NEUTS-80.2* LYMPHS-16.1* MONOS-3.0 EOS-0.3 BASOS-0.3 [**2174-3-12**] 05:10PM PLT COUNT-273 [**2174-3-12**] 05:10PM PT-60.0* PTT-54.0* INR(PT)-6.0* CT HEAD [**2174-3-12**]: IMPRESSION: Bilateral cerebral acute-on-chronic subdural hematoma with effacement of the suprasellar cistern. CT HEAD [**2174-3-13**]: Little change in bilateral small diffuse acute-on-chronic subdural hemorrhages with effacement of the suprasellar cistern. CXR [**2174-3-12**]: IMPRESSION: COPD without superimposed consolidation or effusion. CXR [**2174-3-12**] Heart size and mediastinum are stable. The patient is in mild interstitial pulmonary edema, unchanged since the prior examination. There is no appreciable pleural effusion or pneumothorax. EKG [**2173-3-12**]: Sinus rhythm. P-R interval prolongation. ST-T wave abnormalities. Since the previous tracing of [**2173-12-14**] ST-T wave abnormalities are more prominent. Otherwise, unchanged. EKG [**2173-3-12**]: Sinus rhythm with low amplitude P waves versus ectopic atrial rhythm. First degree A-V delay. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2174-3-12**] P wave amplitude is lower. Q-T interval is more prolonged. Clinical correlation is suggested to evaluate for electrolyte abnormality or a metabolic/toxic derangement. TTE [**2174-3-14**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Dilated aortic arch. Compared with the prior study (images reviewed) of [**2171-11-13**] the findings are similar (PFO not seen on current study as no saline contrast was used.) DISCHARGE LABS: [**2174-3-15**] 04:55AM BLOOD WBC-7.6 RBC-4.15* Hgb-11.7* Hct-35.8* MCV-86 MCH-28.3 MCHC-32.7 RDW-13.9 Plt Ct-251 [**2174-3-15**] 04:55AM BLOOD PT-11.2 PTT-28.0 INR(PT)-1.0 [**2174-3-15**] 04:55AM BLOOD Glucose-99 UreaN-22* Creat-1.5* Na-137 K-3.5 Cl-98 HCO3-29 AnGap-14 Brief Hospital Course: 71 yo F with h/o AF on warfarin, h/o colon cancer, HTN, HLD, and hypothyroidism who initially presented with headache, nausea and vomiting, and was found to have subacute SDH in the setting of supratherapeutic INR. . # Subdural hematomas. Patient presented with HA/N/V after hitting her head on the bed headboard during a nightmare. CT head on [**2174-3-12**] showed subdural hematomas, acute on chronic. INR was 6 on admission. Patient was managed in the MICU initially for frequent neuro checks, holding coumadin, reversing with FFPx2, vitamin K IV and PO, and IV NS. Repeat CT head showed stable SDH on [**2174-3-13**]. She was seen by Neurosurgery, who did not feel there indication for surgical intervention. Neurological exam remained stable and non-focal throughout. Patient was given dilantin but developed a rash; was then switched to keppra for seizure ppx. She was given dilaudid and morphine for pain, without much relief, but did have good pain relief with fiorecet. Patient was drowsy on transfer from MICU to the medicine floor, but mental status improved to AOx3 shortly thereafter. On the floor, her neurological exam remained nonfocal. She remained oriented. Patient had headache that ranged from [**2172-4-4**], worsening with movement. She had tenderness to palpation over ecchymosis on the left side of her head. Pain was controlled with standing acetaminophen 1000mg PO TID. Given stable neuro exam and the nature of these SDHs, neurosurgery felt that it was safe for her to resume coumadin 2.5 mg PO daily without a bridge. INR was 1.0 on the day of discharge. She will be discharged on coumadin 2.5 mg po daily with frequent INR checks. Her goal INR will be 2-2.5, given her A fib and her SDHs. She will follow-up with neurosurgery as an outpatient with a repeat head CT in 8 weeks, and she should continue keppra seizure ppx at least until this time. . # Hypoxia: After reversal of supratherapeutic INR in MICU with FFP and receiving IV NS, patient noted to be hypoxic with sats down to 90% on RA. She was also found to have S3, JVD, and bibasilar crackles, concerning for possible systolic HF. CXR showed vascular congestion. EKG with no evidence of ischemia. She does have h/o HTN, and no O2 requirement at home. She received lasix 10 mg IV x2 and had good urine output, returning to a euvolemic state by transfer to the floor. After this, she no longer required supplemental oxygen, and her exam findings improved. TTE was obtained, showing no evidence of systolic dysfunction, but did show LVH. She should follow-up with her cardiologist for futher evaluation as an outpatient. . # Anemia: Noted to have normocytic anemia. This was stable during the admission. Reticulocytes were 1.1. Anemia workup was unrevealing, including normal iron studies, B12, and folate. There was no evidence of active bleeding and CT head showed stability of SDHs. Please consider further workup as an outpatient if patient is persistently anemic, including appropriate cancer screenings. . # HTN: Continued amlodipine, triamterene, HCTZ. . # Afib: Patient with history of a fib and flutter s/p ablation. She was in sinus rhythm on the EKGs obtained during the admission and remained in sinus rhythm on telemetry. We continued home amiodarone. Anti-coagulation management as above under the SDH section. . # GERD: Continued omeprazole. . # HLD: Continued rosuvastatin. . # Hypothyroidism: Continued levothyroxine. . # Home safety: ICU mentioned concern for possible elder abuse, based solely on the unusual nature of her story for how she hit her head and sustained the SDH (nightmare induced by her amiodarone causing her to become alarmed at night and hit her head on the headboard of her bed). Patient was asked questions about home safety, and she had no home safety concerns. Family seemed quite supportive. Patient's primary care physician should continue to evaluate home safety concerns after discharge. Transitional Issues: -Needs follow-up with PCP, [**Name10 (NameIs) 2086**], and Neurosurgery -Will have repeat CT head in 8 weeks at time of Neurosurgery follow-up -Should remain on Keppra until Neurosurgery follow-up -Will be discharged to home with VNA and home PT -Should have INR checked [**2174-3-17**] with results sent to PCP [**Name10 (NameIs) 102461**] have LFTs checked again soon (have been chronically elevated on amiodarone and statin; now on Keppra as well). Medications on Admission: Amiodarone 200mg QD Amlodipine 10mg QD Amoxicillin 500mg TID Levothyroxine 50mcg QD Omeprazole 20mg QD Rosuvastatin 20mg QD Triamterene- HCTZ 37.5-25mg QD Warfarin 2.5mg tablet MWF, 5mg on T,Th, [**Last Name (LF) **],[**First Name3 (LF) **] Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Goal INR 2-2.5. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea/vomiting. Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnoses: Subdural hematomas Supratherapeutic INR Secondary Diagnoses: Atrial Fibrillation s/p cardioversion x 2 and PVI [**6-9**] Hypothyroidism Hyperlipidemia Hypertension Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 31926**], You were admitted to hospital for headache, nausea, and vomiting. We found that you had bleeding around the brain and an INR anticoagulation level that was very high. You initially were treated in the intensive care unit, where they reversed your anticoagulation and gave you pain medicines. Repeat head imaging showed that the bleeding around the brain was stable (not growing). Neurosurgery doctors saw [**Name5 (PTitle) **] and did not think that you needed surgery. You were transferred to the medicine floor, where you received tylenol for the headache. Because the bleeding was stable, we re-started your home coumadin. Your goal INR will be 2-2.5 after discharge. You will go home on a medicine called keppra for preventing seizures related to bleeding around the brain. You will get repeat head imaging and see the neurosurgery doctors in [**Hospital 702**] clinic. You had some shortness of breath and required oxygen in the intensive care unit. Sometimes this can be due to heart failure. You had an echocardiogram (ultrasound of the heart), which showed no evidence of heart failure. You do have a thick left ventricle, which can happen with long-term high blood pressure. Your heart showed no atrial fibrillation during the admission. We continued your home amiodarone and blood pressure medicines. You should follow-up with your outpatient cardiologist. We made the following changes to your medications: -STARTED coumadin 2.5 mg tab, take 1 tab by mouth once per day. This is for your atrial fibrillation. Your goal INR is 2-2.5. Please continue to have your INR monitored. -STARTED keppra 500 mg tab, take 1 tab by mouth two times per day. This is to prevent seizures related to bleeding around the brain. You should take this medication until you see the Neurosurgeon in follow-up. -STARTED tylenol 1 gram three times per day. This is for your headache. You should not take more than 4 g per day of tylenol, since this can hurt your liver. You can stop taking this medication in a few weeks when your headache goes away. -STARTED ondansetron 4 mg every 8 hours as needed for nausea. You should attend the appointments listed below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] G. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 3329**] *We are working on a follow up appointment for your hospitalization with your primary care physician [**Name Initial (PRE) 176**] 1 week. The office will contact you at home with an appointment. If you have not heard within 2 business days please call the office. Department: CARDIAC SERVICES When: MONDAY [**2174-5-2**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *You have also been placed on a cancellation list. The office will contact you at home if a sooner appointment becomes available. Department: RADIOLOGY When: TUESDAY [**2174-5-17**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2174-5-17**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "V10.05", "790.92", "V58.61", "272.4", "V45.72", "584.9", "244.9", "E917.7", "585.3", "530.81", "403.90", "285.9", "427.31", "852.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12460, 12523

6830, 10753

279, 285

12773, 12773

3014, 6519

15139, 16625

1707, 1725

11519, 12437

12544, 12604

11253, 11496

12924, 14354

6535, 6807

1765, 2328

12625, 12752

10774, 11227

14383, 15116

231, 241

313, 1185

12788, 12900

1207, 1635

1651, 1691

2353, 2995

55,204

198,883

35610

Discharge summary

report

Admission Date: [**2132-5-28**] Discharge Date: [**2132-7-5**] Date of Birth: [**2079-3-29**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: concern for worse decompensated liver failure, transferred to liver service from [**Location **] service Major Surgical or Invasive Procedure: Peritoneal tap [**2132-5-29**] Endoscopic ultrasound [**2132-6-2**] Diagnostic paracentesis History of Present Illness: 53 yo female with ETOH cirrhosis recently discharged from [**Hospital1 18**] with decompensated liver cirrhosis was electively admitted last night for an [**Hospital1 2963**] to evaluate a GE junction polyp. Since admission, her SBPs had been in the 80s (likely near baseline given cirrhosis), was given 10 mg IV vitamin K, and 4 units of FFP for the procedure. She also underwent a diagnostic paracentesis this afternoon which did not show any evidence of SBP. A therapeutic paracentesis was aborted when air was noted in the line, and concern for bowel perforation. A followup KUB did not show any free air. The patient did not go to [**Hospital1 2963**] because of the low BP and concern for presentation consistent with decomensated liver failure. The patient was subsequently transferred to the [**Hospital Ward Name **] to be followed by the liver service. . On the floor, the patient complains of [**2133-7-13**] abdominal pain that is diffuse in nature but worse over left side (upper/lower quadrants). Earlier it was [**3-18**]. She also describes a sensation of deeper pain radiating from middle of her abdomen towards her backside but claims this is a frequent pain complaint common to her baseline abdominal pains. She was noted to be somnolent earlier today after receiving morphine for pain. Also of note, rectal exam done showed external hemorrhoids and positive guiac noted. Past Medical History: Cirrhosis with grade I esophageal varices HTN Anxiety/depression PTSD s/p appendectomy Polyp at GE junction; not previously biopsied (planned as outpt) Social History: Patient states she quit drinking in [**2132-3-9**]. Prior to that she was drinking 4-5 drinks every day x6 years. She lives with her father and brother in [**Name (NI) 9101**], [**Hospital3 **]. She used to work as a waitress/cashier but currently she is unemployed. She denies any tobacco use or any IVDU. . Family History: Mother with Renal Cell Cancer and died at age 64. Father healthy and in his mid-80s now. No FHx of liver or gallstone disease, or autoimmune diseases. Physical Exam: VS: 97.8F, BP 104/50, HR 84, RR 16, oxygen saturation level 97% RA. GEN: jaundiced skin, somnolent female in mild distress at rest, easily arousable with verbal stimulus and A&Ox3 on questioning HEENT: NC/AT, PERRLA, +scleral icteris, CVS: S1/S2 regular, no murmurs/rubs/gallops LUNGS: Clear to auscultation bilaterally, no rales/wheezes ABDOMEN: distended, diffuse tenderness to mild palpation; most prominent at RUQ/RLQ vs. left side, hepatomegaly, no guarding and no rebound tenderness. Drain pouch over right side abdomen draining amber colored (~150cc) peritoneal fluid from tap site. EXT: 3+ edema, pitting over LEs, worse at ankles and present up to knee level b/l. NEURO:CNs [**3-20**] WNL grossly, strength of upper extremities [**5-11**] bilaterally and LE testing deferred. Light touch sensation in tact throughout. Positive Asterixis SKIN: Diffuse jaundice, small 1-3mm scabs spread over arms, torso, backside Pertinent Results: [**2132-5-28**] 08:00PM GLUCOSE-106* UREA N-21* CREAT-1.0 SODIUM-132* POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-18* ANION GAP-14 [**2132-5-28**] 08:00PM estGFR-Using this [**2132-5-28**] 08:00PM ALT(SGPT)-37 AST(SGOT)-119* ALK PHOS-269* AMYLASE-56 TOT BILI-21.1* [**2132-5-28**] 08:00PM LIPASE-35 [**2132-5-28**] 08:00PM CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-2.0 [**2132-5-28**] 08:00PM WBC-26.9* RBC-3.35* HGB-11.3* HCT-35.1* MCV-105* MCH-33.6* MCHC-32.1 RDW-15.0 [**2132-5-28**] 08:00PM PLT COUNT-167 [**2132-5-28**] 08:00PM PT-21.6* PTT-40.2* INR(PT)-2.1* [**2132-7-4**] 06:18AM BLOOD WBC-34.6* RBC-3.07* Hgb-9.8* Hct-29.1* MCV-95 MCH-32.0 MCHC-33.8 RDW-20.0* Plt Ct-183 [**2132-7-3**] 05:30AM BLOOD WBC-32.4* RBC-3.41* Hgb-10.8* Hct-32.2* MCV-94 MCH-31.7 MCHC-33.6 RDW-18.6* Plt Ct-160 [**2132-7-2**] 05:15AM BLOOD WBC-30.2* RBC-3.24* Hgb-10.3* Hct-30.0* MCV-93 MCH-31.7 MCHC-34.2 RDW-19.5* Plt Ct-140* [**2132-7-1**] 05:28AM BLOOD WBC-34.4* RBC-3.47* Hgb-11.0* Hct-31.5* MCV-91 MCH-31.5 MCHC-34.8 RDW-18.1* Plt Ct-119* [**2132-6-30**] 10:12PM BLOOD WBC-33.5* RBC-3.31* Hgb-10.6* Hct-29.7* MCV-90 MCH-32.1* MCHC-35.8* RDW-18.0* Plt Ct-115* [**2132-6-30**] 10:07AM BLOOD WBC-32.7* RBC-2.84*# Hgb-9.1* Hct-26.1* MCV-92 MCH-32.0 MCHC-34.8 RDW-18.5* Plt Ct-127* [**2132-6-30**] 04:50AM BLOOD WBC-29.5* RBC-2.26*# Hgb-7.3* Hct-20.9*# MCV-92 MCH-32.2* MCHC-34.9 RDW-18.8* Plt Ct-117* [**2132-6-29**] 06:40AM BLOOD WBC-44.9* RBC-3.08* Hgb-9.7* Hct-29.2* MCV-95 MCH-31.6 MCHC-33.3 RDW-17.7* Plt Ct-186 [**2132-6-28**] 06:15AM BLOOD WBC-49.7* RBC-3.30* Hgb-10.5* Hct-31.4* MCV-95 MCH-31.9 MCHC-33.5 RDW-17.5* Plt Ct-219 [**2132-7-4**] 06:18AM BLOOD PT-26.2* PTT-50.5* INR(PT)-2.6* [**2132-6-28**] 06:15AM BLOOD Plt Ct-219 [**2132-7-4**] 06:18AM BLOOD Glucose-106* UreaN-99* Creat-4.8* Na-140 K-5.0 Cl-99 HCO3-14* AnGap-32* [**2132-7-3**] 10:21PM BLOOD Glucose-110* UreaN-98* Creat-4.0* Na-138 K-4.8 Cl-102 HCO3-10* AnGap-31* [**2132-6-21**] 09:05AM BLOOD Glucose-102 UreaN-42* Creat-1.2* Na-134 K-4.3 Cl-99 HCO3-17* AnGap-22* [**2132-6-17**] 05:30AM BLOOD Glucose-102 UreaN-29* Creat-0.4 Na-133 K-4.2 Cl-100 HCO3-20* AnGap-17 [**2132-6-5**] 03:10PM BLOOD Glucose-136* UreaN-20 Creat-1.1 Na-141 K-2.2* Cl-109* HCO3-19* AnGap-15 [**2132-7-4**] 06:18AM BLOOD ALT-23 AST-68* LD(LDH)-384* AlkPhos-100 TotBili-41.3* [**2132-6-24**] 06:15AM BLOOD ALT-32 AST-82* AlkPhos-157* TotBili-40.3* [**2132-6-22**] 06:15AM BLOOD ALT-32 AST-108* AlkPhos-161* TotBili-42.0* [**2132-6-10**] 05:45AM BLOOD ALT-28 AST-83* AlkPhos-242* TotBili-26.8* [**2132-6-9**] 06:55AM BLOOD ALT-27 AST-87* AlkPhos-261* TotBili-27.6* [**2132-7-4**] 06:18AM BLOOD Albumin-4.7 Calcium-8.2* Phos-9.2* Mg-2.8* . CT abd/pel 1. No evidence of bowel obstruction. Fluid filled, borderline distended loops of small bowel and colon, compatible with ileus. 2. Unchanged moderate amount of simple ascites. 3. Simple cholelithiasis without acute cholecystitis. 4. Diffuse anasarca in the lower abdominal soft tissue. . . Renal U/S: 1)No hydronephrosis. 2) Right pleural effusion and intra-abdominal ascites. Brief Hospital Course: 53 yo F with ETOH cirrhosis admitted for elective [**Month/Day/Year 2963**] to evaluate polyp at GE junction who was found to have worsening baseline ascites, low BP, leukocytosis, hyponatremia and admitted for stabilization / concern for decompensated liver failure. Patient had a [**Hospital 81037**] hospital course including worsend liver failure and encephalopathy. MELD scores always in the 40s. It was determined that she went home and drank cause an acute alcoholic hepatitis on background of cirrhosis. Her LFTs never recovered. She was not a liver xplant candidate and did not respond to tx for alc hep. She fell and became completely deconditioned. She had multiple GI bleeds that we more like oozes but did drop her pressure requiring xfusions. She was noted to have leukocytosis with WBC into the 40s with no cause despited infectious workup. She was treated for VRE UTI. Hem/Onc consult and determined this to be leukomoid reaction [**3-10**] to alc hep. Also developed an ileus and tube feeds were held. Finally in the end she developed ARF thought [**3-10**] to HRS. She became anuric and there was delay in starting dialysis and family meeting were held to discuss that this was a bridge to nowwhere. She was made DNR/DNI and transferred to the ICU for worsening tachhypnia in setting of metabolic acidosis. She was made CMO by family and died on [**2132-7-5**]. Medications on Admission: 1. Thiamine HCl 100 mg PO daily 2. Multivitamin One (1) Tablet PO DAILY 3. Folic Acid 1 mg PO DAILY 4. Hydroxyzine HCl 25 mg Tablet One (1) Tablet PO Q6H (every 6 hours) as needed for pruritis. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Metoprolol Tartrate 12.5mg PO TID 8. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO TID (3 times a day). 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) packet PO once a day. 10. Lactulose 10 gram/15 mL Solution Sig: 15-30 mL PO three times a day as needed for [**3-11**] BM daily: Please take as needed to have [**3-11**] bowel movements daily. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2132-7-6**]

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icd9cm

[ [ [] ] ]

[ "45.16", "54.91", "99.04", "38.93", "99.07", "96.6", "50.13", "99.62", "38.98" ]

icd9pcs

[ [ [] ] ]

8936, 8945

6620, 8005

383, 477

8996, 9005

3531, 6597

9061, 9098

2420, 2572

8904, 8913

8966, 8975

8031, 8881

9029, 9038

2587, 3512

239, 345

505, 1898

1920, 2075

2093, 2404

63,755

111,041

31150

Discharge summary

report

Admission Date: [**2154-2-8**] Discharge Date: [**2154-2-16**] Date of Birth: [**2085-9-18**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2154-2-8**] Redo sternotomy, with Patch Repair of Pseudoaneurysm under Deep Hypothermic Circulatory Arrest History of Present Illness: This is a 65 year old male with known coronary disease, status post coronary artery bypass grafting surgery in [**2137**]. He is an active smoker and has severe COPD confirmed by PFT and recent CT scan. On a CT scan in [**2151-8-14**], there was an incidental finding of a focal aneurysmal outpouching of his ascending aorta along with a left lingula mass. Further review by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] thought it looked like a penetrating atherosclerotic plaque that had ulcerated and that it was only covered by a very thin aortic wall and thus was at risk for rupture. He underwent a stent graft repair of this in [**2151-11-14**]. Follow-up CT scan has shown an endoleak with expanding pseudoaneurysm into his aortic arch. Given his endoleak and expanding psuedoaneurysm, it has been decided to return to the operating room for repair. Past Medical History: - Pseudoaneurysm of aortic arch and endoleak - Coronary Artery Disease - COPD - Hyperlipidemia - Hypertension - Calcified aorta - New finding of Left lingula lung mass - Bilateral Pleural Effusions - Hypothyroidism - Trauma to lower extremities - Emphysema - Past Myocardial infarction [**11/2137**] - Trauma from fall with multiple broken bones - s/p coronary artery bypass grafting surgeryx5 in [**2137**] - [**Hospital3 **] Dr. [**Last Name (STitle) **] - s/p Polypectomy [**2151**] - s/p Right elbow seroma, s/p debridement and drainage - s/p Appendectomy - s/p Abdominal Aortic Aneurysm Repair [**2152-6-26**] - s/p 1. Left subclavian to left common carotid artery bypass with 8-mm PTFE graft. 2. A left common carotid to right common carotid artery bypass using 8-mm ring PTFE graft. 3. Exposure of left axillary artery. 4. Ultrasound-guided access of right common femoral artery. 5. Exposure of left common femoral artery. 6. Bilateral placement of catheter into the aorta. 7. Selective catheterization of coronary artery bypass graft. 8. Coronary angiogram. 9. Aortogram. 10.Endovascular stent graft repair of ascending thoracic pseudoaneurysm with Talent 40 x 40 x 46-mm endograft. 11.Perclose closure of right common femoral arteriotomy. - Prior Left thoracentesis Social History: Occupation: retired Lives with wife in [**Name (NI) 1411**] Race:Caucasian Tobacco:[**1-14**] cigarettes daily ETOH:[**4-18**] glasses of wine daily Family History: Brothers with CAD. One brother died of MI at age 57, another brother with CABG in early 50's. No known aneurysmal disease Physical Exam: PREOP EXAM Physical Exam Pulse: 63 SR Resp: 16 O2 sat: 96% RA B/P Right: 160/76 Left: 158/82 Height: 69" Weight: 220lb General: WDWN gentleman appearing mildly short of breath with conversation. Smells of smoke. Skin: Warm, dry, chronic lower extremity venous stasis changes. No cyanosis noted. There is some clubbing noted. Well healed sternotomy. Multiple well healed incisions on neck and supraclavicular area. HEENT: NCAT, PERRL, Sclera anicteric, OP benign, remaining upper teeth in fair repair, lower teeth absent Neck: Supple [X] Full ROM [X] No JVD Chest: Diminished breath sounds at bases left>right. Insp/Exp crackles. Delayed expiration. Heart: RRR, Nl S1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Well healed left abdominal incision Extremities: Warm [X], well-perfused [X] Trace LE Edema Varicosities: Left GSV surgically absent from open saphenectomy. Right GSV may have been disrupted below knee due to trauma. Multiple incisions along R GSV tract below knee. Thigh may be usable. Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: Trace Left: Trace PT [**Name (NI) 167**]: Trace Left: Trace Radial Right: 2 Left: 2 Carotid Bruit Right: None Left: quiet left bruit Pertinent Results: [**2154-2-8**] Intraop TEE: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with mild global free wall hypokinesis. The descending thoracic aorta is mildly dilated. The aortic valve leaflets are moderately thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is a stent in the ascending aorta beginning just outside the valve. No residual aneurysm is seen. Image quality limitation may be due to clot from the leak. Post-CPB: The patient is A-Paced, on no inotropes. EF is slightly reduced to 45-50%. RV systolic fxn remains mildly reduced. MR remains 1+ Trace AI. Aorta intact. [**2154-2-16**] 04:20AM BLOOD WBC-11.2* RBC-2.77* Hgb-8.4* Hct-26.6* MCV-96 MCH-30.3 MCHC-31.6 RDW-15.3 Plt Ct-267 [**2154-2-16**] 04:20AM BLOOD Glucose-124* UreaN-24* Creat-1.4* Na-137 K-4.2 Cl-104 HCO3-29 AnGap-8 Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent redo sternotomy repair of pseudoaneurysm involving the distal ascending aorta with bovine pericardial patch using deep hypothermic circulatory arrest. For surgical details, please see the operative note. Within 24 hours, he awoke neurologically intact and was extubated without incident. He was transfused with PRBC's to maintain a hematocrit near 30%. He remained in the CVICU for aggressive bronchial hygiene and tenuous pulmonary status with baseline COPD. He maintained stable hemodynamics and was transferred to the step down unit on postoperative day two. Physical therapy was consulted for evaluation of his strength and mobility. He became acutely confused on POD#3. This confusion was felt to be related to Ativan which was discontined and within 24-48 hrs his confusion had resolved. Also on POD#3 serous sternal drainage was noted on his sternal wound without any erythema or sternal click. He was placed on emperic antibiotic coverage. He remained afebrile with stable white blood counts and without any sign of infection. He remained in a normal sinus rhythm. He had an pleural air leak postoperatively, however chest tubes and pacing wires were removed without incident. He remained in the hospital for extended period due to continued drainage and on post-operative day eight this drainage had resolved and he was discharged with ten days of Keflex to Newbridge on the [**Hospital **] Rehabilitation Center. Medications on Admission: Crestor 40mg daily, Lisinopril 10mg daily, Synthroid 137mcg daily, Lasix 20mg daily, metoprolol tartrate 25mg daily, Aspirin 81mg daily, Ferrous sulfate 325mg twice daily, Folic acid 1mg daily, Proventil inhaler prn. 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: Two (2) Tablet PO DAILY (Daily). 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days: sternal drainage. 5. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: - Pseudoaneurysm of Aortic Arch with Endoleak, s/p repair - Coronary Artery Disease, s/p CABG [**2137**] - COPD - Hyperlipidemia - Hypertension - Calcified aorta - Hypothyroidism - Emphysema - s/p Abdominal Aortic Aneurysm Repair [**2152-6-26**] - s/p Left subclavian to left common carotid artery bypass with 8-mm PTFE graft. 2. A left common carotid to right common carotid artery bypass using 8-mm ring PTFE graft. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with 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 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**] [**Telephone/Fax (1) 170**] Date/Time:[**2154-3-11**] at 2:30 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2154-2-27**] at 3:00p [**Location (un) 620**] office Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] in [**4-18**] 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** Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2154-3-20**] 11:15 Completed by:[**2154-2-16**]

[ "459.81", "V46.2", "403.90", "272.4", "E939.4", "585.9", "278.00", "512.2", "E878.2", "292.81", "305.1", "412", "996.1", "427.31", "496", "244.9", "441.2", "440.0", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "39.49", "39.61", "39.52" ]

icd9pcs

[ [ [] ] ]

8055, 8149

5362, 6841

321, 433

8611, 8822

4297, 5339

9592, 10479

2828, 2952

7109, 8032

8170, 8590

6867, 7086

8846, 9569

2967, 4278

269, 283

461, 1345

1367, 2644

2660, 2812

74,350

120,625

10771

Discharge summary

report

Admission Date: [**2166-11-3**] Discharge Date: [**2166-11-5**] Date of Birth: [**2109-10-2**] Sex: F Service: ORTHOPAEDICS Allergies: Percocet Attending:[**First Name3 (LF) 9855**] Chief Complaint: Frozen shoulder and rotator cuff tendinitis Major Surgical or Invasive Procedure: Left shoulder arthroscopy and biceps tendon repair History of Present Illness: 57 yo female with history of DM, HTN, HLD, hypothyroidism, OSA admitted for frozen shoulder and rotator cuff tendinosis since fall in [**2165-11-14**] and is POD 0 of left shoulder arthroscopy and biceps tendon repair, admitted for pain control and somnolence. She underwent the procedure this AM, and was out of the OR by noon. A post op nerve block was attempted twice with no effect. For pain control, the patient was treated with a total of 1.6 mg of dilaudid, 2 tabs of percocet, 150mcg X2 fentanyl boluses, 25mg of benadryl and 600mg neurontin all prior to 3pm. The patient then became markedly somnolent, with a respiratory rate of 4 by 6:30pm. At that time she was evaluated by anesthesia who reported she was arousable to jaw lift, and did not feel she required narcan or intubation. No labs were sent in the PACU. By 10pm, she was breathing at a rate of [**8-24**] bpm, but still markedly somnolent. The patient is being transferred to the [**Hospital Unit Name 153**] from the PACU for pain control and somnolence. . Currently, she reports mild headache and pain at the surgical site. . REVIEW OF SYSTEMS: (+)ve: pain at the surgical site (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: -Diabetes Mellitus, type 2; on oral hypglycemics at home, last A1c 8.1% on [**2166-9-30**]. -Hypothyroidism -Bilateral thyroid nodules, followed yearly with ultrasound and stable per last ultrasound [**2166-9-5**] -Hypertension -Hyperlipidemia -seasonal allergies -GERD -OSA -chronic microcytic anemia -severe eczema -fibromyalgia, depression -left shoulder supraspinatus rotator cuff tear -ischemic colitis Social History: Recently unemployed. Does not smoke or drink. Occasional glass of wine. Married. Two children. Family History: One son - diagnosed at 21 with medullary sponge kidney, periodic hypokalemic paralysis, Another son - asthma Physical Exam: T=100.1 BP=109/85 HR=102 RR=18 O2=96% on 3L NC GENERAL: Pleasant, easily arousable, somnolent, in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Using accessory muscles to breath, prolonged expiratory phase, expiratory wheezes. ABDOMEN: mildy distended, NABS. Soft, NT, ND. No HSM EXTREMITIES: dressing changed on [**11-4**], incisions C/D/I,LUE dressing clean dry and intact, in sling, no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**11-15**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission Labs: [**2166-11-3**] 11:32PM WBC-7.7 RBC-3.33* HGB-9.8* HCT-27.9* MCV-84 MCH-29.4 MCHC-35.0 RDW-15.6* [**2166-11-3**] 11:32PM PLT COUNT-213 [**2166-11-3**] 11:32PM GLUCOSE-123* UREA N-14 CREAT-0.6 SODIUM-138 POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-20* ANION GAP-15 [**2166-11-3**] 11:32PM CALCIUM-8.1* PHOSPHATE-4.4 MAGNESIUM-1.5* [**2166-11-3**] 11:32PM TYPE-ART TEMP-37.8 PO2-70* PCO2-48* PH-7.35 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA VENT-SPONTANEOU Brief Hospital Course: 57 yo female with history of DM, HTN, HLD, hypothyroidism, OSA POD 0 of left shoulder arthroscopy and biceps tendon repair, admitted for respiratory failure. #. Respiratory Failure: Felt that her respiratory failure was secondary to overuse of narcotics and atelectasis post-op in the setting of a history of OSA. Her respiratory status improved after her sedating medications were held and she was given BiPap overnight for sleep apnea. The morning of POD 1 she was in stable condition and pain improved. She was stable for discharge to home in stable condition on medications by mouth. #. S/P left shoulder arthroscopy and biceps tendon repair: Pain not well controlled with local nerve block, however overuse of narcotics led to somnolence. She was subsequently managed with IR morphine po for pain control. #. DM: Her oral hypoglycemics were initially held and she was treated with an insulin sliding scale. #. HTN: Lisinopril initially held and was restarted on POD 1. #. Hyperlipidemia: Continued home simvastatin. #. Hypothyroidism: Continued home levothyroxine 50mcg QD, 100mcg on Mon and Wed. # OSA: The patient has not tolerated CPAP in the past, but in the setting of somnolence it was used to aid respiration. #. GERD/history of ischemic colitis: Continued on home PPI. #. FEN: Diet was advanced as tolerated #. CODE STATUS: Full confirmed with husband Medications on Admission: SORIATANE CK - 25 mg Kit - one daily ZYRTEC/loratadine (not sure if daily or prn) GLIPIZIDE 5 mg [**Hospital1 **] LEVOTHYROXINE 50 mcg daily, 100 mcg Mon and Wed LISINOPRIL 10 mg daily METFORMIN SR - 750 mg [**Hospital1 **] OMEPRAZOLE - 20 mg daily SIMVASTATIN - 20 mg Tablet qhs Ferrous Sulfate 325 mg daily EPA+DHA - (OTC) - 4 Capsule(s) by mouth [**Hospital1 **] (550 mg comb epa+dha per cap. =4400mg/d) Discharge Medications: 1. Morphine 15 mg Tablet Sig: [**11-15**] - 1 Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. APAP 325 mg Tablet Sig: 1-2 Tablets PO every 6 hours as needed as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Glipizide as taken prior to surgery Discharge Disposition: Home Discharge Diagnosis: s/p Left RTC repair respiratory desaturization secondary to narcotic use Discharge Condition: stable Discharge Instructions: please follow your discharge plan as outlined in your paperwork. Keep the incision clean and dry. Please apply a dry sterile dressing daily as needed for drainage or comfort. If you have any shortness of breath, increased redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may not bear weight on your left arm. Please resume all of the medications you took prior to your admission unless discussed with your provider. [**Name10 (NameIs) **] all medication as prescribed by your provider. [**Name10 (NameIs) 35204**] free to call our office with any questions or concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2166-11-18**] 1:30 Provider: [**First Name8 (NamePattern2) 2747**] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Date/Time:[**2166-11-18**] 12:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2166-11-17**] 9:30 Completed by:[**2166-11-4**]

[ "401.9", "327.23", "518.81", "727.61", "727.62", "311", "727.00", "726.0", "244.9", "338.18", "729.1", "250.00", "272.4" ]

icd9cm

[ [ [] ] ]

[ "83.63", "80.81", "83.88", "80.41" ]

icd9pcs

[ [ [] ] ]

6854, 6860

4083, 5478

317, 369

6977, 6986

3582, 3582

7708, 8208

2488, 2598

5938, 6831

6881, 6956

5504, 5915

7010, 7685

2613, 3563

1522, 1927

234, 279

397, 1503

3598, 4060

1949, 2358

2374, 2472

28,761

189,296

30636

Discharge summary

report

Admission Date: [**2195-1-21**] Discharge Date: [**2195-1-26**] Date of Birth: [**2131-9-5**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catherization [**2195-1-21**] Off pump coronary artery bypass graft x1 (left internal mammary artery > left anterior descending) [**2195-1-22**] History of Present Illness: 63 year old female with history of coronary artery disease, presented to cardiologist with angina and abnormal stress test. Referred for cardiac catherization. Past Medical History: Hyperlipidemia Diabetes type II, diet controlled CAD GERD Irritable bowel syndrome Depression Arthritis, s/p cervical cortisone injection this past year Remote h/o migraines Tonsillectomy Social History: She is married with two grown children. She works part time doing volunteer work. Tobacco denies ETOH rarely Family History: Father died of an MI at age 46. Her mother died of CHF at age 83. Older brother diagnosed with angina in his late 50??????s. [**Name (NI) **] brother has ??????rapid heart beat??????. Physical Exam: General no acute distress, pleasant Skin unremarkable HEENT PERRLA, EOMI Neck supple full rom Chest CTA bilat Heart RRR no M/R/G Abd soft ND, NT, +BS Ext warm well perfused no edema Varicosities bilaterally Neuro grossly [**Name (NI) 5235**] Pertinent Results: [**2195-1-25**] 09:35PM BLOOD Hct-27.9* [**2195-1-25**] 07:10AM BLOOD WBC-9.2 RBC-2.96* Hgb-9.0* Hct-26.3* MCV-89 MCH-30.5 MCHC-34.2 RDW-14.8 Plt Ct-269 [**2195-1-21**] 11:15AM BLOOD WBC-7.4 RBC-4.05* Hgb-11.7* Hct-35.9* MCV-89 MCH-29.0 MCHC-32.6 RDW-14.4 Plt Ct-356 [**2195-1-21**] 11:15AM BLOOD Neuts-67.3 Lymphs-25.3 Monos-3.2 Eos-3.5 Baso-0.7 [**2195-1-25**] 07:10AM BLOOD Plt Ct-269 [**2195-1-22**] 11:15AM BLOOD PT-13.7* PTT-28.2 INR(PT)-1.2* [**2195-1-21**] 11:15AM BLOOD Plt Ct-356 [**2195-1-21**] 11:15AM BLOOD PT-13.2 PTT-26.5 INR(PT)-1.1 [**2195-1-25**] 07:10AM BLOOD Glucose-121* UreaN-18 Creat-0.6 Na-143 K-4.3 Cl-109* HCO3-25 AnGap-13 [**2195-1-21**] 11:15AM BLOOD Glucose-113* UreaN-14 Creat-0.6 Na-138 K-4.5 Cl-103 HCO3-25 AnGap-15 [**2195-1-21**] 11:15AM BLOOD ALT-19 AST-20 CK(CPK)-57 AlkPhos-69 Amylase-32 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2195-1-25**] 07:10AM BLOOD Mg-2.2 [**2195-1-21**] 11:15AM BLOOD VitB12-289 Folate-11.9 Hapto-267* Ferritn-18 [**2195-1-21**] 11:15AM BLOOD %HbA1c-6.7* Cardiology Report ECG Study Date of [**2195-1-22**] 3:06:06 PM Sinus rhythm. Normal traciang. Compared to the previous tracing the P-R interval is normal. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 85 184 94 396/439 52 0 40 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 72646**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 72647**] (Complete) Done [**2195-1-22**] at 10:14:13 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2131-9-5**] Age (years): 63 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: OP -CABG ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.0 Test Information Date/Time: [**2195-1-22**] at 10:14 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 5741**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% [**Pager number **] - Ascending: 3.0 cm <= 3.4 cm [**Pager number **] - Descending Thoracic: 2.0 cm <= 2.5 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. [**Pager number **]: Normal ascending [**Pager number 5236**] diameter. Simple atheroma in descending [**Pager number 5236**]. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Pre-CABG: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic [**Pager number 5236**]. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Post OP-CABG x 1: Patient in SR, on no inotropes. Preserved biventricular systolic fx. No AI. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. Other parameters as pre-CAB. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2195-1-22**] 10:19 Brief Hospital Course: Underwent cardiac catherization that revealed coronary artery disease to left anterior descending artery with instent restenosis. Referred to cardiac surgery and underwent preoperative work up. On [**1-22**] she was taken to the operating room and underwent off pump coronary artery bypass graft surgery, see operative report for further details. She was transferred to the ICU for hemodynamic monitoring. In the first twenty four hours she was weaned from sedation, awoke neurologically [**Month/Year (2) 5235**], and was extubated without difficulty. On POD 1 she was started on betablockers and transferred to the post op floor. Physical therapy worked with her for strength and mobility. She continued to progress with no complications and was ready for discharge home POD 4 with services. Medications on Admission: ASA 325mg daily Atenolol 25mg daily Crestor 10mg daily Fluoxetine 40mg daily Nexium 40mg daily Plavix 75mg daily NTG SL ICAPs Isosorbide Lenexa 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. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 5. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 10. home meds you may resume your Icaps Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Coronary artery disease s/p off pump cabg Diabetes mellitus type 2 Gastric esophageal reflux disease Irritable bowel syndrome Depression Anxiety Asthma Arthritis Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Please call to schedule appointments Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**Name (NI) 72648**] in 1 week ([**Telephone/Fax (1) 8506**]) Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-15**] weeks Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2195-1-26**]

[ "V45.81", "493.90", "564.1", "300.4", "414.01", "250.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "88.53", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

8385, 8419

6310, 7112

296, 451

8625, 8632

1457, 5164

9097, 9499

994, 1180

7306, 8362

8440, 8604

7138, 7283

8656, 9074

5213, 6287

1195, 1438

246, 258

479, 640

662, 852

868, 978

27,245

139,474

32080

Discharge summary

report

Admission Date: [**2198-9-23**] Discharge Date: [**2198-9-26**] Date of Birth: [**2117-3-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: chest pain and shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization with 1 stent placed History of Present Illness: 81 yo with a history of CAD who presented to an OSH today with chest pain. The patient reports that he started to experience chest pain about three days ago associated with shortness of breath. The pain came on after he worked on an iron stove for a couple of hours. The chest pain was associated with ambulation. However this morning at about 3am he started to have chest pain at rest associated with more severe shortness of breath. He went to [**Hospital3 7569**] where he was found to be in pulmonary edema with a SBP of 80-90 and O2 Sats in the low 80s. He was given Lasx iv 10mg and was transiently on BIPAP. An EKG revealed LBBB with no prior EKG for comparison. He was started on Heparin. Initial enzymes revealed a CK of 132, Ck-MB 36 and an index of 27, trop I of 1.41. He was transferred to [**Hospital1 18**] for further management. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He endorses a cough productive of thick sputum for several weeks. He denies any abdominal pain or dysuria. 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 prior to the current event. He never had any pulmonary edema or [**Location (un) **]. . In the ED the patient was found to have a HR at 104, BP 126/86, O2SAt of 100% on NRB. He was complaining of CP [**1-20**] and Nitro gtt was continued from the OSH. However his BP was low on Nitro gtt and he was then given MOrphine and Nitro gtt was titrated off as he was chest pain free. A Plavix load of 600mg was given and Zofran was given for nausea. . He currently is chest pain free and breathing comfortably. He only complains of mild chest pain with inspiration which he has not noticed before. He denies any other complaints. Past Medical History: CAD with MI in [**2187**], pt underwent angiogram at [**Hospital1 498**] (no stent placed) s/P ICD placement in [**2193**] at [**Hospital1 **] Prostate Cancer, no intervention, "slow growing" per patient HTN h/o nephrolithiasis Gout h/o pancreatic duct obstruction Borderline Diabetes, diet controlled Social History: Social history is significant for the absence of current tobacco use. Past tobacco use over 50years ago. There is no history of alcohol abuse. Pt worked as a Firefighter and is currently still very active working with lumber. He ambulates 2 flights of stairs easily. Family History: There is no family history of premature coronary artery disease or sudden death. Father lived to [**Age over 90 **]years. Physical Exam: VS: T 98.7, BP 97/71, HR 72, RR 18, 95 O2% on 5L Gen: NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry mucous membranes Neck: Supple with JVP of 10 cm. CV: PMI laterally displaced. RR, distant heart sounds. No S4, no S3. Systolic murmur [**2-13**] over RUSB radiating into his carotids. Different more holosystolic murmur [**1-16**] over apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No wheeze, rhonchi. Crackels about 1/3 up bilaterally. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ with bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2198-9-23**] ADMISSION LABS CBC: WBC-17.1* RBC-5.07 Hgb-16.2 Hct-46.3 MCV-91 MCH-31.9 MCHC-34.9 RDW-15.0 Plt Ct-188 . COAGS: PT-13.2* PTT-126.1* INR(PT)-1.2* . CHEMISTRY: Glucose-146* UreaN-17 Creat-1.3* Na-144 K-5.1 Cl-107 HCO3-22 AnGap-20 Calcium-8.6 Phos-3.0 Mg-2.2 . CEs: [**2198-9-23**] 06:55AM BLOOD CK(CPK)-301* CK-MB-56* MB Indx-18.6* cTropnT-0.42* [**2198-9-23**] 04:00PM BLOOD CK-MB-108* MB Indx-18.3* cTropnT-1.32* [**2198-9-24**] 12:30PM BLOOD CK-MB-37* MB Indx-15.9* cTropnT-1.69* [**2198-9-25**] 04:45AM BLOOD CK-MB-20* MB Indx-11.0* cTropnT-2.10* . CHOLESTEROL PANEL: Cholest-169 Triglyc-111 HDL-45 CHOL/HD-3.8 LDLcalc-102 . DIABETES MONITORING: %HbA1c-5.9 . STUDIES: TTE [**2198-9-23**] The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) with global hypokinesis. The inferior and infero-lateral walls are thinned and akinetic. There is no ventricular septal defect. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Ischemic cardiomyopathy with severely depressed LVEF. Aortic stenosis is present but the severity cannot be determined from this study. If clinically indicated, a complete TTE is recommended to clarify the severity of AS. . [**9-24**] CARDIAC CATH: COMMENTS: 1. Selective coronary angiography of this right dominant system shows 1 vessel severe coronary artery disase. The LMCA shows mild calcifications without critical lesions. The pLAD has 90% lesion. The rest of the vessel and its branches are without obstructive disease. The LCx is a non-dominant vessel with 40% lesion in its mid-section. The RCA is a dominant vessel with 40% lesion in its mid-section. 2. Resting hemodynamic measurement shows aortic stenosis with a peak to peak gradient of 30mmHg and calculated valve area of 0.8cm2. The central aortic pressure is normal at 108/65mmHg. The left sided filling pressure is elevated with a PCWP and LVEDP of 25mmHg. There is moderate to severe pulmonary hypertension with a pulmonary artery systolic pressure of 61mmHg. The cardiac index is mildly depressed at 2.3 L/min/m2. 3. Successful stenting of the proximal LAD with a 3.0 X 18 mm MiniVision baremetal stent postdilated to 3.25 with no residual stenosis (see PTCA comments for detail). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate aortic stenosis with moderately elevated LVEDP. 3. Pulmonary hypertension. 4. Mildly depressed cardiac output. 5. Successful stenting of the proximal LAD with a bare metal stent. Brief Hospital Course: 81 yo with CAD who presents with NSTEMI and CHF. Had cath with 1VD and stenting with BMS. Hospital course discussed by problem: . # NSTEMI: Pt likely with UA initially and plaque rupture leading to NSTEMI. EKG changes improved with Heparin, Nitro, Morphine, ASA and Plavix load. Patient was then chest pain free, and intervention occurred the following morning. At cath a BMS was placed to the proximal LAD. Integrilin gtt was begun peri-procedurally and continued for 18 hours post-cath. Medical management was continued with ASA, plavix, atorvastatin, added ezetimibe (lipid panel revealed LDL not at goal) and metoprolol 12.5mg [**Hospital1 **] as tolerated. Attempt at ACE held due to CRI. Serial EKGs revelaed LBBB. . # Valve disease: ECHO with possible significant AS, however poor study. Might need preload for adequate CO. . # CHF, acute: no history of chronic CHF, but EF is severely depressed at 15-20% with evidence of ischemic cardiomyopathy. Was mildly hypervolemic following cath and diuresed well to 20mg IV lasix. Care taken not to overdiurese in setting of AS. . # Rhythm: Sinus, one run of VT, about 20 beats. Started metoprolol as above for anti-arrhythmia effects. Prior ICD in place. . # Borderline diabetes: HbA1c WNL at 5.9%. RISS prescribed prn. . # HTN: well controlled (actually borderline hypotensive) throughout this stay with addition of beta blockade and diuretic . # Leukocytosis: Likely a stress response in the setting of acute MI, as it resolved spontaneously. However to rule out infection a U/A was sent (negative), and urine culture was negative. CXR was without convincing evidence of infiltrate (volume overload). . # Chronic Renal failure: stable at baseline 1.3, GFR of 40-50. . # Gout: cont Allopurinol at renal dose . # GERD: cont Omeprazole . # FEN: cardiac, low salt diet, diabetic . # Prophylaxis: was on heparin gtt followed by sQ heparin tid, bowel regimen, PPI . # Code: full Medications on Admission: Atorvastatin 80mg Qdaily Lisinopril 10mg Qdaily Toprol XL 25mg Qdaily Allopurinol 300mg Qdaily Omeprazole 20mg Qdaily Aspirin 81mg Qdaily Vit B12 250mcg Qdaily Vit E 400 IU Qdaily Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: NSTEMI . Secondary: Aortic Stenosis Borderline DM HTN Chronic Renal Failure Gout GERD Discharge Condition: stable, improved, chest pain free Discharge Instructions: You were admitted to the hospital with chest pain and shortness of breath. You were found to have had a heart attack, and were taken to the catheterization lab, where a stent was placed into an artery that was closed off. After the blockage was opened your symptoms dramatically improved. . Please take all your medicines as prescribed. You have a new medication called Zetia, which is for high triglycerides, you should take this in addition to the Atorvastatin. Please keep all of your outpatient appointments. We have also decreased your lisinopril to 2.5 mg daily. . If you experience any symptoms that are disturbing to you, such as chest pain or shortness of breath, please call your doctor or go to the nearest ER. Followup Instructions: please follow-up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. ([**Telephone/Fax (1) 20587**]). You have an appointment for [**2198-10-3**]. 3pm. You can call for changes. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2198-10-2**]

[ "424.1", "410.71", "428.0", "414.01", "274.9", "530.81", "585.9", "428.23", "403.90", "V45.02" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.66", "36.06", "37.23", "88.56", "00.45" ]

icd9pcs

[ [ [] ] ]

10330, 10336

7340, 9268

350, 396

10475, 10511

4182, 7068

11281, 11658

3114, 3237

9499, 10307

10357, 10454

9294, 9476

7085, 7317

10535, 11258

3252, 4163

276, 312

424, 2488

2510, 2814

2830, 3098

12,268

100,674

17944

Discharge summary

report

Admission Date: [**2115-5-30**] Discharge Date: [**2115-6-4**] Date of Birth: [**2061-3-22**] Sex: F Service: ADMISSION DIAGNOSIS: Breast cancer. DISCHARGE DIAGNOSES: 1. Breast cancer. 2. Status post [**Last Name (un) 5884**] on the right, mastectomy. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman who had a recent diagnosis of right breast cancer. Core biopsy returned as invasive carcinoma. The patient had a lumpectomy and sentinel node biopsy which were negative but with positive margins. Patient went back for re-excision and again had positive margins. The patient is now consulted for a right mastectomy with [**Last Name (un) 5884**], free flap reconstruction. The patient understands all surgical alternatives, and has agreed to this decision. PAST MEDICAL HISTORY: 1. Mitral valve prolapse. 2. Status post C section. 3. Status post right breast biopsy. 4. Status post right lumpectomy with sentinel node. ALLERGIES: Penicillin and sulfa. MEDICATIONS: 1. Vitamins. 2. Calcium. 3. Antioxidant. PHYSICAL EXAMINATION ON ADMISSION: Vital signs stable, afebrile. General: Is in no acute distress. Chest was clear to auscultation bilaterally. Cardiovascular is regular, rate, and rhythm without murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended with no masses or organomegaly. Extremities are warm, noncyanotic, nonedematous x4. Neurologic is grossly intact. HOSPITAL COURSE: The patient was admitted for semielective mastectomy with [**Last Name (un) 5884**] on the right reconstruction. The patient was taken to the operating room on [**2115-5-30**], and had the procedure performed as outlined above. The patient tolerated the procedure well without complication in the postoperative course, she was immediately placed in the Intensive Care Unit for close monitoring. The patient had flap checks per protocol q 30 minutes for the first 12 to 24 hours followed by q1 hour followed by q2 hour checks. The flap seemed to be doing well, and a Doppler probe was left close to the venous outflow postoperatively. Flap was seen to be doing very well, and the patient was transferred to the floor on postoperative day #3. Subsequent to this, the patient had an unremarkable hospital stay, and the Doppler probe was removed on postoperative day #4, the patient subsequently discharged to home. DISCHARGE CONDITION: Good. DISPOSITION: Home. DIET: Adlib. MEDICATIONS: Resume all home medications. 1. Magnesium hydroxide. 2. Milk of magnesia prn. 3. Percocet 5/325 [**1-24**] q4-6h prn. 4. Colace 100 mg [**Hospital1 **]. 5. Clindamycin 300 mg q6 x7 days. 6. Enteric coated aspirin 81 mg q day. DISCHARGE INSTRUCTIONS: The patient is to followup with Dr. [**First Name (STitle) **] in his clinic within one week. No heavy lifting. Patient should return if any problems with either incision sites or any signs of cellulitis or infection. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 5745**] MEDQUIST36 D: [**2115-6-3**] 09:28 T: [**2115-6-3**] 11:56 JOB#: [**Job Number 49686**]

[ "228.09", "424.0", "174.8" ]

icd9cm

[ [ [] ] ]

[ "85.41", "85.7", "86.83" ]

icd9pcs

[ [ [] ] ]

2394, 2678

185, 271

1453, 2372

2703, 3199

148, 164

300, 796

1085, 1435

818, 1070

25,031

162,057

22606

Discharge summary

report

Admission Date: [**2181-5-11**] Discharge Date: [**2181-5-17**] Date of Birth: [**2100-3-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Lipitor Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: s/p IVC filter placement [**2181-5-11**] s/p Coronary Artery Bypass Graft x3 (Left internal Mammary > left anterior descending artery, Saphenous vein graft > Obtuse marginal, Saphenous vein graft > right coronary artery), PA thrombectomy under circulatory arrest [**2181-5-12**] s/p Cardiac Catherization [**2181-5-12**] History of Present Illness: 81 year old male with productive cough for past 2 months with increasing dyspnea on exertion. Workup revealed three vessel coronary artery disease and a pulmonary embolism. Past Medical History: Diverticulitis Hypertension Back Pain Elevated Cholesterol Left Foot Drop Cataracts COPD with acute bronchitis Vertebral fusion Social History: Retired electrical contractor Lives with nephew ETOH occasional Tobacco quit [**2171**] smoked for 50 years Family History: NC Physical Exam: Admission Vitals 144/74, 84, 22, wt 69kg Neck supple, Full ROM Chest CTA bilat Heart RRR Abd soft, NT, ND +BS Ext warm, well perfused, no varicosities Pulses +2 PT, DP, Fem, no carotid bruits Discharge Vitals 99, 106/52, SR 68, 18, 93% RA Neuro A/Ox3 nonfocal Pulm CTA Cardiac RRR Sternal inc no drainage, no erythema sternum stable Abd soft, NT, ND BM [**5-16**] Ext warm, no edema Left leg inc no erythema no drainage Pertinent Results: [**2181-5-15**] 06:45AM BLOOD WBC-10.1 RBC-2.98* Hgb-9.1* Hct-27.5* MCV-92 MCH-30.7 MCHC-33.2 RDW-13.4 Plt Ct-207 [**2181-5-11**] 07:00PM BLOOD WBC-11.2* RBC-4.77 Hgb-14.3 Hct-41.7 MCV-87 MCH-29.9 MCHC-34.2 RDW-12.9 Plt Ct-212 [**2181-5-16**] 09:25AM BLOOD PT-25.2* PTT-49.0* INR(PT)-2.5* [**2181-5-11**] 07:00PM BLOOD PT-13.4* PTT-28.8 INR(PT)-1.2* [**2181-5-11**] 07:00PM BLOOD Plt Ct-212 [**2181-5-15**] 06:45AM BLOOD Glucose-88 UreaN-23* Creat-1.3* Na-139 K-4.2 Cl-101 HCO3-29 AnGap-13 [**2181-5-13**] 03:35PM BLOOD Glucose-115* UreaN-25* Creat-1.8* K-4.6 [**2181-5-11**] 07:00PM BLOOD Glucose-129* UreaN-15 Creat-1.1 Na-137 K-4.3 Cl-101 HCO3-24 AnGap-16 [**2181-5-11**] 07:00PM BLOOD ALT-17 AST-23 LD(LDH)-205 AlkPhos-64 TotBili-0.8 [**2181-5-14**] 03:02AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.5 CHEST (PA & LAT) [**2181-5-15**] 3:05 PM FINDINGS: Compared with [**2181-5-12**], multiple tubes and catheters have been removed. A left chest tube remains in unchanged position at the base. No pneumothorax is seen. The lungs are clear. No CHF. Small bilateral effusions appear. IMPRESSION: No pneumothorax. Echocardiogram Date/Time: [**2181-5-12**] at 11:51 Test: TEE (Complete) MEASUREMENTS: Right Atrium - Four Chamber Length: *5.2 cm (nl <= 5.0 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: *0.24 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%) Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm) Aorta - Ascending: 2.8 cm (nl <= 3.4 cm) Aortic Valve - Valve Area: *2.3 cm2 (nl >= 3.0 cm2) Pulmonary Artery - Main Diameter: 2.8 cm INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]S. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. Dilated main PA. Dilated branch PA. PERICARDIUM: Small pericardial effusion. Conclusions: Pre Bypass: Left ventricular wall thicknesses and cavity size are normal. LVEF >60%. Right ventricular is mildly enlarged with normal function. The right atrium is mildly enlarged.. There are simple atheroma in the aortic arch and descending thoracic aorta. 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 main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is a large echogenic mass seen in the right main pulmonary artery about 2-3 cm distal to the branchpoint. It is visible both on TEE and epicardial echo. There is a small amount of flow around the mass. There is a small pericardial effusion. Epiaortic scan was completed at sites of crossclamp, cannulation, and proximal grafts. There was a small flat plaque on the posterior wall near the proposed site of cannulation, but otherwise the sites were clear of plaques. Post Bypass: Preserved biventricular function. LVEF >60%. There is no longer a mass in the right main pulmonary artery, although the borders appear somewhat irregular at the site of the previous mass. Flow is nonturbulent in the main and branch pulmnary arteries. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2181-5-12**] Venous Ultrasound Acute, partially occlusive thrombus involving left common femoral vein, possibly extending proximally, no thrombus identified in the superficial femoral or popliteal veins in the left. Hematology Service Addendum by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58621**], MD, PHD on [**2181-5-15**]: Attending: Asked to see this patient for a possible hypercoagulable state. Patient interviewed, examined, past hx and labs reviewed. This is an 81 yo man with a recent history of a CABG procedure during which time he was found to have a large pulmonary embolus, removed by embolectomy. He also had a left common femoral vein clot. Patient had taken coumadin in the past. Physical exam shows only rhonchi lower lung fields bilaterally, no adenopathy or organomegaly. Labs: WBC 10.8, Hgb 9, Plat 154,000, aPTT 60, INR 1.3-1.4, Creast 1.4 Impression: Cardiovascular disease with recent PE and DVT, now on coumadin. Given that he will likely need continual anticoagulation for his severe PE, I do not see the purpose of a workup for a hypercoag state at this time, as this will not change his future treatment, which is likely to be lifelong anticoagulation. Brief Hospital Course: Ms. [**Known lastname 58622**] was transferred from [**Hospital **] Hospital on [**2181-5-11**] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner. On [**2181-5-12**], he was taken to the operating room where he underwent coronary artery bypass grafting to three vessels as well as a pulmonary embolism thrombectomy given that the intraoperative echo revealed a pulmonary embolus. Please see operative report for further details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. A lower extremity ultrasound was performed which showed a left common femoral deep vein thrombosis. The vascular surgery service was consulted and IVC filter was inserted. On postoperative day one, he was weaned from sedation, awoke neurologically intact and was extubated. A Beta blocker, aspirin and a statin were resumed. The hematology service was consulted given his hypercoagulable state. It was recommended as he had already received heparin in the setting of an acute thrombus, that a hypercoagulable work-up be performed as an outpatient as results would be unreliable at this time. Likely, lifelong anticoagulation would be recommended. Heparin as a bridge to coumadin was continued for anticoagulation. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his pre-op weight. Physical therapy followed patient during entire post-op course for assistance with his strength and mobility. He continued to make steady process without any post-op complications and was discharged to rehab on post op day five. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as an outpatient. Dr. [**Last Name (STitle) 58623**] will manage his coumadin dosing once he is discharged from rehabilitation. His goal INR is 2.0-3.0 for pulmonary embolism and deep vein thrombosis. He will also need a hypercoagulable work-up with his primary care provider as an outpatient. Medications on Admission: ASA 81mg daily Atenolol 25mg daily MVI Albuterol Lasix 20mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 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. 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Take for 5 days then stop. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days: Take for five days with lasix then stop. 9. Coumadin 1 mg Tablet Sig: Take as directed for Goal INR 2.0-3.0 Tablets PO once a day: Start [**2181-5-18**]. Goal INR is 2.0-3.0 for pulmonary embolism and deep vein thrombosis. Dose accordingly. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Coronary Artery Disease s/p CABG x3 Pulmonary Embolus s/p PA thrombectomy under circulatory arrest Hypertension Elevated cholesterol COPD Left foot drop Vertebral fusion Cataracts Deep Vein Thrombosis Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. 7)Coumadin for pulmonary embolism and deep vein thrombosis. Goal INR is 2.0-3.0. Dr. [**Last Name (STitle) 58623**] will follow coumadin on discharge from rehab. Please call to arrange appointment for blood draw (PT/INR) for day after discharge from rehab. [**Telephone/Fax (1) 58624**] 8)Will need outpatient hypercoaguable workup and routine age specific cancer screening by primary care physician. Followup Instructions: Dr [**Name (NI) **] (Surgeon) in 1 month. ([**Telephone/Fax (1) 170**]) Please call for appointment. Dr [**Last Name (STitle) 58623**] (PCP) in [**1-23**] weeks for routine postoperative visit and immediately following discharge from rehab for coumadin management([**Telephone/Fax (1) 58624**]). Please call for appointment. Dr [**Last Name (STitle) 911**] (Cardiologist) in 2 weeks. Please call for appointment PT/INR goal 2.0-3.0 for pulmonary embolism - first check to be day after discharge from rehab. Dr. [**Last Name (STitle) 58623**] will monitor PT/INR once discharged from rehab. Please call office to notify planned discharge date from rehab. *Will need an outpatient hypercoaguable workup and routine age specific cancer screening with primary care physician. Completed by:[**2181-5-17**]

[ "415.19", "414.01", "496", "453.41", "401.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "38.7", "38.05", "39.61" ]

icd9pcs

[ [ [] ] ]

10124, 10195

6858, 8937

307, 630

10440, 10447

1586, 6835

11361, 12164

1126, 1130

9054, 10101

10216, 10419

8963, 9031

10471, 11338

1145, 1567

248, 269

658, 832

854, 984

1000, 1110

22,497

130,822

14299

Discharge summary

report

Admission Date: [**2133-4-5**] Discharge Date: [**2133-4-17**] Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 724**] is an 88-year-old gentleman transferred to this hospital. He had sustained a fall on the [**4-3**], and he was admitted to the [**Hospital6 **] for evaluation of syncope. He was ruled out for myocardial infarction during his admission. Two days after his fall, they noticed that his right upper extremity was weak, and they noted some alteration in mental status, where he was confused and was refusing to swallow properly and was difficult to awaken. Therefore a head CT was done, which showed a large right subdural collection with mixed new and old blood. The Neurosurgery team at [**Hospital1 69**] was [**Name (NI) 653**], and Mr. [**Known lastname 724**] was transferred to the Neurosurgical Intensive Care Unit in this hospital for burr hole vs. a craniotomy and evacuation of the left subdural hematoma. He has had no history of being on anticoagulants or anti-platelet therapy. The family gives a history of multiple falls in the recent past, and also significant orthostatic hypotension leading to many of these falls. PHYSICAL EXAMINATION: The patient is sleepy but responds to voice, and he attempts to talk in Mandarin. The pupils, left is post-surgical, and the right reacts to light. It is difficult to assess the cranial nerves as the patient was not really cooperative at this stage. He had bilateral conjunctivitis. The left arm was full strength, was [**4-5**], and the right upper extremity had no response to pain. The left lower extremity was [**4-5**], and the right lower extremity withdraws briskly to pain, but there was paucity of movement in the right lower extremity. The plantars were upgoing bilaterally. Respiratory: Air entry was equal bilaterally, with no wheeze or crepitations. Cardiac: Heart was regular rate and rhythm, heart sounds heard. PAST MEDICAL HISTORY: Significant for hypertension. ALLERGIES: No known drug allergies. MEDICATIONS: Norvasc, Meclizine. ASSESSMENT AND PLAN: This is an 88-year-old hypertensive with a left subdural hematoma and right-sided hemiparesis. The plan was to load him with Dilantin 1 gram intravenously, followed by maintenance of 100 mg three times a day, and to prepare him for surgery. HOSPITAL COURSE: Details of the surgery can be found in the operative note. He had a mini-craniotomy and the subdural was evacuated. The patient was sleepy in the immediate postoperative period. Therefore, the endotracheal tube was left in situ to assist with ventilation. He was extubated 48 hours post-surgery. At that time, the weakness of the right upper extremity had improved to a great extent, and it was about [**3-5**]+/5. The patient was transferred to the Neurosurgical floor from the Intensive Care Unit on the [**4-9**], where his vitals were stable. He was awake, alert, oriented when somebody who could speak Mandarin was with him, but he had occasional episodes of waxing and [**Doctor Last Name 688**] levels of consciousness and some agitative spells. He received aggressive chest physiotherapy, but both the bedside and the video oropharyngeal swallow study were unsuccessful, and the patient could not be fed orally. Therefore a percutaneous endoscopic gastrostomy tube was placed on the [**4-10**] by the Interventional Radiology team. Some amount of bloody aspirate was obtained from this, so therefore the tube was not used for the next 48 hours, but the patient's hematocrit remained stable, and therefore tube feeds were started and advanced to goal. During his stay in the Neurosurgical floor, he also developed a temperature to 101. A chest x-ray revealed bilateral basilar atelectasis. The sputum showed mixed oropharyngeal flora. Blood cultures were negative, and urine culture showed no growth. He was started on Levaquin 500 mg as a first dose and 250 mg by mouth once daily for the next five days. His hematocrit on the [**4-13**] was 32.8, white cells 10.7, platelets 180, INR 1.1, PT 12.8, PTT 30.1. His sodium was 137, potassium 3.8, chloride 101, bicarbonate 28, BUN 15, creatinine .7, glucose 143. Liver function tests were fine, with a total bilirubin of .5. He did not rule in for a myocardial infarction in this hospital. His Dilantin level on the [**4-7**] were 17.9, and another level is pending tomorrow. CONDITION AT DISCHARGE: Mr. [**Known lastname 724**] is awake, alert and oriented, and attempts to converse both in English and in Mandarin. His left upper extremity and lower extremity are full strength, and he moves them freely. The right upper extremity is 4+/5, and he moves it spontaneously. The right lower extremity is also full strength. The patient cannot have anything orally, as he has failed the video oropharyngeal swallow study performed yesterday. He is being transferred to a rehabilitation facility tomorrow, on the [**2133-4-17**]. Condition at discharge is stable. POST-DISCHARGE PLAN: The patient is to follow up with Dr. [**Last Name (STitle) 1327**] in three weeks' time, and a repeat head CT without contrast needs to be performed prior to his appointment with Dr. [**Last Name (STitle) 1327**]. [**First Name8 (NamePattern2) 1339**] [**Name8 (MD) **], M.D. [**MD Number(1) 1341**] Dictated By:[**Doctor Last Name 22706**] MEDQUIST36 D: [**2133-4-16**] 21:42 T: [**2133-4-17**] 00:18 JOB#: [**Job Number 42453**]

[ "518.0", "401.9", "E888.9", "852.20", "997.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "44.32", "01.31" ]

icd9pcs

[ [ [] ] ]

2369, 4430

1217, 1955

4445, 5016

127, 1194

5033, 5504

1979, 2350

8,224

130,179

44999

Discharge summary

report

Admission Date: [**2153-2-6**] Discharge Date: [**2153-2-17**] Service: MEDICINE Allergies: Clindamycin / Vancomycin Attending:[**First Name3 (LF) 5301**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: intubation History of Present Illness: The patient is a 83 yo female w/ h/o bilateral pe's, pneumonia, pulmonary hypertension and emphysema who presents with dyspnea. The patient has chronic dyspnea that has steadily worsened such that she has been breathing very heavy in the last 3 days. She has no cp, cough, pleuritic pain, or fevers with dyspnea and dyspnea is worse with activity. She only notes she may have had chills lately. With this she has felt very weak and tired lately, and the night prior to admission she felt as if she was going to collapse. Patient did not lose consciousness, and may have had some palpitations prior to this episode. In addition to the above, the patient has had decreased po intake, nausea x 1 week (and 2 episodes of non-bloody vomitius), associated with po intake. She denies abd pain, dysuria, hematuria, diarrhea (although chronically she stools ~ 3x/day). She has had no sick contacts to her knowledge either. Per the family, it seems as if the patient has many issues, that have recently escalated and they are most concerned with her recent fatigue and inablility to do activities given her sob. . In ed pt. was hypoxic and placed on nrb. She was given 40 iv lasix and 60 prednisone x 1. In ED she underwent CTA Chest, which ruled out PE. CT Abdomen showed gallbladder wall thickening, confirmed by RUQ US. Surgery was consulted to consider HIDA scan. Past Medical History: 1. s/p THR 22 years ago complicated by clot in leg 2. s/p cataract surgery 3. Back pain s/p corticosteroid injections 4. PFTs [**8-13**]- FEv1- 52; FVC- 54%, FEV1/FVC 104: restrictive ventilatory defect 5. CHF: diastolic dysfunction ef 50% 6. Emphysema (2 L home oxygen) 7. Bilateral PE's ([**Date range (1) 96188**]) 8. Multiple pna's recent in [**12-13**] 9. Pulmonary hypertension 10. Recent right arm fx Social History: pt. is from [**Country **] and lives in an independent senior facility with vna 2 x/week. Son in area very involved in her care. No smoking (now or history), etoh or drugs Family History: No heart or lung disease in family. Physical Exam: VS: T: 96.5; BP: 120/80; HR: 114; RR: 22; O2: 93-94% on 10 L FM mask. Gen: fatigued pale female, appears frail HEENT: Right surgical pupil. Left pupil ERRLA, sclera anicteric, pale conjunctiva, mm dry, no oral lesions Neck: JVD 8-10 cm. No LAD CV: Tachy no m/r/g Lungs: wheezes throughout but no crackles noted. no accessory muscle use. moving air well. Abd: NABS. soft, nt, nd Ext: 1+ pitting edema b/l to knees Neuro: non-focal, cn intact Pertinent Results: admission labs: [**2153-2-5**] 08:45PM PT-32.8* PTT-31.8 INR(PT)-3.5* [**2153-2-5**] 08:45PM PLT COUNT-193 [**2153-2-5**] 08:45PM WBC-7.8 RBC-3.57* HGB-10.8* HCT-31.7* MCV-89 MCH-30.2 MCHC-33.9 RDW-17.1* [**2153-2-5**] 08:45PM CK-MB-NotDone cTropnT-<0.01 [**2153-2-5**] 08:45PM CK(CPK)-66 [**2153-2-5**] 08:45PM GLUCOSE-126* UREA N-30* CREAT-1.2* SODIUM-134 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17 [**2153-2-5**] 08:56PM PO2-27* PCO2-34* PH-7.40 TOTAL CO2-22 BASE XS--3 [**2153-2-5**] 09:49PM TYPE-ART O2 FLOW-5 PO2-52* PCO2-23* PH-7.44 TOTAL CO2-16* BASE XS--5 INTUBATED-NOT INTUBA [**2153-2-6**] 05:50AM CK-MB-NotDone [**2153-2-6**] 05:50AM cTropnT-<0.01 [**2153-2-6**] 05:50AM LIPASE-56 [**2153-2-6**] 05:50AM ALT(SGPT)-18 AST(SGOT)-31 CK(CPK)-55 ALK PHOS-87 AMYLASE-71 TOT BILI-0.7 . results: cta: IMPRESSION: 1) No evidence of PE. 2) Persistent multifocal ground glass opacities with interval resolution of peribronchiolar patchy opacities and multifocal nodular opacities seen on the prior CT of [**2152-12-16**], suggesting a resolving infectious process. 3) Significant atherosclerotic burden of the aorta and its major tributaries, 4) Thickened gallbladder wall, with hyperenhancing gallbladder mucosa. . CxR: [**2-5**]: .Interval improvement of multifocal patchy opacities, likely consistent with resolving pneumonia . [**2-6**] US ruq: CONCLUSION: Edematous gallbladder wall without significant luminal distention and without gallstones. There was no focal tenderness directly over the gallbladder. The lack of a more distended gallbladder lumen plus the prominent hepatic veins, and the appearance of the lungs on today's CTA study suggests the gallbladder edema may be due to third spacing of fluid secondary to congestive heart failure. Clinical correlation is recommended, but in nearly all cases of acute cholecystitis, the lumen is much more distended than we see in this patient. If necessary, this could be further evaluated with a radionuclide biliary scan. . ct head [**2-11**]: IMPRESSION: No evidence of acute intracranial hemorrhage or significant change from prior study. MRI with diffusion-weighted images is more sensitive in the evaluation for acute ischemia/infarct and for vascular detail. . echo [**2153-2-12**]: Conclusions: The left atrium is normal in size. There is asymmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. The right ventricular cavity is dilated with borderline depressed right ventricular function (not full visualized). [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no Brief Hospital Course: 1. Dyspnea: The patient presented with acute on chronic dyspnea and given her history of multiple pneumonias, chills and per patient's family low temperatures the concern was for a recurrent pneumonia. Another concern originally was for COPD exacerbation. The patient was treated with azithromycin and ceftriaxone for presumed pneumonia and prednisone and nebulizers for COPD exacerbation. The pulmonary team was consulted and felt most of this was due to fluid overload so th patient was diuresed. The patient improved, but on [**2153-2-10**] she was noted to be cyanotic off oxygen so placed on 4L and became unresponsive, with junctional rhythm (AV dissociation ?). A code blue was called for unresponsiveness and hypoxia (80%). She was intubated and placed on dopamine drip due to hypotension and sent to CCU. Her course in the CCU involved being weaned off pressors and her hypotension resolved. She was extubated on [**2-12**] without any issues. She was treated with high dose steroids for her pulmonary status and also treated for presumed aspiration pneumonia with ceftriaxone and flagyl. She had a CTA that was negative for PE. She was transferred back to the floor, and at that time she was weaned off steroids and completed a 7 day course of ceftriaxone and flagyl for aspiration pneumonia. The patient improved on the floor and pulmonary felt most of her symptoms were related to her pulmonary hypertension and some fluid overload. She was started on sildenafil and diuresed. She was doing well at discharge and will continue her inhalers, sildenafil and will have close follow-up as an outpatient with pulmonary. . 2. Nausea: The patient's nausea and abdominal discomfort was attributed to her enlarged gallbladder. With diruesis this improved. Surgery saw the patient and did not see the need for a HIDA scan. Her urine was negative for infection, and with diuresis she no longer complained of nausea or pain. . 3. SVT: On tele the patient had several episodes of SVT and remained asymptomatic. The abnormal rhythm always broke without intervetion, and she was treated with a beta-blocker that helped to keep her in a normal rate. She will continue the beta-blocker as an outpatient, and should have it titrated up if her pressure can tolerate this. . 4. presyncope: The patient described presyncope, and this could have been due to a number of factors. Her vitals revealed orthostasis and with fluids she improved. She was ruled out for MI, and the only other possible cause was her SVT, which resolved with a beta-blocker. The patient felt better at discharge and will continue her beta-blocker and will work with physical therapy at rehab. . 5. Diastolic dysfunction: The patient presented with volume overload and improved with diuresis, a low sodium diet and with a beta-blocker. She should have her weight followed at discharge and if she appears overloaded may need more lasix. She will be discharged with a low dose of lasix and a beta-blocker. . 6. Bilateral PE's: The patient has a history of PE, but 2 CTA's were performed and were negative for PE. She was maintained on her coumadin and this was held for several days due to supratherapeutic INR. As an outpatient she should continue to have her INR checked and have her [**Month/Day (1) **] between [**2-10**]. She should have her coumadin adjusted accordingly. . 7. anemia: The patient's baseline hematocrit is around 30-33. While in the CCU she had a HCT drop of 4 points, but the recheck was back at her baseline. She had iron studies consistent with iron deficiency anemia but iron was held and may need to be started as an outpatient. Her hematocrit remained fairly stable during her course and should be followed as an outpatient. She never required transfusions during her course. . 8. Acute on chronic renal insufficiency: The patient was never formally diagnosed with renal insufficiency though her baseline was noted to be around~ 1.2-1.5. In the unit her creatinine increased to 1.8 and this was attributed her hypotension, as once her hypotension improved so did her creatinine. Her renal function normalized at discharge and should continue to be followed as an outpatient. . 9. leukocytosis: The patient had leukocytosis for most of her course and this was attributed to steroids. She remained on antibiotics for a possible pulmonary source and blood and urine cultures were sent. All cultures are negative to date, though some are still pending and should be followed at rehab. . 10. Steroid induced hyperglycemia: The patient required insulin while on steroids and may have some underlying diabetes. The patient will have ssi written for at rehab, but a formal diagnosis of diabetes may be immenent and should be addressed as an outpatient. Medications on Admission: 1. toprol xl 25 qd 2. albuterol 2 puffs q 6 hr prn 3. ipratroprium 2 puffs qid prn 4. timolol 0.5 % one drop right eye qd 5. coumadin 3 mg qhs 6. lisinopril 5 mg qd Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day. 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 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. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): coumadin. 5. Outpatient Lab Work Please have your INR checked in 2 days. Your [**Month/Day (3) **] is [**2-10**] 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q1-2H () as needed for wheezing. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Sildenafil 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for sbp < 100. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp <100 and hr < 55. 14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Humalog 100 unit/mL Cartridge Sig: follow ss Subcutaneous per ss. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: 1. Hypoxia 2. Pneumonia 3. CHF 4. Acute on chronic renal insufficiency 5. COPD exacerbation 6. Steroid induced hyperglycemia 7. Anemia 8. Pulmonary hypertension 9. SVT Discharge Condition: stable, tolerating medications Discharge Instructions: You were admitted for hypoxia, which was related to your fluid status and possibly an infection with a COPD exacerbation. The most likely cause though is your pulmonary hypertension. You were diuresed, treated with antibiotics, and treated with steroids. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet, to maintain fluid balance. . You also will need your INR checked 2 days after discharge to verify you are on the appropriate dose of coumadin. . You will continue all home medications, except the toprol xl. New medications include metoprolol, pantoprazole, aspirin, colace, senna, lasix and sildenafil. You will no longer take lisinopril. . Call your doctor or go to the emergency room for vomiting, worsened dizziness, fainting, new headache, chest pain or worsened shortness of breath. Followup Instructions: 1. You have a pulmonary appointment as follows: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2153-3-15**] 4:10 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2153-3-15**] 4:30 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] /DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2153-3-15**] 4:30 2. You have an appointment with your primary doctor as follows: Thursday [**2153-2-22**] at 10:45 am with Dr. [**First Name (STitle) **] #[**Telephone/Fax (1) 133**].

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icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "99.60", "00.17" ]

icd9pcs

[ [ [] ] ]

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4423

Discharge summary

report

Admission Date: [**2105-9-21**] Discharge Date: [**2105-9-30**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 19017**] is a 66yo M w/ a PMH of COPD, CAD, and hyperglycemia who presents with SOB. He was just discharged from [**Hospital1 18**] on [**2105-9-20**] after being hospitalized for 3 days with similar symptoms. He was treated for a COPD flare with PO prednisone and levofloxacin. He states he was feeling well upon discharge and was stable for several hours at home. He went to bed, but was woken up by SOB. He took several nebulizer treatments without any improvment in his symptoms. He had not yet gotten any of his prescriptions filled, so he did not take any additional antibiotics or steroids. His wife then woke up and saw that he was in respiratory distress and called EMS. He was brought to the ER for further evaluation. He notes that he did not have any chest pain, palpitations, LH, or dizziness, but did have a "sticking" sensation in his chest yesterday which is his anginal equivalent. In the ER, VS on admission were T 98.1, BP 92/53, HR 106, RR 25, sats 93% on 4L. Given IVF bolus, nebs, and abx. SBP remained in the 80s, sats varied from 100% on 2L to 93% on 4L. In total, he received ~1700cc of IVF and made 470cc of UOP. SBP remained in the 80s so pt was transferred to the ICU for further monitoring. He was also given a dose of solumedrol for COPD flare. EKG was w/o any acute changes. . ROS: ? fever (does not have a thermometer); denies chills; no URI sx; + cough productive of green sputum; + SOB as above; denies palpitations; denies n/v/d; + good PO intake; + constipation; no blood; denies dysuria, hematuria, difficulty urinating; denies LE edema or pain; + LBP with constipation Past Medical History: # COPD on 4 L O2 at home w/ BiPAP qhs - s/p multiple admissions and intubations for flares - [**3-/2105**]: FEV1 0.56(23%)and FEV1/FVC 40% # 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**]) - [**4-9**] 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 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 and step-son. His step-son is "trouble" with a history of drug use, possible drug dealing and brings guns in the house. Pt does not feel safe 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: On admission: VS - T 99.2, BP 83-101/48-49, HR 61-92, RR 27, sats 97% on 4L nc Gen: Thin male, appears older than stated age. HEENT: Sclera anicteric. PERRL, EOMI. OP clear, no exudates or CV: Difficult to hear, but RR, normal S1, S2. No murmurs appreciated. Lungs: Diffuse expiratory crackles and wheezes. Abd: Soft, NTND. + BS. No masses. No HSM. Ext: No edema, 2+ radial/DP pulses bilaterally. Neuro: AAOx3. CN II-XII grossly intact. Strength 5/5 in UE and LE bilaterally, both distally and proximally. Pertinent Results: MICRO: [**2105-9-21**] blood cx x2 pending [**2105-9-19**] sputum cx: GRAM STAIN: >25 PMNs and <10 epis; 3+ GNR, 4+ multiple organisms c/w OP flora RESPIRATORY CULTURE (Final [**2105-9-21**]): MODERATE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. 9/15/007 blood dx x2 NGTD [**2105-9-18**] [**1-8**] blood cx + CNS, [**Last Name (un) 36**] not tested . IMAGING: EKG 9/17/007: NSR, rate of 96, normal axis, normal intervals, ? rSR' in V1, V2, III (unchanged from prior), flattened T waves in precordial leads, no ST changes . CXR [**2105-9-21**]: Lungs again noted to be hyperinflated. Mild bibasilar atelectasis is identified. Cardiac and mediastinal silhouettes are stable. There is no evidence of pneumothorax, infiltrate or effusion. IMPRESSION: 1. No acute cardiopulmonary process. 2. Stable hyperinflation of the lungs. . [**2105-3-27**] PFTs: SPIROMETRY - Pre drug Actual Pred %Pred FVC 2.07 3.49 59 FEV1 0.56 2.41 23 MMF 0.18 2.72 7 FEV1/FVC 27 69 40 . ECHO [**2103-8-20**]: The left atrium is normal in size. 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. The right ventricular cavity is mildly dilated with good systolic function. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Mild right ventricular cavity enlargement with preserved global biventricular systolic function. Brief Hospital Course: COPD: Hospitalized multiple times in the past month with COPD exacerbations. He is being discharged today with follow up planned with pulmonologist on Friday [**10-2**]. He is currently on Prednisone 40 mg po qd, standing nebs, advair, and is using his BiPap at night. He has rarely been on less that 40 mg of Prednisone over the past month. For that reason, rather than prescribing a taper, he was d/c'd with plan to continue Prednisone 40 mg until he sees his pulmonologist (contact[**Name (NI) **] by email) in 2 days for instructions as to whether he is ready to taper. Additionally, he was originally in the [**Hospital Unit Name 153**] on this admission pulmonary team there suggested treatment for pseudomonas given that this was isolated in his sputum. He completed a 10 day course of Cefepime [**9-30**]. CAD: Stable. Continued ASA, statin. Verapamil restarted, lisinopril held for low-normal BP. HYPOTENSION on admission: Unclear etiology. Given elevated cell counts and BUN/Cr, likely dehydration. Responded well to IVF. HYPERLIPIDEMIA: Cont on home dose atorvastatin. . UNSAFE AT HOME/ ELDER AT RISK: Pt felt unsafe at home, afraid of his step son whom he believed to be dealing drugs. According to VNA, bullets holes seen in pt's home window. Elderly protective services were contact[**Name (NI) **] and they contact[**Name (NI) **] police. Restraining order was generated by [**Location (un) 86**] Municiple Court (I reviewed the actual document) and step son's belongings were removed from patient's home. Pts wife agreed with this. Elder risk services deemed pt safe to return home, pt felt safe. Medications on Admission: MEDS: (per d/c summary [**2105-9-20**]) Alb neb Q4h prn Ipratroprium neb Q4 prn CaCO3 500mg PO QID Trimethoprim-Sulfamethoxazole 160-800 mg PO 3X/WEEK (MO,WE,FR) Aspirin 81mg PO DAILY Pantoprazole 40mg PO Q24H Sertraline 50mg PO DAILY Finasteride 5mg PO DAILY Verapamil 240mg PO Q24H Lisinopril 5mg PO DAILY Atorvastatin 10mg PO DAILY Lactulose 30 ML PO Q8H prn Lorazepam 1mg PO BID Morphine 15mg 1-2 Tablets PO Q6h prn Levofloxacin 500mg PO Q24H ** never filled this script Prednisone 60mg PO QD - as per taper ** never filled this script Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day: Take 4 tabs per day until you see Dr. [**Last Name (STitle) 575**]. He will let you know when you can take less. Disp:*40 Tablet(s)* Refills:*0* 4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) treatment Inhalation Q2H (every 2 hours) as needed for wheezing. 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 6. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 17. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: COPD exacerbation Discharge Condition: stable, o2 sat 94% on 4Lnc Discharge Instructions: Please continue all home home medications. Be sure to take the prednisone 40 mg. You need to be sure to keep your appointment to see your lung doctor. He will tell you when you can start taking lower doses of prednisone. Call your primary care doctor or return to the ER with any concerning symptoms. Followup Instructions: You need to be sure to keep your appointment to see your lung doctor. Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2105-10-2**] 9:30 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2105-10-2**] 9:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2105-10-2**] 9:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2105-9-30**]

[ "724.2", "414.01", "600.00", "V45.61", "272.0", "401.9", "276.51", "530.81", "491.21" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9418, 9476

5469, 6396

319, 326

9538, 9567

3762, 5446

9920, 10590

3140, 3220

7688, 9395

9497, 9517

7123, 7665

9591, 9897

3235, 3235

276, 281

354, 1986

6410, 7097

2008, 2610

2627, 3123

82,184

193,116

53048

Discharge summary

report

Admission Date: [**2146-10-4**] Discharge Date: [**2146-10-13**] Date of Birth: [**2100-4-2**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 473**] Chief Complaint: abdominal pain, swelling concerning for recurrent abdominal malignancy Major Surgical or Invasive Procedure: * You underwent an exploratory laparotomy on [**2146-10-4**]. History of Present Illness: Ms. [**Known lastname 6944**] is a 46 year old woman with a history of prior rectal adenocarcinoma s/p [**Month (only) **] in [**2138**] as well as ampullary adenocarcinoma in association with a type 1 choledochal cyst s/p Whipple in [**2139**] who reported being in her usual, fairly good state of health until approximately [**Month (only) 958**] of this year at which time she noted the onset of nagging abdominal pain in her lower quadrants bilaterally. The patient reported that she lost ~5lbs as she developed early satiety initially and later noted that she proceeded to both gain back the weight as well as experience progressive abdominal distention. She was in touch with her PCP, [**Name10 (NameIs) **] and onc physicians regarding her symptoms and underwent an EGD to further evaluate these symptoms. This EGD showed varices of unclear origin (gastric or duodenal) by report. During this same time ([**6-/2146**]), Ms. [**Known lastname 6944**] additionally underwent a CT and PET scan at an OSH which were notable for an area in the superior portion of the abdomen which was concerning for malignancy. That imaging showed mild ascites with what appears to be a patent portal vein. She then underwent percutaneous sampling of the concerning lesion which reportedly revealed adenocarcinoma. Given these findings, Ms. [**Known lastname 6944**] [**Name (NI) 86765**] and was seen by Dr [**Name (NI) 468**] in [**8-/2146**] for evaluation for potential surgical interventions. Past Medical History: rectal adenocarcinoma s/p [**Month (only) **] with colostomy in [**2138**] adenocarcinoma at the ampulla of Vater in association with a type 1 choledochal s/p hepaticojejunostomy, CCY in [**2139**] GERD perineal wound drainage procedures depression Social History: Ms. [**Known lastname 6944**] [**Last Name (Titles) 22381**] worked as a substitute school teacher. She is married, with one child. She does not smoke, drinks at most 1-2 drinks per day. She denies any use of IVDU. Family History: Mother: brain cancer. Reports several family members with Gi malignancies. Physical Exam: VS: 101.2 100.2 77 90/50 16 97RA GEN: AAOx3, NAD CV: RRR, nml s1/s2, no m/r/g Resp: CTAB Abd: distended, non-typanic, non-tender, incision w/ staples intact and re-inforced with suture, scant leakage at wound site Ext: no c/c/e Pertinent Results: [**2146-10-6**] 07:00PM BLOOD WBC-5.1 RBC-2.98* Hgb-10.1* Hct-28.5* MCV-96 MCH-33.8* MCHC-35.4* RDW-14.3 Plt Ct-84* [**2146-10-4**] 10:15PM BLOOD PT-14.1* PTT-28.2 INR(PT)-1.2* [**2146-10-8**] 08:12AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-133 K-4.2 Cl-95* HCO3-33* AnGap-9 [**2146-10-5**] 03:32AM BLOOD ALT-95* AST-48* LD(LDH)-115 AlkPhos-504* TotBili-0.4 [**2146-10-8**] 08:12AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.7 Mg-2.0 [**2146-10-7**] 07:00AM BLOOD CEA-2.8 [**2146-10-7**] 07:00AM BLOOD CA [**54**]-9 -PND CT A/P [**2146-10-6**]: findings are consistent with recurrence of tumor at the choledochojejunostomy site, resulting in biliary dilation and severe narrowing of the portal vein. Sequela of portal venous hypertension are therefore likely related to this portal vein near-occlusion. Otherwise, main portal vein and hepatic veins are without filling defect to suggest thrombus. Intermediate density ascites consistent with sanguinous ascites observed at surgery, though without evidence of acute hemoperitoneum. Brief Hospital Course: Ms. [**Known lastname 6944**] was admitted to the HPB Surgical Service for an exploratory laparotomy on [**2146-10-4**] following several months of vague abdominal pain and distention as well as radiographic and biopsy proven evidence of abdominal malignancy. On [**2146-10-4**], the patient underwent an exploratory laparotomy, with was complicated by the presence of at least 2 L of bloody ascites which limited the scope and extent of the procedure. A sample of this fluid was obtained for cytology, which was later found to be negative for malignant cells. Ms. [**Known lastname 6944**] was safely extubated following the procedure but experienced laryngospasm which required protective reintubation and admission to the ICU overnight on POD#0(reader referred to the Operative Note for details). The patient was safely extubated on the morning of POD#1 without difficulties. She oxygenated well, was breathing comfortably, with a normalized ABG, and was therefore transferred to the floor. The patient remained hemodynamically stable. Neuro: The patient's pain was initially treated with a fentanyl epidural with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. She required intermittent IV Dilaudid prior dressing change. CV: The patient remained hemodynamically satble post-operatively. Of note, however, she did receive 1 1L bolus on POD#0 for low urine output, and she responded appropriately to this treatment. Ms. [**Known lastname 6944**] continued to remaine stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient experienced an episode of laryngospasm following intial extubation post-operatively on [**2146-10-4**] which required immediate protective reintubation on POD#0. Following admission to the ICU on POD#0, the patient was successfully and safely extubated on the morning of POD#1 and she was transferred to the floor. Since arrival on the floor, the patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. On POD#2 the patient's wound was noted to be expressing a significant amount of bloody ascites which was initially controlled with an appliance. Given the large amount of continued treatment, the wound was re-inforced with suture and a hepatology consult was obtained to assess for liver disease. On their recommendations a CT abdomen/pelvis was performed which noted a patent portal venous system and hepatic dilitation consistent with recurrence of malignancy. On the hepatology team's further recommendation, the patient was started on aldactone, spironolactone, and a low-sodium diet in an attempt to reduce production of ascites fluid. Ms. [**Known lastname 6944**] continued to produce varying amounts of ascites drainage from the wound throughout her hospital course. Following several days in which the patient was treated with an appliance, it was ultimately decided on POD#8 to proceed with a negative pressure dressing to better control the inferior lateral portion of the abdominal wound. This dressing worked well and effectively sealed off and controlled the flow of fluid. By the time of discharge, the wound was healing well, with scant stapline line erythema but with no warmth, evidence of purulent drainage, or tenderness on palpation. ID: The patient's white blood count and fever curves were closely monitored. Her preop WBC was 7.9 and remained normal throughout her hospitalization. The patient was noted to have low-grade fevers on POD#5, but remained asymptomatic otherwise and, as she self-defervesced, required no further work-up at that time. Ms. [**Known lastname 6944**] was noted to have low grade fevers on POD#7 in addition to some erythema around the inferior portion of the wound. The patient was otherwise asymptomatic with a normal WBC. She was given several doses of Keflex immediately following. This was subsequently discontinued on POD#8 given a significant improvement in the appearance of the pt's wound as well as a normalization of Ms. [**Known lastname 6945**] fevers. She remained stable from an ID perspective for the rest of her hospitalization, with good appearing wound s/p negative pressure dressing application. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's hematocrit was 29.6 post-operatively and remained stable throughout the remainder of her hospitalization. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile, with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: lexapro 40' prilosec Discharge Medications: 1. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-30**] Inhalation Q6H (every 6 hours) as needed for wheezing. 4. ipratropium bromide 0.02 % Solution Sig: [**1-30**] Inhalation Q6H (every 6 hours) as needed for wheezing. 5. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: allcare vna Discharge Diagnosis: * recurrent abdominal carcinoma * portal hypertension * ascites Discharge Condition: Condition: Good Mental Status: AAOx3 Ambulatory status: ambulating independently at baseline Discharge Instructions: * Please resume all regular home medications , unless specifically advised not to take a particular medication. * Please take any new medications as prescribed. * Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. * Avoid lifting weights greater than [**6-7**] lbs until you follow-up with your [**Month/Year (2) 5059**], who will instruct you further regarding activity restrictions. * Avoid driving or operating heavy machinery while taking pain medications. * Please follow-up with your [**Month/Year (2) 5059**] and Primary Care Provider (PCP) as advised. Incision Care: * Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. * Avoid swimming and baths until your follow-up appointment. * You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. * If you have staples, they will be removed at your follow-up appointment. * If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. * Call your [**Month/Year (2) 5059**] or seek medical advice if you notice increased leakage from your wound. Wound Vac: * A visiting nurse will come to your home to help you with the wound vac. * The foam packing the wound needs to be changed every 3 days. * Please contact your [**Name2 (NI) 5059**] if you notice increased drainage around the wound, redness, pain at the insicion site, or begin to have fevers or chills. * Record how much fluid is collected in the wound vac container daily. * Your [**Name2 (NI) 5059**] will determine at the post-operative check how long you will require the use of a wound vac. Followup Instructions: * Follow-up with Dr. [**Last Name (STitle) 468**] for a postoperative check. The clinic phone number is: [**Telephone/Fax (1) 2835**]. We will call you for follow-up. * Follow-up with your oncologist Dr. [**Last Name (STitle) **] [**2146-10-14**] at 10:30AM. * Be sure to have your electrolytes checked during your visit with Dr. [**Last Name (STitle) **]. * Follow-up with your Primary Care Provider (PCP) as needed following discharge. Completed by:[**2146-10-13**]

[ "273.8", "998.83", "478.75", "788.20", "V44.4", "197.6", "789.59", "195.8", "155.1", "V10.09", "E878.8", "799.02", "456.8", "311", "572.3", "530.81", "197.7", "V10.06", "276.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "03.90", "54.91", "54.11", "39.32", "96.04" ]

icd9pcs

[ [ [] ] ]

10204, 10246

3867, 9283

373, 437

10354, 10370

2814, 3844

12242, 12712

2474, 2550

9355, 10181

10267, 10333

9309, 9332

10473, 11091

11106, 12219

2565, 2795

263, 335

465, 1952

10385, 10449

1974, 2225

2241, 2458

31,999

198,085

53279

Discharge summary

report

Admission Date: [**2151-1-26**] Discharge Date: [**2151-1-29**] Service: MEDICINE Allergies: All drug allergies previously recorded have been deleted Attending:[**First Name3 (LF) 613**] Chief Complaint: SOB Major Surgical or Invasive Procedure: RIJ triple lumen catheter History of Present Illness: Mr. [**Known lastname 3175**] is an 88M with DM and CAD s/p CABG who presents with SOB. Approximately 10 days prior to admission, he developed a cough productive of yellow sputum, with some associated coryza and headache. He was prescribed an albuterol inhaler by his PCP and told to follow up if his symptoms worsen. The evening prior to admission, he developed a fever to 100.8F for which he took tylenol. He also had chills and sweats. The morning of admission, he did feel short of breath and took nitroglycerine. He had no associated chest discomfort, lightheadedness/palpitations, nausea, or vomiting. Review of systems otherwise negative for abdominal discomfort, dysuria, myalgias, arthralgias, no diarrhea or constipation. Only sick contact was wife who had some nausea/vomiting at home, no contact with children. In the ED, his vitals were T 98.2 P 70 BP 74/32 RR 16 O2 96% on room air. A central line was placed and he was given approximately 2 liters of saline as well as levofloxacin 750mg and Zosyn 4.5g empirically for pneumonia. His blood pressures improved to the 110-120's without need for any pressors. He was admitted to the [**Hospital Unit Name 153**] for management of possible sepsis. Past Medical History: 1)CAD: [**2137-10-28**]: CABG with lima to LAD, SVG to RCA-PLB, and SVG to LCX- OM1 [**2138-1-29**]: NQWMI, CHF [**2139-7-21**]: Cath: SVG to RCA occluded, patent SVG to LCX, patent LIMA to LAD. Native RCA 70%. Medical management. 2) CHF with preserved EF 55% by echo in [**11-5**] (Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) **] St practice) 3) Atrial arrhythmias/ PAF, not on anticoagulation 4) Senorineural Hearing Loss since age 5 (adept at sign language and can read lips when you speak very slowly) 5) Renal insufficiency (baseline creatinine 1.1-1.5) 6) chronic venous stasis with recurrent left leg cellulitis 7) osteoarthritis 8) Cataracts OU 9) Stable right middle lobe and diffuse nodules followed on serial CT scans. 10) Diabetes Mellitus type II: diet controlled 11) Dyslipidemia 12) BPH s/p TURP 13) DVT in distant past Social History: 40 pack-year tobacco. Quit in [**2117**]. No alcohol use. The patient lives with his wife (who is also hearing impaired) and has his son [**Name (NI) **] nearby as well. Ambulates with walker, quite functional despite PMH. Family History: Father and Mother died of MI (unknown age) Physical Exam: Vitals T 98.2 P 69 BP 151/63 RR 17 O2 96% RA General: Comfortable appearing elderly man in no acute distress HEENT: Rhinophyma, sclera white, conjunctiva pale, moist mucus membranes. Neck: JVP at ear Pulm: Lungs with bilateral crackles at bases, no dullness to percussion CV: Regular S1 S2 +S3 no murmurs Abd: Soft, +bowel sounds, nondistended, some discomfort to palpation LLQ without rigidity or guarding. Guaic negative in ED. Extrem: Warm, LLE>RLE chronic per patient's son. 2+ bilateral pitting edema of LE> Neuro: Alert, answers appropriately Derm: Hyperpigmentation of LE c/w venous stasis. Lines/tubes/drains: Foley, RIJ Pertinent Results: LABS ON ADMISSION: [**2151-1-26**] 12:20PM WBC-24.2*# RBC-4.03* HGB-13.1* HCT-37.3* MCV-93 MCH-32.4* MCHC-35.0 RDW-13.8 [**2151-1-26**] 12:20PM NEUTS-89* BANDS-5 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2151-1-26**] 12:20PM PLT SMR-NORMAL PLT COUNT-162 [**2151-1-26**] 12:20PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.9 [**2151-1-26**] 12:20PM ALT(SGPT)-21 AST(SGOT)-28 CK(CPK)-137 ALK PHOS-55 AMYLASE-39 TOT BILI-0.6 [**2151-1-26**] 12:20PM LIPASE-27 [**2151-1-26**] 12:20PM CK-MB-4 cTropnT-0.15* proBNP-[**Numeric Identifier 109652**]* [**2151-1-26**] 12:20PM GLUCOSE-169* UREA N-43* CREAT-2.0* SODIUM-139 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-19* ANION GAP-17 [**2151-1-26**] 12:29PM LACTATE-2.8* [**2151-1-26**] 02:31PM FIBRINOGE-416* [**2151-1-26**] 04:29PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2151-1-26**] 04:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG EKG Irregular 56bpm likely atrial fibrillation, left axis with LAFB, QRS 122ms, T inversions V1-V6 and III, vF which appear new in comparison to [**3-5**] EKG CXR COMPARISON: Chest radiograph of [**2150-4-22**]. SINGLE PORTABLE ERECT VIEW OF THE CHEST AT 1255 HOURS: There has been little interval change since the prior examination. Within the lungs, there is no focal consolidation, pleural effusion or pneumothorax. Pulmonary vasculature is unchanged. Cardiomegaly is stable, and median sternotomy wires and surgical clips are unchanged. There is no hilar or mediastinal lymphadenopathy. IMPRESSION: No acute cardiopulmonary process. My read - question of increased opacity left CP angle ECHOCARDIOGRAM [**2151-1-27**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-10mmHg. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis with more prominent hypokinesis of the inferior wall (LVEF = 40-45 %). Right ventricular chamber size is normal with mild global free wall hypokinesis. 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 trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: 88M whose PMH includes CAD s/p CABG, DM II, CKD, and sensorineural hearing loss, presents with cough, dyspnea, and hypotension, initially requiring MICU care. 1. Cough/Dyspnea: Fever, leukocytosis, and dyspnea suggestive of pneumonia. Although CXR not officially read as showing new infiltrate, there is increased opacity at left base, and clinical context supports community-acquired pneumonia. He was stabilized in the MICU on empiric ceftriaxone and azithromycin, and blood cultures remained negative. He was transferred to the floor on [**1-27**] and maintained normal oxygen saturation on room air. His symptoms significantly improved, and the ceftriaxone was switched to cefpodoxime the day before discharge. He will complete a total 14-day course. 2. CAD/ acute on chronic diastolic CHF/ acute systolic CHF: His exam and high proBNP were consistent with CHF, especially after aggressive volume resuscitation in the ED. He diuresed well with IV lasix in the MICU. EKG was without acute ischemic changes and cardiac enzymes were negative. Mildly elevated troponin was attributed to the CHF as well as renal insufficiency. He was transferred to the floor on [**1-27**] and was started on his outpatient lasix dose, 60mg, confirmed with his cardiologist, Dr. [**Last Name (STitle) **]. As the last TTE in our system was from [**2143**], another one was obtained on [**1-27**] and showed decreased LVEF to 40-45%. This was discussed with Dr. [**Last Name (STitle) **], who confirmed his last TTE was actually in [**2150-10-29**] and showed preserved LVEF with diastolic dysfunction. Clinic notes and echo report were faxed and placed in the patient's inpatient chart, and a summary was typed into his OMR. His newly depressed LVEF is likely in the setting of the above acute infection with early sepsis, and a follow-up echo in the outpatient setting was deferred to Dr. [**Name (NI) 80071**] discretion. He was maintained on his lisinopril, ASA, and Plavix. He was not discharged on a beta blocker for reasons explained below. 3. paroxysmal atrial fibrillation/ asymptomatic bradycardia: Mr. [**Known lastname 3175**] is not on chronic anticoagulation, and he was not on a beta-blocker on admission for unclear reasons. While in the MICU, he had been started on low-dose metoprolol as part of his CHF regimen. On the floor he had episodic bradycardia (down to 30s or 40s), usually during sleep, and upon awakening was confirmed to be asymptomatic. BP remained stable. Further review of the records faxed from Dr. [**Last Name (STitle) **] revealed he had a Holter monitor [**11-5**] which showed occasional bradycardia with pauses. His metoprolol was discontinued, and he remained asymptomatic and hemodynamically stable. If he were to become symptomatic, he knows to further discuss with his cardiologist re further mgmt (eg pacemaker). 4. Acute renal failure: Creatinine elevated from baseline ~1.4-1.6, with bland urinalysis. Suspected pre-renal etiology given BUN/Cr >20:1 with decreased forward flow in setting of decompensated CHF. Creatinine improved with diuresis, and his ace inhibitor was resumed. 5. ?Coagulopathy: INR elevated in absence of coumadin use. Given his initial presentation to the MICU with early sepsis, DIC was ruled out. He has no known chronic liver disease, and despite decompensated CHF, his LFTs were normal. Hepatitis serologies were sent and pending at the time of discharge. He had mild hypoalbuminemia so the most likely explanation is nutritional. He had no evidence of bleeding. Further evaluation was deferred to the outpatient setting. 6. BPH: Continued home finasteride and terazosin. 7. DM II: Diet controlled at home, covered with insulin sliding scale, stable. 8. chronic venous stasis: no evidence cellulitis, no acute issues 9. F/E/N: tolerated regular diet well 10. communication: with patient via sign interpreter, also with son [**Name (NI) **] daily by phone Medications on Admission: Potassium chloride 10mg PO daily Aspirin 325mg PO daily Clopidogrel 75mg PO daily Lasix 60mg PO daily Lisinopril 40mg PO daily Isosorbide dinitrate 40mg PO daily Zocor 20mg PO daily Finasteride 5mg PO daily Terazosin 5mg PO QHS Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. Disp:*60 * Refills:*0* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Isosorbide Dinitrate 40 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:*30 Tablet Sustained Release(s)* Refills:*0* 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 7. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 10. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: community-acquired pneumonia acute on chronic diastolic congestive heart failure acute systolic congestive heart failure paroxysmal atrial fibrillation asymptomatic bradycardia acute renal failure on chronic kidney disease SECONDARY: sensorineural hearing loss coronary artery disease s/p CABG [**2136**], s/p NSTEMI [**2137**], s/p DES to RCA [**2147**] dyslipidemia chronic venous stasis BPH s/p TURP Discharge Condition: Hemodynamically stable on room air, tolerating regular diet, ambulating with walker. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Cardiologist: [**Name6 (MD) 1730**] [**Name8 (MD) **], MD [**First Name (Titles) **] [**Last Name (Titles) **] St [**2151-2-4**] 1:00pm with sign interpreter Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2151-2-10**] 9:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2151-9-21**] 10:15 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2151-1-29**]

[ "414.00", "250.00", "389.10", "486", "600.00", "V12.51", "286.9", "V45.81", "428.43", "427.89", "428.0", "585.9", "038.9", "584.9", "272.4", "995.92", "459.81", "412", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11405, 11463

5968, 9891

267, 294

11911, 11998

3437, 3442

12147, 12720

2728, 2772

10169, 11382

11484, 11890

9917, 10146

12022, 12124

2787, 3418

224, 229

322, 1536

3457, 5945

1558, 2468

2484, 2712

24,656

189,064

8593

Discharge summary

report

Admission Date: [**2168-5-13**] Discharge Date: [**2168-5-18**] Date of Birth: [**2111-7-17**] Sex: M Service: ORTHOPAEDICS Allergies: Quinine Attending:[**First Name3 (LF) 3645**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: [**2168-5-13**] L4-5 pseudoarthrosis treated with L3-L5 DLIF followed by revision posterior decompression and fusion. History of Present Illness: HPI: 56 M DM with back pain PMH: Type 2 DM. ESRD [**1-5**] DM, s/p cadaveric renal Tx 10/[**2162**]. Participating in research study. h/o C.diff '[**61**] (per pt report), HTN hypercholesterolemia, GERD Obesity, h/o chronic low-grade temps (99.5), recently resolvedd, h/o right charcot foot, s/p CCY PLAN: POD1: D/c PCA, oral pain meds, Advance diet,OOB to chair if possible. Labs POD2: Advance activity as tolerated. Labs [x]HTN up to 200 SBP, Renal recs Amlodipine [ ]Renal Fellow [**Pager number 30138**] call with any quesions, electrolyte issues [ ]Xrays Standing [ ]US Transplant Kidney (hypotensive intraop with SBP in the 70's) [**3-/2788**] Past Medical History: - Type 2 DM - ESRD [**1-5**] DM, s/p cadaveric renal Tx 10/[**2162**]. Participating in research study. - h/o C.diff '[**61**] (per pt report) - HTN - hypercholesterolemia - GERD - Obesity - h/o chronic low-grade temps (99.5), recently resolved - h/o right charcot foot - s/p CCY Social History: - Patient works as a music teacher at a local school. He lives at home with his wife and his mother. - Patient denies smoking, alcohol use and other drug abuse. Family History: N/A Physical Exam: Peripheral neuropathy at the level of the Maleoli BLE INC CDI x 2 Left Psoasas improving, 4/5 strength Brief Hospital Course: The patient was admitted post op. He became hypertensive and was started on amlodipine. His blood pressure was then well controlled. He was seen by the renal team who ordered a renal ultrasound. The ultrasound showed normal flow to and from the organ with slightly increased intrarenal resistance. He was seen by PT. His incicions were clean and dry. He was discharged ot rehab in stable condition with written follow up instrucitons and precautionary guidance. Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day (). 6. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection four times a day. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Insulin 70/30 [**Hospital1 **] 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). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day (). 6. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 11. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection four times a day. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Insulin 70/30 32 units in the AM 16. Insulin 70/30 20 units in the PM Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: [**2168-5-13**] L4-5 pseudoarthrosis treated with L3-L5 DLIF followed by revision posterior decompression and fusion. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: No bending No twisting No lifting Physical Therapy: WBAT, Walking Treatments Frequency: Daily PT, [**Name (NI) 30139**] Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1352**] in 2 weeks. Follow up with your nephrologist in 2 weeks to check you blood pressure - A new medicaiton was started by your nephrology care team while you were in the hospital.

[ "250.60", "272.0", "276.1", "V58.67", "E878.1", "996.81", "530.81", "722.52", "996.49", "401.9", "V15.88", "357.2", "278.00", "584.9", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "81.06", "80.51", "84.52", "81.62", "84.51", "81.38" ]

icd9pcs

[ [ [] ] ]

4687, 4757

1730, 2199

282, 402

4919, 4919

5214, 5442

1583, 1588

3437, 4664

4778, 4898

2225, 3414

5070, 5104

1603, 1707

5122, 5136

5158, 5191

233, 244

430, 1085

4934, 5046

1107, 1388

1404, 1567

16,186

197,085

43169

Discharge summary

report

Admission Date: [**2188-8-2**] Discharge Date: [**2188-8-9**] Date of Birth: [**2123-3-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: Femoral dialysis catheter AV fistula repair Hematoma evacuation History of Present Illness: Briefly, pt is a 65 y/o M w/hx of ESRD s/p txp [**2183**] who presented with increasing lethargy and decreased POs. In the ED, he was found to be hypotensive at 80/40 and bradycardic in the high 40s-low 50s. His initial labs revealed a K of 9.2 (hemolyzed, repeat 7.5), bicarb 6, BUN 249, and creatinine 10.8 (from 140/4.9 on [**2188-7-16**]). His ABG was 7.11/24/116. His ECG showed a new LBBB but no peaked T's. For his hyperkalemia, he received insulin/glucose, calcium gluconate, 2 amps of bicarb, and kayexalate. For his hypotension he received 2 L NS and hydrocortisone 100 (given that he is on chronic prednisone). He improved to systolics in the 100s. His hospital course was c/b a right femoral artery laceration incurred during placement of HD catheter. He subsequently developed an AV fistula and groin hematoma which required transfusion of [**11-29**] units of prbcs and operative repair [**8-5**]. . Currently, he is feeling well and is anxious to get out of the hospital. He denies f/c/ns, lh/dizziness, cp, sob, n/v, abd pain, groin pain, melena, hematechezia. Past Medical History: 1. Renal tb as a child, s/p nephrectomy, then developed secondary FSGS in remaining kidney which failed, requiring transplant [**9-/2183**] (cadaveric), c/b post-op rejection, c/b BK viremia, now transplant failing and pt in midst of w/u for living related txp. 2. CAD s/p CABG [**1-22**], c/b hemothorax and DVT (R subclavian, RLE) 3. HTN 4. DM 5. GI bleed [**2-20**] duodenal ulcer 6. DVT 7. Anemia, on aranesp 8. Depression 9. Gout 10. s/p appy Social History: Lives in [**Location 2624**] with his wife. [**Name (NI) **] tobacco or EtOH Family History: noncontributory. Father died when pt was 12 years old. Physical Exam: T: 97.0 P: 48 BP: 107/34 R: 18 98% RA Gen: lethargic male, A&O, appears ill, intermittent tremor in all 4 extremities HEENT: NC, AT. Perrl, eomi, sclerae anicteric, MM dry. Neck: supple, no JVD. Lungs: decreased breath sounds at the left base, o/w CTA bilaterally. CV: bradycardic, irregular, difficult to ausculate heart sounds over breathing (pt snoring) Abd: soft, nontender, nondistended. Normoactive bowel sounds. Palpable renal graft in RLQ, nontender. Ext: no edema, good dp. AV fistula in LUE without palpable thrill but does have audible bruit. Skin: warm and dry, mild erythema over back of neck. Neuro: CN II-XII intact, strength 5/5 x4. + clonus bilaterally. Pertinent Results: 140 106 235 160 AGap=29 5.1 10 10.5 Comments: Gap Verified Notified [**Doctor First Name 11556**] @ 1050am [**2188-8-3**] Note Updated Reference Range As Of [**2188-7-18**] Verified - Consistent With Other Data CK: 916 MB: 61 MBI: 6.7 Trop-*T*: 0.62 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 7.3 Mg: 1.5 P: 12.6 [**2188-8-2**] 6:00p 140 111 240 52 AGap=27 5.7 8 10.6 Comments: Anion Gap Verified Notified [**Female First Name (un) **] [**2115**] [**2188-8-2**] Note Updated Reference Range As Of [**2188-7-18**] Ca: 7.0 [**2188-8-2**] 5:10p Color Yellow Appear Clear SpecGr 1.015 pH 5.0 Urobil Neg Bili Neg Leuk Neg Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC 0-2 Bact Mod Yeast None Epi 0-2 [**2188-8-2**] 3:53p pH 7.11 pCO2 24 pO2 116 HCO3 8 BaseXS -20 Comments: Verified Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy Type:Art Na:137 K:6.0 Glu:145 Lactate:1.4 [**2188-8-2**] 2:18p Na:137 K:7.5 Comments: Not Hemolyzed Verified [**2188-8-2**] 2:00p ADD ON, GROSSLY HEMOLYZED 132 106 249 74 AGap=29 9.2 6 10.8 D Comments: Anion Gap Verified Hemolysis Falsely Elevates K Notified [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] In The Ew [**2188-8-2**] At 3:10 Pm Note Updated Reference Range As Of [**2188-7-18**] Verified By Dilution CK: 1103 MB: 64 MBI: 5.8 Trop-*T*: 0.69 Comments: Notified Rah 1604 [**2188-8-2**] Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Mg: 1.7 P: 14.0 D ALT: 25 AP: 56 Tbili: 0.2 Alb: 3.2 AST: 66 LDH: Dbili: TProt: [**Doctor First Name **]: 232 Lip: 497 Other Blood Chemistry: Cortsol: 22.6 Normal Diurnal Pattern: 7-10am 6.2-19.4 / 4-8pm 2.3-11.9 92 4.5 9.9 125 31.9 N:82.5 L:10.3 M:5.2 E:1.4 Bas:0.5 Hypochr: 2+ Anisocy: 1+ PT: 12.6 PTT: 36.1 INR: 1.1 Comments: Note New Normal Range As Of 12 Am [**2188-5-17**] Brief Hospital Course: A/P: 65 y/o M w/ESRD s/p CRT [**9-/2183**] who initially presented [**2188-8-2**] with acute worsening in renal function and hypotension. Hospital course c/b rt femoral artery injury during HD catheter placement with subsequent hematoma and AV fisula requiring operative repair and evacuation. . 1. Acute on chronic RF: Initial insult likely multifactorial: prerenal etiology in setting of decreased po intake, ATN from hypotension, ongoing rejection. - underwent HD x1 initially with no further need for dialysis. - cont doxercalciferol for SHPTN, amphogel for hyperphosphetemia - on prednisone, tacrolimus for rejection . 2. Right femoral artery lac/AV fistula: -underwent repair of femoral artery and evacuation of hematoma by vascular surgery [**8-5**]. -good DP/PT pulses -JP drain in place -followed daily by vascular surgery . 3. Anemia - chronic and 2/2 blood loss Transfused ~14 units PRBC; Was continued on epogen, baseline in low 30s. . 4. CV: a. Ischemic: no aspirin or bb [**2-20**] bleeding -on amlodipine and hydralazine for BP control; cont atorvastatin b: Pump: EF 50-55% c. Rhythm: -holding labetolol [**2-20**] bradycardia (Wenkebach); stable BP -had NSVT which was felt [**2-20**] metabolic derangements . 5. Thrombocytopenia: Chronic, platelets usually in low 100s, likely related to long-term immunosuppressives. -decreased while in-house likely [**2-20**] dilational effect of multiple transfusions. -doubt HIT but Ab was checked . 6. FEN -renal, cardiac diet -goal even I/Os . 7. Ppx: pneumoboots, cont PPI given hx GI bleed. -bactrim ss qd given immunosuppression . 8. Comm: with patient and wife. . 9. Code: Full, confirmed w/wife (who is also HCP). Medications on Admission: Prednisone 5 mg daily Allopurinol 100 mg daily Hydralazine 75 mg po tid Protonix 40 mg daily Norvasc 5 mg [**Hospital1 **] Bactrim DS qmwf Prograf 1 mg [**Hospital1 **] Labetalol 200 mg [**Hospital1 **] Flomax Lipitor Lexapro 30 mg daily Bumex 1 mg [**Hospital1 **] Lisinopril 2.5 mg daily Hectoral 2.5 mg daily Hydrochlorothiazide 25 mg qmwf Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Escitalopram Oxalate 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO three times a day. 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Doxercalciferol 2.5 mcg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty (30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml Injection 3X/WEEK (3 times a week). 12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for constipation. Disp:*120 Tablet(s)* Refills:*0* 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 16. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day: Follow up with Dr. [**Last Name (STitle) 1860**] for further instructions. 17. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO Q MWF: Follow up with Dr. [**Last Name (STitle) 1860**] for further instructions. . 18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Acute on chronic renal failure Femoral artery laceration and AV fistula Hematoma Bradycardia Discharge Condition: Stable, decreasing drainage from JP, stable hct Discharge Instructions: You should take all medications as previously instructed with the exception of your Labetolol. This has been held because of a slow heart rate. You should wait until you see you doctor before restarting this medication. Followup Instructions: Please call Dr. [**Last Name (STitle) **] to schedule a follow-up appointment. You should call to schedule an appointment with Dr. [**Last Name (STitle) **] (surgery) in 2 weeks. [**Telephone/Fax (1) 2625**]

[ "427.89", "403.91", "E878.0", "442.3", "250.00", "285.21", "285.1", "287.4", "276.5", "584.9", "998.2", "274.9", "996.81", "V45.81", "E878.8", "998.12", "276.7" ]

icd9cm

[ [ [] ] ]

[ "39.52", "99.04", "39.31", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

8575, 8646

4750, 6430

324, 390

8783, 8833

2866, 4727

9103, 9315

2090, 2147

6823, 8552

8667, 8762

6456, 6800

8857, 9080

2162, 2847

273, 286

418, 1507

1529, 1979

1995, 2074

71,689

100,493

43726

Discharge summary

report

Admission Date: [**2181-12-10**] Discharge Date: [**2181-12-19**] Date of Birth: [**2114-3-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 1968**] is a 67 yo F with hx of stage IV pancreatic cancer with peritoneal carcinomatosis, mets to liver, and palliative abdominal port for drainage of malignant ascites, who presents with nausea and vomiting. This morning at 1AM, Pt's daughter, [**Name (NI) 7279**], called oncologist to state pt has been nauseated and having multiple episodes of bilious non-bloody vomiting throughout night. Daughter notes that she has been nauseated for several days now, since Thursday. Has not taken anything by mouth since then. No worsening abdominal pain, no fevers or chills. She has been more fatigued per her daughter and has not been getting out of bed much. She has had a recent bout with thrush and endorses some paroxyms of throat pain and occasional odynophagia but this is distinct from her newer sensation of nausea/vomiting. She has noticed a new rash recently on her legs and back, ever since using a lidocaine patch last week. This is occasionaly itchy but not painful. She did contact her oncologist who prescribed cephalexin for a possible cellulitis but she has not taken any of this. . Of note, pt had recent admission [**Date range (1) 93970**] for abdominal pain felt due to her worsening disease burden, and underwent palliative abdominal pleurex catheter placement on [**12-7**]. Has not used pleurex cath for ascites drainage yet, was shceudled to do so today. She has had an ongoing problem with severe constipation, being treated as an outpatient with magnesium citrate (last BM 2 days ago on Saturday). She has not had any further BMs or flatus since then. . In the ED, VS: 96.7 137/78 96 16 99% RA. Exam significant for mild lower abd pain b/l lower quadrants, no CVAT, 1+ bilat pitting edema. WBC returned elevated at 32 (95% neutrophils), with hyponatremia to Na 118 and non-hemolyzed K of 6.4. EKG with mild peaked T waves. She was given kayexalate, calcium, insulin, and D50. KUB was non specific without overt bowel obstruction. Abdominal CT scan showed large amount of ascites with catheter in place, pancreatic mass with liver mets, and new peritoneal infiltration, possible lymphatic involvement, with diffuse omental caking and infiltrated mesentery. Thrombosis of left portal vein also noted (stable). She was given Cipro/flagyl and started on NS 150 cc/hr via her port, and was admitted to the [**Hospital Unit Name 153**]. . Currently, she is feeling better but still has some nausea. She denies abdominal pain at the moment. . ONCOLOGIC HISTORY: - [**7-/2181**]: CT scan revealed a pancreatic and liver mass (in the setting of several years of ongoing/worsening abdominal pain) - [**2181-9-6**]: EGD with EUS-guided biopsy of pancreatic msas showed poorly-differentiated pancreatic adenocarcinoma - [**2181-9-19**]: Began palliative weekly gemcitabine (completed 3 cycles) - [**2181-11-10**]: CT scan showed progressive disease in pancreas and liver, as well as a lytic sternal lesion concerning for metastasis - [**2181-11-22**]: started on capecitabine/oxaliplatin due to progressive disease - [**11-16**] - decision made to hold further chemotherapy to maximize [**Hospital 93971**] hospice discussion initiated with palliative care Past Medical History: ONCOLOGIC HISTORY: - [**7-/2181**]: CT scan revealed a pancreatic and liver mass (in the setting of several years of ongoing/worsening abdominal pain) - [**2181-9-6**]: EGD with EUS-guided biopsy of pancreatic msas showed poorly-differentiated pancreatic adenocarcinoma - [**2181-9-19**]: Began palliative weekly gemcitabine (completed 3 cycles) - [**2181-11-10**]: CT scan showed progressive disease in pancreas and liver, as well as a lytic sternal lesion concerning for metastasis - [**2181-11-22**]: started on capecitabine/oxaliplatin due to progressive disease - [**11-16**] - decision made to hold further chemotherapy to maximize [**Hospital 93971**] hospice discussion initiated with palliative care OTHER PAST MEDICAL HISTORY: 1. Status post oophorectomy. 2. Prior blood clot in her fingers for which she was on aspirin. 3. Hypothyroidism. 4. Pulmonary emboli, diagnosed on [**2181-11-10**] for which she is on Lovenox. 5. Metastatic pancreatic cancer Social History: SOCIAL HISTORY: Retured administrative assistant; lives with husband; former smoker Family History: FAMILY HISTORY: Father died of cardiovascular disease; mother died of a stroke; no known history of malignancy Physical Exam: Physical Exam on Admission: VITAL SIGNS: T= 96.3 BP= 109/69 HR= 96 RR= 16 O2= 98% RA GENERAL: chroniciallt ill appearing, cachectic. NAD HEENT: Normocephalic, atraumatic. + conjunctival pallor. No scleral icterus. PERRLA/EOMI. MM quite dry. OP without evidence of thrush. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: slightly distended with pleurex catheter in place in LUQ. BS decreased throughout. + TTP in b/l lower quadrant, no perioneal signs. EXTREMITIES: 2+ peripheral edema, dopplerable dorsalis pedis b/l SKIN: mottled appearance to flanks and lower back with few discrete erythematous macules on anterior thighs. NEURO: A&Ox3. Appropriate. Limited exam grossly intact. Gait assessment deferred . Physical exam on discharge: expired Pertinent Results: Labs on Admission: [**2181-12-10**] 03:40AM BLOOD WBC-32.1*# RBC-4.31 Hgb-13.8 Hct-39.9 MCV-93 MCH-32.1* MCHC-34.6 RDW-18.1* Plt Ct-380 [**2181-12-10**] 03:40AM BLOOD Neuts-95.1* Lymphs-1.6* Monos-3.0 Eos-0 Baso-0.2 [**2181-12-10**] 03:40AM BLOOD Plt Ct-380 [**2181-12-10**] 03:40AM BLOOD PT-12.4 PTT-35.1* INR(PT)-1.0 [**2181-12-10**] 03:40AM BLOOD Glucose-98 UreaN-60* Creat-1.4* Na-114* K-7.6* Cl-83* HCO3-26 AnGap-13 [**2181-12-10**] 03:40AM BLOOD ALT-23 AST-39 AlkPhos-212* TotBili-0.5 [**2181-12-10**] 10:35AM BLOOD Calcium-9.1 Phos-4.5 Mg-3.1* [**2181-12-11**] 05:18AM BLOOD Cortsol-45.1* [**2181-12-10**] 04:56AM BLOOD Lactate-2.2* Na-118* K-6.4* EKG ([**2181-12-10**]): Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing there is no significant change. KUB ([**2181-12-10**]): IMPRESSION: Non-obstructive bowel gas pattern. Left nephrolithiasis. CT a/p ([**2181-12-10**]): IMPRESSION: 1. New large volume ascites. Catheter in place for peritoneal drainage. 2. Large pancreatic mass. Liver metastasis. 3. New areas of peritoneal thickening along the left hemi-diaphragm, infiltration of the mesentery, and diffuse omental cake suggesting peritoneal carcinomatosis. Small bowel wall thickening, probably due to peritoneal tumor involvement. 4. Partial thrombosis of left portal vein, also seen on prior scan. CXR ([**2181-12-10**]): IMPRESSION: No pneumonia. Pathology of Peritoneal fluid [**2181-12-11**]: Positive for malignant cells, consistent with poorly differentiated carcinoma with necrosis. Brief Hospital Course: [**Hospital Unit Name 13533**] [**Date range (1) 93972**]: 67F with stage 4 pancreatic cancer now p/w 4 days of nausea and vomiting, inabaility to tolerate po, and fatigue, found to have hyponatremia, hyerkalemia, and ARF. Each of the problems addressed during this hospitalization are described in detail below. Nausea and vomiting - most likely etiology was believed to be profound ileus from meds, carcinomatosis, vs incomplete SBO vs. extrinsic compresison of mass into UGI tract. Despite recent thrush, it did not appear to be a primary esophageal cause. Other DDx includes peritonitis, primary or secondary, esp given recent catheter placement and elevated WBC count. Has been deemed an unacceptable risk for surgical palliation. The patient was on sips/ clear liquids. Symptomatic control was provided with ondansetron, compazine, ativan. Reglan was added with symptomatic improvement. Pain control was achieved with prn dilaudid and fentanyl patch. 2 liters of Peritoneal fluid was drained and showed 2750 WBCs, 73% polys. The patient was initially started on Cipro/Flagyl/Ceftriaxone for bacterial peritonitis, but was switched to 2g daily Ceftriaxone for treatment of SBP and Cipro/Flagyl were discontinued. Peritoneal fluid Gram stain revealed 4+ PMNs, peritoneal fluid culture is pending at the time of callout from [**Hospital Unit Name 153**]. Urine culture was negative. Blood cultures are pending at this time. IR was called to evaluate the Pleurex catheter. Stage IV Pancreatic Cancer - has been on palliative chemo with recent decision to move towards hospice care as an outpatient. The patient was seen by her oncologist Dr. [**Last Name (STitle) **] during her stay in [**Hospital Unit Name 153**]. Therapeutic drainage of ascites for comfort was performed for comfort (on schedule M, W, F). 2 liters were taken off on [**2181-12-12**]. Hyperkalemia - K 5.5 on admission. The patient received calcium, kayexylate, insulin/D50 in ED. There were no EKG changes. Hyperkalemia resolved by the time of callout from [**Hospital Unit Name 153**]. Hyponatremia - The patient with chronic hyponatremia (Was 129 on d/c on [**11-29**]). Exaceration was believed to be due to a combination of hypovolemia given n/v, ketonuria, urine SG, and ARF as well as siADH. There were no evidence of MS changes or seizure activity. Urine lytes were initially consistent with the picture of hypovolemia. The patient was started on normal saline IVF, sodium levels were monitored q6 hours, with the goal to increase Na levels by 0.5 mEq/hr. By day 2, urine sodium leveled off beween values of 117 and 123 and was not changing with IVF. Urine lytes were conistent with a picture of siADH. Free water restriction was initiated, but salt tablets and other agents for siADH were not given, as the numbers were stable, and the correction during this hospitalization would not affect long term management of this condition. ARF - On admission Cr. 1.4 from a baseline 1.0. Prerenal etiology based on urine lytes. Resolved to baseline with IVF. We renally dosed all medications. Constipation: The patient was started on [**Hospital1 **] standing colace and senna. We also daily miralax and [**Hospital1 **] lactulose. The patient got enemas (Fleet and tap water) and had a bowel movement. h/o PE: The patient received Lovenox, which was renally dosed. Rash - The patient was noted to have fine macular rash on admission of unclear etiology. The rash improved on its own. Hypothyroid: The patient was not able to tolerate PO levothyroxine, and stated that she no longer wants to see this medication. Depression: The patient was not taking PO Citalopram as she was not able to tolerate PO meds. FEN: The patient was able to tolerate sips of water, ice chips. Her diet was not advanced as of callout from [**Hospital Unit Name 153**]. . . . . Pt was called out of [**Hospital Unit Name 153**] on [**2181-12-12**] and transferred to the OMED service. She continued to refuse most PO medications. On [**2181-12-13**], she was made comfort measures only with input from palliative care. All medications were stopped except PPI [**Hospital1 **] as it improved her nausea, enemas for constipation and dialudid. Her vitals and daily were not checked. She had therapeutic paracentesis when her belly was distended and uncomfortable. She was transitioned to a dilaudid drip titrated to comfort. Mrs. [**Known lastname 1968**] passed away on [**2181-12-19**] with her family present. Medications on Admission: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 4. Polyethylene Glycol 3350 17 gram/dose Powder PO DAILY prn 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 9. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours).( if this is at 125mcg/hr??) 10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous every twelve (12) hours. (? if 70 mg) 11. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 12. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO daily 13. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Stage IV pancreatic cancer Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "197.6", "789.51", "253.6", "157.9", "157.1", "276.7", "584.9", "197.2", "244.9", "996.69", "567.29", "197.7", "787.01", "782.1", "789.59", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "54.99" ]

icd9pcs

[ [ [] ] ]

12694, 12703

7266, 11760

332, 338

12773, 12782

5700, 5705

12838, 12848

4681, 4779

12665, 12671

12724, 12752

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4794, 4808

5672, 5681

277, 294

366, 3558

5720, 7243

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4579, 4649

30,019

128,420

43068

Discharge summary

report

Admission Date: [**2176-11-3**] Discharge Date: [**2176-11-6**] Date of Birth: [**2099-7-3**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Hcl Attending:[**First Name3 (LF) 613**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 77 yo [**First Name3 (LF) 8230**]-speaking female w/ a h/o ESRD [**1-5**] IgA nephropathy on HD and recent admission for LGIB [**1-5**] rectal ulcerations who presents with recurrent BRBPR. History obtained with the aid of patient's daughter who acts as an interpreter. Of note, patient was last admitted [**Date range (1) 92896**] for BRBPR x 3 days. According to the daughter, patient received blood transfusions during her last admission although there is no record of blood transfusion in POE or OMR. Regardless, at that time, pt presented with a Hct of 41 which fell to a nadir on 32 over the course of her admission. She was prepped for colonoscopy with Golytely and was found to have ulceration and erythema in the rectum, grade 3 internal hemorrhoids, diverticuli, and polyps in transverse colon(removed) and rectum. Bleeding was presumed secondary to ulcerations. Biopsies were taken granulomatous tissue but no viral inclusions or evidence of malignancy. . Patient had no further episodes of hematochezia until the morning of presentation. At 2 am, patient had an episode of BRBPR. At the time she was otherwise asymptomatic. She continued to have episodes of BRBPR overnight for a total of [**2-4**] BMs. She was brought to the ED this am and had another bowel movement with BRB w/ clots. She has not had another BM since ~8 am this morning. In the ED she complained of lightheadedness but was otherwise without complaint. On presentation, T 98.6, BP 117/69, HR 118, RR 18, O2 98% RA. Soon after presentation, her BP dropped from SBPs in 110s to 70s. She received 500 cc NS bolus w/ SBP increase to 120s and HR decrease to 90s. Hct checked and was 30.5 down from 32.2. Patient admitted to the MICU for closer monitoring. . Upon arrival to the MICU, patient remains hemodynamically stable. No further bleeding. Patient denies any chest pain, shortness of breath, abdominal pain, fevers, chills, lightheadedness. She does note a mild dry cough over the last week. Past Medical History: Chronic Kidney Disease [**1-5**] IgA Nephropathy AV-Fistula placed on [**2176-2-2**] urinary retention, seen by urology yesterday and foley dc'd Anemia of Chronic Kidney disease on Aranesp Benign Hypertension Social History: She lives alone [**Location (un) 32048**] in [**Location (un) 86**]. Her daughters live nearby. She walks with a walker. She is independent with ADLs. Family History: Daughter with kidney problems. Physical Exam: VS: T: 97.8 BP: 139/62 HR: 88 RR: 19 O2 98% 3LNC Gen: Pleasant, well appearing, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. CV: RRR. nl S1, S2. No MRG CHEST: lungs CTAB. R sided HD line NT w/o exudate or erythema. ABD: NABS. Soft, NT, ND. RECTAL: gross blood in rectal vault in ED EXT: WWP. 1+ edema. 1+ DP pulses BL SKIN: No rashes/lesions, ecchymoses. NEURO: A+Ox3. CN 2-12 grossly intact. Moving all extremities Pertinent Results: Admission labs: [**2176-11-3**] 09:15AM WBC-4.1 RBC-3.32* HGB-8.9* HCT-30.5* MCV-92 MCH-26.7* MCHC-29.1* RDW-20.7* [**2176-11-3**] 09:15AM NEUTS-63.3 LYMPHS-31.1 MONOS-4.3 EOS-1.2 BASOS-0.1 [**2176-11-3**] 09:15AM PLT COUNT-180 [**2176-11-3**] 02:35PM HCT-24.4* [**2176-11-3**] 09:57PM HCT-35.7*# [**2176-11-3**] 09:15AM GLUCOSE-139* UREA N-10 CREAT-3.4*# SODIUM-136 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-30 ANION GAP-15 [**2176-11-3**] 09:15AM PT-14.2* PTT-35.0 INR(PT)-1.3* . Discharge labs: [**2176-11-6**] 05:15AM BLOOD WBC-3.3* RBC-3.38* Hgb-9.4* Hct-30.5* MCV-90 MCH-27.9 MCHC-31.0 RDW-19.7* Plt Ct-123* [**2176-11-5**] 05:05AM BLOOD Glucose-80 UreaN-27* Creat-5.7*# Na-138 K-4.3 Cl-100 HCO3-28 AnGap-14 [**2176-11-5**] 05:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.6 . Studies: CHEST (PORTABLE AP) [**2176-11-3**] IMPRESSION: No acute cardiopulmonary process. . ECG Study Date of [**2176-11-3**] Sinus rhythm. Left atrial abnormality. Minimal junctional depression in leads V3 and V6. Compared to the previous tracing of [**2176-10-27**] junctional depressions have appeared. . Colonoscopy [**2176-11-4**] Impression: 1. Grade 1 internal hemorrhoids 2. Diverticulosis of the sigmoid colon 3. Normal mucosa in the colon 4. Otherwise normal colonoscopy to cecum Brief Hospital Course: 77 yo female w/ a h/o ESRD [**1-5**] IgA nephropathy on HD and recent admission for LGIB [**1-5**] rectal ulcerations presents with recurrent hematochezia. . 1. Hematochezia: Last episode was on [**11-4**] AM. This was suspected to be [**1-5**] diverticulosis after her colonscopy. She had no further episodes of BRBPR. After 2 units of PRBCs on admission, her HCT remained stable at ~30 for >72 hours prior to discharge. She was discharged on a bowel regimen. . 2. Acute blood loss anemia: This is from LGIB. She was transfused 2 units of PRBCs on admission. Her HCT stabilized at 30. . 3. Chronic kidney disease, stage V: This is secondary to IgA nephropathy. She was continued on HD. She was continued on sevelamer and started on nephrocaps. . 4. Hypertension: Her outpatient Toprol XL was initially held given her GIB. This was restarted prior to discharge. Medications on Admission: Toprol XL 50 mg daily Nephrocaps 1 cap daily Sevelamer 800 mg tid w/ meals Senna 8.6 mg Tablet [**Hospital1 **] prn Docusate Sodium 100 mg [**Hospital1 **] Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Sevelamer 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. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Hematochezia Diverticulosis Chronic kidney disease, stage V . Secondary: Anemia of Chronic Kidney Disease Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted for bleeding from your rectum. This has stopped. You had a colonoscopy that did not show any active bleeding. The bleeding was probably due to diverticulosis. . Please continue to take your medications as prescribed. Please take your stool softeners and laxatives (Docusate sodium, Senna, Bisacodyl) to help prevent this from happening again. . If you develop further bleeding from the rectum, abdominal pain, or any concerning symptoms, please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 8236**] or go to the Emergency Department. Followup Instructions: Please keep the following appointments: Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2177-2-19**] 11:15 . Please also follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks. An appointment has been made for you on [**11-20**], [**2175**] at 1 PM. The clinic number is [**Telephone/Fax (1) 8236**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "585.5", "583.9", "562.12", "285.21", "V12.72", "403.11", "455.0", "285.1", "V45.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6137, 6143

4548, 5428

282, 296

6315, 6324

3245, 3245

6998, 7539

2715, 2747

5634, 6114

6164, 6294

5454, 5611

6348, 6975

3752, 4525

2762, 3226

237, 244

324, 2298

3261, 3736

2320, 2530

2546, 2699

10,624

199,059

17094

Discharge summary

report

Admission Date: [**2143-1-2**] Discharge Date: [**2143-1-6**] Date of Birth: [**2093-4-16**] Sex: M Service: MEDICINE Allergies: Pseudoephedrine / Sulfa (Sulfonamides) / Ativan Attending:[**First Name3 (LF) 425**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p pericardial drain History of Present Illness: 49 year old male with CLL, followed by Dr. [**First Name (STitle) 1557**], s/p matched sibling donor allo-[**First Name (STitle) 3242**] in [**2-16**] discharged on [**2142-12-30**] after presenting with nausea, chills, tachypnea, hypoxia, and tachycardia after being given platelet transfusion and IVIG, thought to be CHF exacerbation. He was diuresed and breathing greatly improved. Patient denies orthopnea and states he only gets short of breath with activity, which is also limited by his lack of strength. The patient was also recently admitted from [**2142-11-28**] to [**2142-12-26**] for resistant HSV c/b CHF exacerbation. During that admission he was started on captopril and BB. Echo in [**8-20**] with EF 50-55% and in [**9-19**] with EF 20-25%. Patient was seen by cardiologist (Dr. [**First Name (STitle) 437**] in [**10-20**] and it was thought that cardiomyopathy was probably related to chemotherapy (?from campath/alemtuzumab) vs viral. In [**11-19**] showed EF 20% and moderate pericardial effusion without tamponade. He had appointment with Dr. [**First Name (STitle) 437**] today and Echo was done showing large pericardial effusion with early signs of tamponade. Patient had pericardial drain placed by cardiology. Past Medical History: Oncologic history: CLL, diagnosed in [**2137**] Treated with fludarabine then relapsed allo-[**Year (4 digits) 3242**] from his brother in [**2-16**] c/b grade I skin and hepatic GVHD, and febrile neutropenia. In [**7-19**] his CLL relapsed and he underwent DLI in [**9-18**] and [**10-19**]. in [**7-20**] his WBC rose and he developed lyphadenopathy. It was decided to start campath. He has suffered from oral lesions, and has been on famvir. -HTN -Klebsiella sepsis -C. Diff -2nd degree, Mobitz I, heart block. -s/p inguinal hernia repair -Cardiomyopathy: Moderate pericardial effusion and markedly reduced EF (20%) noted on echo in [**9-19**], presumed viral vs. chemotherapy induced. Followed by cardiology. Social History: Married to a nurse, with 3 sons. Worked as a software engineer and math teacher. No tobacco or etoh Family History: NC Physical Exam: T 97.3 HR 115 bp 106/79 RR 24 100% 2L n.c. pulsus 4 Gen: AOx3, lying flat, NAD HEENT: Mucous membranes slightly dry CV: S1, S2 (+) S3, S4, tachycardic, no murmurs appreciated Pulm: CTA-anteriorly Abd: (+) BS, soft, ND/NT right groin: dsg c/d/i, no hematoma or bruit Ext: WWP, 2+ DP pulses b/l Pertinent Results: EKG: Sinus tachy 120, Nl axis, nl intervals, non-specific T wave flattening in I, aVL, II, III, aVF, TWIs V5. . Echo [**2143-1-2**]: EF 10-15%. Nl LA. Mod dilated LV cavity. Severe global LV HK. Nl RV size, but function appears depressed. Trace AR. Trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **] sys pressure. Large circumferential pericardial effusion, measuring 1.3 cm in diastole in front of the right ventricle, and 2.4 cm in front of the right atrium. Brief invagination of the right atrium in late diastole, and of right ventricle, though no sustained chamber collapse. Right ventricular end-diastolic dimension is 1.2 cm. . [**1-2**] Cath lab: RA 5 RV 30/5 PA 25/15 PCWP 14 pericard. press. 5 pre-procedure C.O.: 3.35 post: 3.44 pre-procedure C.I.: 2.20 post: 2.26 . [**2143-1-2**] 09:30AM WBC-4.5 RBC-3.24* Hgb-11.0* Hct-31.3* MCV-97 MCH-34.1* MCHC-35.2* RDW-21.7* Plt Ct-34* Neuts-1* Bands-0 Lymphs-98* Monos-0 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2143-1-3**] 05:48AM WBC-10.5# RBC-3.43* Hgb-11.6* Hct-31.7* MCV-93 MCH-33.9* MCHC-36.6* RDW-21.3* Plt Ct-36* [**2143-1-3**] 03:28PM WBC-22.1*# RBC-2.41*# Hgb-8.8* Hct-23.2*# MCV-96 MCH-36.6* MCHC-37.9* RDW-21.5* Plt Ct-42* [**2143-1-3**] 04:52PM WBC-29.3* RBC-2.72* Hgb-9.5* Hct-26.3* MCV-97 MCH-35.0* MCHC-36.2* RDW-22.1* Plt Ct-61* . [**2143-1-2**] 09:30AM BLOOD Glucose-130* UreaN-15 Creat-0.4* Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 [**2143-1-2**] 09:30AM BLOOD ALT-41* AST-32 LD(LDH)-203 AlkPhos-240* TotBili-0.4 [**2143-1-2**] 09:30AM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.2* Mg-1.6 [**2143-1-3**] 03:50PM BLOOD Lactate-1.4 . [**2143-1-4**]: Echocardiogram: EF 10-15%. 1.There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 2. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. 3.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 4.There is a trivial/physiologic pericardial effusion. . [**2143-1-4**] TECHNIQUE: Axial MDCT images of the abdomen and pelvis were obtained without contrast enhancement. CT ABDOMEN FINDINGS: Images of the lower thorax demonstrate a hiatal hernia. There is a large right pleural effusion and a small left pleural effusion. There is no pericardial effusion. Images of the abdomen demonstrate a dense liver likely secondary to blood transfusions and iron deposition. There is no biliary dilatation. Low density is present in the left lobe of the liver which was not seen previously but has a nonspecific appearance on this non-contrast study. It measures 1.6 x 0.9 cm. There is mild splenomegaly again noted. There is poor visualization of the pancreas, adrenal glands, and kidneys. There is a large amount of ascites. There are no dilated bowel loops. There is no hyperdense fluid in the peritoneal or retroperitoneal space. Dense lymph nodes are present in the porta hepatis and in the paraaortic regions which were seen on the CT from [**2141-8-15**]. CT PELVIS FINDINGS: There is a small focus of gas in the urinary bladder. Surgical clips are present in the anterior lower pelvic wall, suggestive of prior hernia repair. There is a large amount of pelvic free fluid. There is mild atherosclerosis. Bone windows demonstrate a mottled appearance of the ilia and proximal femora is seen bilaterally and is unchanged. IMPRESSION: 1. No peritoneal or retroperitoneal bleed as clinically questioned. 2. Large amount of ascites. Large right pleural effusion and small left pleural effusion. 3. Otherwise, fairly limited evaluation of the abdomen secondary to lack of contrast and large amount of ascites. . Hematocrit trend: [**1-2**] Hct 31.3 [**1-3**] Hct 23.2 [**1-3**] Hct 26.3 [**1-4**] Hct 22.7 [**1-4**] Hct 23.5 [**1-5**] Hct 25.2 [**1-5**] Hct 36.8 Brief Hospital Course: 49 year old male with CLL with cardiomyopathy, EF 10-15% and pericardial effusion with early signs of tamponade s/p pericardial drain. Patient tolerated the procedure well. One day after the drain was placed, it was removed. Several hours after the drain was pulled, the patient had a systolic blood pressure that decreased from 90's to 50's. He was asymptomatic with this blood pressure, was mentating and making urine. His white count increased from 4.5 to 29 in one day. His temp was noted to be 99 degrees. There was an initial concern of septic shock given his immunosuppression and he was started on stress dose steroids as well as Vancomycin and Cefepime. His Hematocrit was also noted to have dropped from 31 to 23 and he was tranfused 2 units. The next day his hematocrit had not increased despite the transfusion and he had an abdominal CT scan that was negative for retroperitoneal bleed. Hemolysis labs were checked and negative. Patient likely had decreasing hematocrit because he is transfusion dependent at baseline requiring [**12-17**] transfusion/week also in setting of positive fluid balance by 1-2 liters/day as he was dehydrated on admission. His Hct increased to 36 and remained stable. . 1. CV: Pump: EF 10-15% by Echo. S/P pericardial drain, fluid sent for flow cytometry (to be followed by Dr. [**First Name (STitle) 1557**]. Echo checked post-procedure and no evidence of reaccumulation of effusion. Patient never had a pulsus during admission. Patient appeared hypovolemic on admission based on low pericardial and RA pressures. Continue Captopril for afterload reduction at decreased dose and titrated up as tolerated. Goal to keep i's and o's even to slightly positive on admission. Lasix dose had recently been increased to 60 mg po qday, and patient was dehydrated on admission as evidenced by swan ganz readings in catheterization lab during pericardial drain placement. Restarted Lasix at 20 po bid per Dr. [**First Name (STitle) 437**] on [**1-6**]. Ischemia: no evidence of ischemia. Cont B-Blocker, titrated up as tolerated. Rhythm: Sinus tachycardia, monitored on Telemetry. . 2. Onc: followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. Sent pericardial fluid for flow cytometry. On prednisone 5 mg po qday. . 3. ID: On Cipro, Flagyl (for C.Diff). Valacyclovir for HSV mucositis. Voriconazole for resistant oral [**Female First Name (un) **] and aspergillosis seen on BAL in the past. Started on Vanco and Cefepime when sbp dropped and temp 99F but these were d/c'ed after 2 days when no infectious source found and all cultures without growth. Started on stress dose steroids as well which were also stopped after two days when no infectious source was found. . 4. Dispo: patient was discharged to home with VNA services after being seen by Physicial Therapy. He is to follow-up with Dr. [**First Name (STitle) 1557**] for Oncology and Dr. [**First Name (STitle) 437**] for Cardiology in one week. Medications on Admission: 1. Metronidazole 500 mg TID 2. Valacyclovir 1000 mg [**Hospital1 **] 3. Metoprolol Succinate 50 mg qday 4. Ciprofloxacin 500 mg q12hrs 5. Captopril 37.5 mg TID 6. Nystatin 100,000 unit/mL Susp 5 ML PO QID 7. Voriconazole 200 mg q12 8. Prednisone 5 mg qday 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg one packet qday 10. Furosemide 60 qday 11. Potassium Chloride 20 mEq qday Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO bid (). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. PICC line care per protocol. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: pericardial effusion cardiomyopathy, EF 10-15% chronic lymphocytic leukemia Discharge Condition: stable Discharge Instructions: Please call your physician or return to the hospital if you experience chest pain, shortness of breath, dizziness or other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1730**] [**Telephone/Fax (1) **] Follow-up appointment should be in 1 week Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 4451**] Follow-up appointment should be in 1 week Completed by:[**2143-1-8**]

[ "117.3", "420.90", "458.8", "428.20", "401.9", "425.9", "790.01", "288.0", "112.0", "428.0", "276.51", "204.10" ]

icd9cm

[ [ [] ] ]

[ "99.04", "97.41", "37.0", "00.17" ]

icd9pcs

[ [ [] ] ]

11006, 11062

6675, 9694

325, 348

11182, 11191

2827, 6652

11383, 11667

2493, 2497

10139, 10983

11083, 11161

9720, 10116

11215, 11360

2512, 2808

266, 287

376, 1622

1644, 2359

2375, 2477

20,475

173,886

6247

Discharge summary

report

Admission Date: [**2109-3-26**] Discharge Date: [**2109-4-1**] Date of Birth: [**2067-5-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: S/p MVC with multiple injuries Major Surgical or Invasive Procedure: [**2109-3-27**] ORIF left tibial fx [**2109-3-29**] Transfused 2 units RBCs History of Present Illness: 41-year-old female with a history of HCV and polysubstance abuse, status post MVC, unrestrained driver car vs. telephone pole. Combative at scene despite GCS 15, intubated. Transferred to [**Hospital1 18**] from LGH, took 72mg morphine to sedate. + for EtOH, cocaine, opiates. Past Medical History: 1. Hepatitis C infection 2. Poly-substance abuse 3. Depression 4. PTSD Social History: 1. Hx of IVDU (Heroin, cocaine), EtOH and tobacco abuse 2. Lives with partner Family History: NC Physical Exam: 101.0 96.5 92/52 96 18 95%3L NAD Abdomen S/NT/ND CTAB Nasal splint in place Right LE has 1+ edema about the surgical site and the dsg are c/d/i with bloody strikethrough on internal dsg. No evidence of hematoma or dehiscence Pertinent Results: [**2109-3-27**] 12:00AM GLUCOSE-102 LACTATE-0.8 K+-3.4* [**2109-3-27**] 12:00AM freeCa-1.11* [**2109-3-26**] 08:45PM GLUCOSE-95 UREA N-6 CREAT-0.4 SODIUM-140 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16 [**2109-3-26**] 08:45PM AMYLASE-35 [**2109-3-26**] 08:45PM ASA-NEG ETHANOL-39* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2109-3-26**] 08:45PM URINE HOURS-RANDOM [**2109-3-26**] 08:45PM PT-12.8 PTT-22.2 INR(PT)-1.0 [**2109-3-26**] 08:45PM FIBRINOGE-354 [**2109-3-26**] 08:45PM URINE RBC-[**3-23**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2109-3-29**] 12:47AM BLOOD PT-12.5 PTT-25.0 INR(PT)-1.0 [**2109-3-29**] 12:47AM BLOOD Plt Ct-350 [**2109-3-29**] 12:47AM BLOOD Neuts-72.1* Lymphs-23.3 Monos-3.1 Eos-1.3 Baso-0.1 [**2109-3-28**] 01:42AM BLOOD WBC-13.0*# RBC-3.43* Hgb-10.8* Hct-30.8* MCV-90 MCH-31.4 MCHC-34.9 RDW-13.5 Plt Ct-489* [**2109-3-29**] 12:47AM BLOOD WBC-7.6 RBC-2.76* Hgb-8.6* Hct-25.1* MCV-91 MCH-31.1 MCHC-34.1 RDW-13.3 Plt Ct-350 [**2109-3-29**] 09:20AM BLOOD WBC-8.0 Hct-35.9*# Plt Ct-358 [**2109-3-26**] 08:45PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2109-3-26**] 08:45PM URINE RBC-[**3-23**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2109-3-26**] 08:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG ## CT face [**2109-3-26**]: 1. Bilateral nasal bone fractures. 2. Sinus disease as described above. 3. There is soft tissue swelling in the left forehead. ## CT RLE [**2109-3-26**]: Comminuted bicondylar tibial plateau fracture, with considerable depression. Additional oblique fracture involving proximal tibial diaphysis. ## TL spine [**2109-3-26**]: L1 nonacute vertebral compression fracture with anterior wedging and mild loss of T12-L1 intervertebral disk space height. Brief Hospital Course: ORTHO: Ms. [**Last Name (un) 24313**] was admitted to the trauma service for multiple injuries sustained after her motor vehicle collision. She underwent internal fixation of her right tibial plateau fracture on [**2109-3-27**]. The patient was placed in a knee brace and put on lovenox prophylaxis. Recommendations were made to avoid weight-bearing on that extremity for 10 weeks. She was also found to have a compression fracture of L1 on her initial workup. The patient was placed in a TLSO brace when she was able to sit up in bed. Lumbar spine films were taken with the brace on and revealed a stable fracture. She thereafter was able to ambulate with the help of the physical therapist. The patient received two units of PRCs for a drop in her hematcrit. The latter subsequently remained stable throughout her stay. Her physical therapy sessions were interrupted by her decision to leave the hospital against medical advice. ## PLASTICS: The patient's nasal fractures were seen by the plastic surgery team and recommendations were made to place her in a nasal splint. She remained stable in that aspect and did not require further management. ## NEURO/PSYCH: The patient was initially extremely drowsy and poorly responsive to our questioning. Her home medications were obtained from her PCP and included seroquel, effexor and klonopin. Once her medical regimen was readjusted, her mental status dramatically improved. The night prior to leaving against medical advice, the patient was agitated, requesting more pain medications. She was seen by our psychiatry team and was deemed competent to make her own decisions. ## DISPOSITION: The patient left against medical advice on [**2109-4-1**] with prescription for dilaudid and lovenox. We have explained that she needed additional sessions of physical therapy and was unsafe to return home at this moment. She has understood the risks. Medications on Admission: Klonepin Seroquel Effexor Discharge Medications: 1. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous once a day for 2 weeks. Disp:*14 * Refills:*0* 2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**4-24**] hours as needed for 4 days. Disp:*20 Tablet(s)* Refills:*0* 3. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Quetiapine Fumarate 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: 1. Right tibial plateau fracture 2. Bilateral nasal fractures Discharge Condition: Fair AMA Discharge Instructions: you were hospitalized in the trauma service for injuries you sustained after your motor vehicle crash. your right leg fracture was repaired by the orthopedic surgeons. you were placed on a blood thinner to prevent blood clots in your leg. you must take this daily injection for 2 weeks. please return to the orthopedic surgery clinic in 2 weeks [**Telephone/Fax (1) 5499**]. return to your regular doctor or the ER to remove your sutures in 1 week. you have decided to leave the hospital against medical advice and have understood the risks of doing so. Followup Instructions: [**Hospital 5498**] Clinic in 2 weeks Suture removal in 1 week Completed by:[**2109-4-1**]

[ "802.0", "070.70", "823.00", "E816.0", "305.00", "805.4", "807.01", "305.60", "305.50" ]

icd9cm

[ [ [] ] ]

[ "96.04", "21.71", "99.04", "78.17", "79.36", "96.71" ]

icd9pcs

[ [ [] ] ]

5564, 5614

3067, 4960

344, 422

5720, 5730

1200, 3044

6334, 6427

933, 937

5036, 5541

5635, 5699

4986, 5013

5754, 6311

952, 1181

274, 306

450, 728

750, 822

838, 917

21,413

127,753

45365

Discharge summary

report

Admission Date: [**2172-3-23**] Discharge Date: [**2172-3-31**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 689**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Upper Endoscopy Colonoscopy Tunnelled Hemodialysis Catheter History of Present Illness: 84 yo man with a PMH significant for CAD, AFib, ESRD on HD, PVD, severe mitral regurg who p/w BRBPR. He was recently hospitalized at the [**Hospital1 **] in [**2-2**] for incision and drainage of a left foot hematoma. He was discharged to rehab on [**2172-2-24**] where he subsequently required intermittent blood transfusions. During the 24 hours prior to admissions, his Hct dropped from 28 to 24 and was noted to have several episodes of grossly bloody stools with large clots. He received NS and 1 units PRBCs with repeat Hct of 21. He was sent to [**Hospital1 **] for further management. . In the ED, his pulse was 70 and his bp was 130s/70s. His stool was guaiac positive. No NG lavage was done. He was not transfused due to multiple antibodies. He was given protonix, vanco, levo, and flagyl. . He was admitted to the MICU for further care. NG lavage was negative. Has received 2 units of PRBC since admission with Hct stable for the past 24 hours, 25.3-28.5. . [**Hospital1 4273**] chest pain, SOB, dizziness, abdominal pain. Past Medical History: 1)ischemic cardiomyopathy w/severe LV systolic dysfunction with EF of 30% 2)CAD 3)severe mitral regurgitation 4)Atrial fibrillation, s/p ICD-not anticoagulated 5)Peripheral [**Hospital1 1106**] disease, s/p bypass leg surgery 6)ESRD on HD T/H/S (via R subclav permacath) 7)Anemia on Procrit and iron supplementation 8)? CVA [**90**] years ago with left facial numbness 9)Hypothyroidism 10) s/p right above the knee popliteal bypass graft in [**2160**] and a left femoral popliteal artery bypass graft with revision that included the left femoral to anterior tibial artery jump graft in [**2167**] Social History: Smoked 1 ppd x 50 yrs, quit [**2163**]. Reported heavy EtOH use in past, none currently. currently at [**Hospital1 **]. Lives with his wife in [**Name (NI) **]. 2 children living in [**State 8449**].Retired maintenance worker at [**Hospital3 **]. Family History: NC Physical Exam: T: 96.9 BP: 172/45 P: 78 R: 21 100% on 2LNC 24 hour I/O: 2920/2168 Gen: elderly male in NAD, lying comfortably in bed HEENT: NC, AT, anicteric, MM dry Neck: supple Lungs: Rales on left lower base. CV: RRR, holosystolic systolic murmer heard best at the right sternal border Abd: soft, nt/nd, +bs Ext: No edema Skin: eccymosis on arms. Tophi on toes bilaterally. Dressing over left foot. Pertinent Results: Admission Labs: [**2172-3-23**] 04:25AM BLOOD WBC-6.8# RBC-2.64* Hgb-8.4* Hct-25.0* MCV-95 MCH-32.1* MCHC-33.8 RDW-17.3* Plt Ct-159 [**2172-3-23**] 04:25AM BLOOD Neuts-72.9* Lymphs-18.3 Monos-4.5 Eos-3.9 Baso-0.4 [**2172-3-23**] 04:25AM BLOOD PT-13.1 PTT-33.3 INR(PT)-1.1 [**2172-3-23**] 04:25AM BLOOD Glucose-97 UreaN-54* Creat-3.8* Na-136 K-4.6 Cl-105 HCO3-21* AnGap-15 [**2172-3-23**] 04:25AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0 [**2172-3-26**] 06:19AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.1 Mg-1.7 [**2172-3-29**] 04:37AM BLOOD Cortsol-13.3 . Most Recent Labs: [**2172-3-31**] 09:02AM BLOOD WBC-5.1 RBC-3.22* Hgb-10.4* Hct-30.0* MCV-93 MCH-32.2* MCHC-34.5 RDW-18.6* Plt Ct-152 [**2172-3-31**] 09:02AM BLOOD Plt Ct-152 [**2172-3-31**] 09:02AM BLOOD Glucose-87 UreaN-38* Creat-4.6* Na-137 K-3.9 Cl-102 HCO3-24 AnGap-15 [**2172-3-30**] 05:43AM BLOOD Calcium-7.6* Phos-3.8 Mg-2.0 . . Tagged RBC scan on [**2172-3-23**]: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 60 minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images show increased tracer activity in the left upper quadrant which is due to uptake in an enlarged spleen. Dynamic blood pool images show no evidence of active gastrointestinal bleeding. IMPRESSION: No active gastrointestinal bleeding identified. Splenomegaly. . Chest X-ray on [**2172-3-23**]: The left-sided [**Date Range 4448**] is seen with leads in unchanged position. A right hemodialysis line is seen with tip in the superior vena cava. The cardiomediastinal silhouette is within normal limits.A left retrocardiac opacity is less conspicuous on the current examination. IMPRESSION: 1. Left retrocardiac opacity has minimally improved and may represent atelectasis or pneumonia. . Upper endoscopy [**2172-3-25**]: Erythema, edema, friability in the stomach body, antrum and pylorus compatible with Severe gastritis Erosions in the stomach body Small hiatal hernia Otherwise normal EGD to second part of the duodenum . Colonoscopy [**2172-3-25**]: Diverticulosis of the sigmoid colon and descending colon Polyps in the Throughout the colon Angioectasias in the cecum Otherwise normal colonoscopy to cecum Brief Hospital Course: . # GI BLEED: Patient initially admitted to MICU due to dramatic hematocrit drop. This subsequently stabilized after 2 units PRBC transfusion. NG lavage was negative. Patient was prepped and underwent esophagogastroduodenoscopy and colonoscopy. EGD showed severe gastritis and colonoscopy showed numerous diverticuli and adenomatous polyps. Tagged RBC scan was negative. Likely multifactorial bleed due to above 3 causes, with diverticular bleed probably greatest contributor. The patient's hematocrit was relatively stable throughout the hospital stay. The patient received 2 more units of PRBCs. Patient is scheduled for follow-up with GI as an outpatient for removal of polyps. H. pylori antibody test was positive. Triple therapy with PPI, amoxicillin, and clarithromycin (all renally dosed) was strated on [**2172-3-30**] to be continued for a total of 14 days. . # C. DIFF: Patient developed diarrhea on hospital day 5. It was thought that the diarrhea was likely secondary to C. diff and he was emperically started on metronidazole on [**2169-3-29**]. C. diff toxin assay was sent and subsequently came back positive [**2172-3-29**]. He should continue on flagyl for at least 7 days beyond H. pylori triple therapy. . # HYPOTENSION: Patient was initially hemodynamically stable on presentation, and in fact, became hypertensive later in MICU course. His home regimen of antihypertensive was therefore restarted as follows: Hydralazine, Valsartan, Metoprolol. Imdur was restarted on [**2172-3-25**]. On hospital day 5 the patient had hypotensive episode with systolic BP between 80-90. Fluid was given and BP medications were held to maintain stable systolic blood pressure >120. It was thought that the hypotensive episode was due to hypovolemia secondary to 1.6 kg fluid removed during hemodialysis earlier that day, as well as significant volume depletion secondary to his diarrhea from C. Diff. No further hypotensive episodes were noted after fluid resuscitation. . # FEVER: On hospital day 5, patient had fever of 101. His fever was thought to be secondary to C. diff infection, as diarrhea was present at that time (see above). Blood cultures were negative for several days, and still pending at the time of discharge. His temperature normalized after initiation of Flagyl for C. diff. . # A FIB: Patient has a [**Date Range 4448**]. Rate was stable and he was continued on amiodarone. . # ESRD: Patient was dialyzed Tu/Th/Sa via subclavian permacath. His HD catheter was repositioned on this admission. He was continued on nephrocaps, erythropoietin at dialysis and neurontin. The renal service followed him throughout this admission. Next HD session planned for Friday, [**4-3**]. . # LEFT FOOT HEMATOMA: s/p I&D on his last admission by [**Month (only) 1106**] surgery. He was continued Papain and becaplermin. He will follow up with [**Month (only) **] as previously scheduled as an outpatient. . # HYPOTHYROIDISM: Continued levothyroxine . # ACCESS: PICC placed prior to this admission. Also had peripheral IV, and HD cath. Tunnel line catheter cuff was found to be exposed on [**2171-3-25**] and a new line was placed by IR on [**2172-3-25**]. PICC line was pulled prior to discharge. . # CODE STATUS: Full . # DISPO: patient was discharged to rehab in stable condition on [**2172-3-31**]. . . Medications on Admission: morphine 3 mg IV q2h:prn tylenol prn albuterol neb prn tylenol w/codeine prn glycerin supp prn senna prn trazodone 25 mg qhs valsartan 80 mg daily hydralazine 25 mg q6h toprol 125 mg daily nephrocaps nystatin 6 ml po tid accuzyme ointment to foot daily insulin sliding scale imdur 30 mg daily levothyroxine 125 micrograms daily colace 100 mg tid neurontin 300 mg q48h aztreonam 0.125 grams q6h and at hemodialysis TIW becaplermin to wound daily epo at HD amiodarone 200 mg daily aspirin 325 mg daily atorvastatin 20 mg daily Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: PRIMARY: 1) GI bleeding 2) C. Difficile infection 3) H. Pylori 4) End-stage renal disease on HD 5) Hypotension SECONDARY: 1) Atrial fibrillation 2) Left foot hematoma Discharge Condition: Stable, improved from the time of admission Discharge Instructions: Please call your doctor or go to the ER if you experience any worsening of your diarrhea, fever/chills, dizziness, nausea/vomiting, abdominal pain, or any other concern. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: 1) [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2172-4-9**] 8:00; E SUITE GI ROOMS Date/Time:[**2172-4-9**] 8:00 2) [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2172-4-15**] 3:15 3) Please call the radiology department to set up a Small-Bowel follow through. Call [**Telephone/Fax (1) 327**] for an appointment. 4) Please call your primary care doctor for a follow up appointment after discharge from rehab.

[ "585.6", "008.45", "562.12", "041.86", "285.1", "535.51", "424.0", "458.0", "211.3", "414.01", "244.9", "427.31", "443.9", "285.21" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.95", "39.95", "45.23" ]

icd9pcs

[ [ [] ] ]

8931, 9001

5020, 8356

249, 311

9212, 9258

2712, 2712

9577, 10147

2282, 2286

9022, 9191

8382, 8908

9282, 9554

2301, 2693

182, 211

339, 1376

2728, 4997

1398, 2000

2016, 2266

25,915

193,527

27151

Discharge summary

report

Admission Date: [**2114-4-4**] Discharge Date: [**2114-4-20**] Date of Birth: [**2034-1-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: transferred from [**Doctor Last Name **] [**Doctor Last Name 22583**] for worsening hypoxia, low UOP Major Surgical or Invasive Procedure: BiV ICD placement [**2114-4-4**] Chest tube placement Central line placement Endotracheal intubation History of Present Illness: Pt. is an 80 y/o with with cardiomyopathy, increasing CHF symptoms, here for upgrade from single chamber ICD to BiV ICD. Pt. presented to EP lab and a VVIR BiV ICD was placed without incident. Had some oozing around incision site afterwards -> pressure dressing placed. He was given 40 mg IV Lasix -> 800 cc UOP after dose. . Pt. reports that he has been having progressive DOE for several months. He reports he can climb 13 steps at home now, but is very winded afterwards, while 6 months ago he did not have difficulty with this. He gets winded with walking from room to room. He also reports substernal chest pain with activity with no radiation, that is relieved with rest. He also had an episode of "fainting" recently, ~1 month ago per his report (in [**11-27**] per d/c summary from OSH), where his ICD fired. This lead to repeat testing of the ICD and the decision to change to a BiV pacer per his report. ROS negative for recent fevers, does report chronic rhinorrhea, occ. twinges of abd pain which he attributes to AAA, no constipation or diarrhea, no dysuria, 4 episodes of nocturia/night, chronic LE edema that waxes and wanes, though it never fully resolves. Reports chronic orthopnea, sleeps with one pillow at home. Past Medical History: - Syncope at home in [**11-27**] -> ICD fired -> to OSH where interrogation of ICD showed VF - ICD placed in [**3-27**] for inducible VT on EP testing - Ischemic CM- EF 20% in [**11-27**] - Atrial fibrillation/Tachy-brady syndrome on Coumadin - AAA s/p stenting in '[**11**] - HTN - CAD s/p CABG in '[**02**] - MVR - Hx Endocarditis - BPH - Chronically elevated LFTs Social History: retired, lives with wife, former heavy EtOH use, former heavy smoker Family History: brother with CAD, died of MI at 69 Physical Exam: VS: T 96.1 BP 111/68 P 70 R 18 97% on 2L Gen: A+O x 3, NAD HEENT: PERRL, EOMI Neck: supple, no JVD appreciated at 45 degrees, no carotid bruits CV: RRR, + S4, 2/6 systolic murmer loudest at apex Lungs: decreased BS at L base, no crackles Abd: soft NTND, + BS, no bruits auscultated Ext: 3+ pitting edema to mid-thigh bilaterally, 1+ DP pulses bilaterally Skin: chronic venous stasis changes bilat LE, no rashes Neuro: CN 2-12 intact, no focal numbness or weakness Pertinent Results: Admission Labs: [**2114-4-4**] 09:15PM PLT COUNT-154 [**2114-4-4**] 09:15PM WBC-11.5* RBC-3.42* HGB-11.9* HCT-35.9* MCV-105* MCH-34.8* MCHC-33.1 RDW-19.1* [**2114-4-4**] 09:15PM TRIGLYCER-58 HDL CHOL-68 CHOL/HDL-2.1 LDL(CALC)-61 [**2114-4-4**] 09:15PM MAGNESIUM-1.9 CHOLEST-141 [**2114-4-4**] 09:15PM GLUCOSE-228* UREA N-47* CREAT-1.4* SODIUM-139 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-32 ANION GAP-14 . CXR [**4-5**]: PA and lateral upright chest radiograph was obtained and compared to the previous portable erect chest x-ray from [**4-4**], [**2113**]. . New coronary sinus lead was added. The heart size is markedly enlarged with large amount of left pleural effusion and adjacent lung consolidation. No change in comparison to the previous film is demonstrated. . CXR [**4-7**]: A defibrillator is present in the left anterior chest wall with RV and coronary sinus leads. An increasing effusion is present occupying the lower two thirds of the left hemithorax. The right lung is clear. Heart size is difficult to evaluate. However, the left atrium and right ventricle appear enlarged. Prior fractures of the left eighth and ninth ribs may relate to prior surgery. . IMPRESSION: Increasing left effusion. . Head CT [**4-7**]: FINDINGS: There is an 8-mm right-sided subdural hematoma, which does not cause significant mass effect or shift of the normally midline structures. There is age-appropriate involutional changes. The [**Doctor Last Name 352**]-white matter differentiation appears preserved. There is no hydrocephalus. The osseous structures are unremarkable. Mild mucosal thickening in the right ethmoid sinuses. . IMPRESSION: 1. Small 8-mm right-sided subdural hematoma with no significant mass effect or shift of the normally midline structures. . Head CT [**4-8**]: FINDINGS: Examination is limited secondary to patient motion. There has been no change in the size or appearance of the small right frontoparietal subdural hematoma. This hematoma measures 7 mm, and does not cause significant mass effect or midline shift. The density values of the brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation remains preserved. The ventricles are normal in size. The surrounding osseous and soft tissue structures are unremarkable. The visualized paranasal sinuses again show mild thickening in the right ethmoid sinus. . IMPRESSION: No interval change in the small right subdural hematoma without mass effect or midline shift. . ECHO [**2114-4-11**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. /worsening dyspnea. Height: (in) 69 Weight (lb): 162 BSA (m2): 1.89 m2 BP (mm Hg): 100/63 HR (bpm): 77 Status: Inpatient Date/Time: [**2114-4-11**] at 09:30 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W014-0:44 Test Location: West Echo Lab Technical Quality: Adequate MEASUREMENTS: Left Atrium - Long Axis Dimension: *7.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *7.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *7.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: *6.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.9 cm Left Ventricle - Fractional Shortening: *0.28 (nl >= 0.29) Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm) Aorta - Ascending: *4.2 cm (nl <= 3.4 cm) Aorta - Arch: *3.1 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 0.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 2.67 Mitral Valve - E Wave Deceleration Time: 196 msec TR Gradient (+ RA = PASP): *33 to 34 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) INTERPRETATION: Findings: LEFT ATRIUM: Marked LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Severely depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Dilated RV cavity. RV function depressed. Abnormal septal motion/position consistent with RV pressure/volume overload. AORTA: Mildly dilated aortic root. Moderately dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral valve annuloplasty ring. Moderate to severe (3+) MR. Eccentric MR jet. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Significant PR. The end-diastolic PR velocity is increased c/w PA diastolic hypertension. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Left pleural effusion. Conclusions: . CT ABDOMEN W/O CONTRAST [**2114-4-13**] 2:38 AM TECHNIQUE: MDCT axial images from the lung bases through the pubic symphysis were obtained without oral or intravenous contrast according to the referring physician's request. CT ABDOMEN WITHOUT CONTRAST: There is a moderate right and a smaller left pleural effusion with adjacent bibasilar atelectasis. Pacer wires are seen within the right atrium and ventricle. Optimal evaluation of the visceral organs is limited due to lack of intravenous contrast. Allowing for this factor, there is moderate ascites with small pockets of fluid intercalating throughout the mesentery within the abdomen. No definite liver lesions are identified. The gallbladder is slightly distended with dense material likely sludge. There is fatty displacement throughout the pancreas. The kidneys are symmetric in size without stones or evidence of hydronephrosis. There is enhancement in the renal cortex from perhaps prior contrast administration. Please correlate clinically. There are several loops of small bowel which demonstrate wall thickening in the left lateral abdomen. There is no evidence of small-bowel obstruction, intraperitoneal abscess or pneumatosis. There is a 4.4 x 4.2 cm abdominal aortic aneurysm which is traversed by a bypass graft which extends from the level of the renal arteries to the femoral vessels. CT OF THE PELVIS WITHOUT IV CONTRAST: A Foley catheter is seen within a nondistended bladder. Air in the bladder is likely iatrogenic. There is moderate pelvic ascites. Air and some contrast is seen within the rectum. There is no inguinal or pelvic lymphadenopathy. No pelvic free air is seen. Note is made of diffuse edema within the soft tissues of the abdomen and pelvis. BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are identified. IMPRESSION: 1. Limited study secondary to lack of intravenous contrast. Several areas of thickened small bowel which could represent edema from volume overload/low albumin or possible ischemic/infectious colitis. 2. Bilateral pleural effusions, right greater than left, with adjacent bibasilar atelectasis. 3. Moderate intra-abdominal ascites. 4. 4.4 x 4.2 cm abdominal aortic aneurysm with associated endograft. 5. Renal cortex enhancement. Patient was given iv contrast approximately two days prior. This finding is consitent with a delayed nephrogram and may be seen in etiologies such as ATN. Please correlate clinically. . CHEST (PORTABLE AP) [**2114-4-17**] 10:27 AM PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to several studies dating back to [**2114-4-12**], most recently [**2114-4-16**]. FINDINGS: The heart remains enlarged with persistent evidence of mild congestive failure. Again seen are bilateral pleural effusions, left greater than right, with associated basilar opacities. These are essentially stable in appearance. There is a left-sided thoracostomy tube which courses medially and terminates within the midline. There has been an increase in the extent of subcutaneous emphysema seen outside the lateral left chest wall. In addition, there is a new/recurrent basilar left pneumothorax. This was not present on the most recent prior examination, but was seen on the examination of [**4-13**]. The endotracheal tube has been removed since the prior examination. IMPRESSION: 1. Recurrent left basilar pneumothorax. 2. Persistent mild congestive failure. Unchanged appearance of bilateral pleural effusions with associated basilar opacities. 3. Increase in subcutaneous air overlying the left lateral chest wall. . [**2114-4-15**] 2:43 pm SPUTUM Site: EXPECTORATED Source: Expectorated. GRAM STAIN (Final [**2114-4-15**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. BURKHOLDERIA (PSEUDOMONAS) CEPACIA. MODERATE GROWTH. YEAST. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BURKHOLDERIA (PSEUDOMONAS) CEPACIA | Brief Hospital Course: 80M with CHF (EF 20%, 2+ MR & TR), A fib/tachy brady syndrome, s/p BiV ICD placement 1wk prior to admission, then found to have small stable SDH, with increasing L sided loculated bloody effusion s/p chest tube placement [**4-12**]. Developed ARF [**1-25**] contrast nephropathy and CHF (low-output). . 1) Hypoxic respiratory failure: DDx includes increasing pleural effusion (see discussion below), CHF, PE, pneumonia. Was sating 100% on 100% NRB however was eventually intubated on [**4-12**] [**1-25**] hypoxia and cyanosis. Extubated [**2114-4-17**] with initally good oxygenation and ventilation. S/p chest tube [**4-12**] with drainage of large bloody effusion that was causing right mediastinal shift and inverted diaphragm on left. A-line and central lines placed for close BP/ABG monitoring and pressors. After extubation the patient's mental status did not improve, and he became hypotensive despite pressors on [**4-19**]. His breathing worsened, and after discussion with his family (all present) his pressors were discontinued. He was visited by a priest, and he received IV doses of morphine for comfort. He died at 1:35am on [**2114-4-20**]. . 2) Pleural effusion: On [**4-5**] he had a BiV upgrade; the effusion was present post-procedure, and there were no films immediately pre-procedure. He had a tap [**4-11**] which revealed a exudative fluid, no growth on gram stain, cytology negative. The gross description was of dark, blody, viscous fluid. The differential includes acute hemorrhage related to the PM placement, venous communication into pleural space, malignancy, aortic process. Effusion was bloody/loculated and drained when chest tube was placed. Pt originally scheduled for VATs procedure by Thoracic however had acute resp failure; however since no growth on pleural fluid cx unlikely infected. Anticoagulation was held. . 3) Fevers: DDx includes UTI (recent [**4-7**] with E. coli), empyema, PCR pocket infection, bacteremia (no line), pneumonia (B cepacia on sputum). Hemodynamically stable, although lactate 12.1 on admission. Met criteria for sepsis with RR > 20 and WBC > 12 with suspected infection, so sepsis protocol initiated and RIJ line placed. Apache score is 27 but xigris not started given known subdural hematoma. Patient completed 11 days of zosyn and 1 week of steroids. He intermittantly required pressors to maintain urine output. . 4) ARF/low UOP: Cr peaked at 4 (up from 1.5), likely pre-renal as aggressively diuresed and also likely ATN from contrast nephropathy. Seen by renal consult service with recs for optimization of medical management; no dialysis needed. Discussions with family about goals of care with decision for no HD should the need arise. Maintained decent UOP when on dobutamine and vasopressin. . 5) MS Changes: Likely component of chronic low-level dementia, with acute worsening with hospitalization, uremia, UTI, and SDH. B12 and folate WNL. Avoided any meds that could worsen confusion. Continued dilantin. Followed by neurology consult service. . 6) Coagulopathy/Thrombocytopenia: INR 3.1 on admission, likely from abx + coumadin, although last reported coumadin dose was [**3-30**]. Wife thinks pt's MS declined in past week and that he might have been taking his coumadin without knowing it. Received 10 units unit FFP and 10 mg SC Vit K for RIJ and L chest tube placement [**4-12**] and reversal of INR for concern of worsening mental status and increased ICH. Decreased platelets but HIT Ab negative. Labs suggestive of DIC but no active bleeding. . 7) CHF: EF 20% 12/05, [**1-25**] ischemic cardiomyopathy. In cardiogenic shock on admission with poor forward flow as indicative of decreased UOP and cyanotic extremities. Quickly weaned off pressors (for BP support) although later restarted to maintain urine output. Diuresed with PRN lasix doses with initial good response but then minimal response later in hospitalization. . 8) A fib, tachy brady, s/p Pacer Placement: Pacer working well, with stable echymosis. Completed IV antibiotics for post pacer placement. After discussion with family about goals of care (and DNR/DNI status), decision was made to turn off the ICD function to prevent defibrillation. Coumadin held given SDH. . 9) Hx Guaiac pos stools: Relatively new finding. Hematocrit stable, with no need for acute intervention (especially given risk-benefit ratio related to respiratory status). . 10) Glucose Intolerance: No h/o diabetes, but with persistent hyperglycemia on chem 7. Controlled on insulin drip. . 11) CAD: Continued ASA and BB (held as appropriate). Lipids WNL . 12) BPH: Continued Urotraxal . 13) Depression: Continued Zoloft . 14) FEN: continued TF/consulted nutrition, MVI, Folate, monitor lytes and replete PRN . 15) PPx: PPI, bowel regimen PRN, pneumoboots . 16) Access: PIV, RIJ and A line . 17) Dispo: ICU . 18) Code: Initially full, then changed to DNR/DNI after extubation after long discussions with wife. ICD turned off per wife's request. . 19) Contact: Wife, [**Name (NI) 26196**], [**Telephone/Fax (1) 66633**] Medications on Admission: Coumadin 5/2.5 mg (last dose 4/7) Lasix 40 mg QD Zoloft 50 mg QD Bromocriptine 2.5 mg QHS Toprol XL 25 mg QD ASA 81 mg QD MVI Ferrous Sulfate Folate 1 mg QD Uroxatral 10 mg QD Zaroxlyn 5 mg twice a week Noritate 1% cream Discharge Medications: None Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Respiratory failure Acute renal failure Ischemic Cardiomyopathy, EF 20% upgrade to BiV ICD CAD s/p CABG in '[**02**] Atrial Fibrillation Tachy Brady Syndrome s/p AAA stenting '[**11**] HTN Right pleural effusion Pneumonia DIC Guiac-positive stool Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "34.91", "99.07", "99.04", "38.93", "96.04", "00.51", "38.91", "34.09" ]

icd9pcs

[ [ [] ] ]

17372, 17431

12027, 17071

413, 516

17722, 17733

2818, 2818

17786, 17793

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17343, 17349

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544, 1787

2835, 5358

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29,162

101,678

49280

Discharge summary

report

Admission Date: [**2186-7-16**] Discharge Date: [**2186-7-21**] Date of Birth: [**2135-4-22**] Sex: M Service: MEDICINE Allergies: Cocaine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Thoracic back pain and leg weakness Major Surgical or Invasive Procedure: T4 laminectomy History of Present Illness: 51 yo man w/ PMH of esophageal CA s/p chemo and radiation w/ known progressive disease presented to OSH [**7-16**] for evaluation of new onset LE paralysis. He had upper back pain for 2 days prior to admission. On the day of presentation he woke up and noted LLE weakness. Over the course of the day he developed RLE weakness and came to the ED for further evaluation. His ROS is significant for reporting no bowel movements or urination for 1-2 days. . Team was concerned for spinal cord compression, but could not get MRI as pt has surgical clips after traumatic head injury. CT myelogram showed occlusion of spinal canal at T4, so taken emergently to OR. Found epidural abscess, which was washed out. . On POD#2, pt became acute dyspneic and hypoxic to 77% after nasotracheal suctioning. ABG 7.40/40/43 on 100% FM. On arrival to MICU, Sats ranged from 85-95% on NRB + 6L NC; briefly placed on BiPAP, but oxygenation actually decreased with this. After repositioning and chest PT, Sats stabilized between 90-96% on 6L NC. Past Medical History: -Esophageal CA s/p chemo and radiation- Oncologist is Dr. [**First Name (STitle) **] [**Name (STitle) 103290**] stenting after radiation induced esophageal stenosis -Suicide attempt ([**2171**]) w/ a circular saw, surgically repaired injury w/ L eye ptosis and brain clips, treated at [**Hospital1 2025**] -GERD -HTN -Former EtOH -MI's x 2 ([**2174**], [**2175**]?) Social History: Homeless; lived in shelter before diagnosis of cancer, but has been living with his mother since being treated for cancer. -tobacco: 1ppd (80 PYH) -"off and on" EtOH use, occasional marijuana, history of cocaine use Family History: noncontributory Physical Exam: T: 96.4 BP: 112/74 HR: 101 R 22 O2Sats 86-96% on 6L + NRB; pulsus 8 mm Hg Gen: able to speak [**12-20**] words between breaths, wearing NRB and 10L NC Neck: Supple. Lungs: bronchial breath sounds, Left lower and mid fields; rhonchorous R field. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect.Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: II: Pupils round and reactive to light w/ mild anisocoria (R>L) III, IV, VI: Extraocular movements intact bilaterally with few beats of nystagmus, ptosis of L eye 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: No pronator drift. Normal bulk and tone bilaterally in UE. LE decreased muscle bulk. No adventitious movements, no tremor, no asterixis. D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE Right 5 - - - - - - - > 0 - - - - - - - - - > Left 5 - - - - - - - > 0 - - - - - - - - - > REFLEXES: Toes: mute bilaterally B T Br Pa Pl Right 2+ 2+ 2+ 0 0 Left 2+ 2+ 2+ 0 0 SENSORY SYSTEM: -light touch: symmetric and intact in UE; sensation in legs intact to deep pressure only -pinprick: absent until T3-T4 bilaterally (L side is slightly higher than R), pt able to feel touch very faintly at T12 posteriorly COORDINATION: nl [**Doctor First Name **] in UE GAIT: unable to access Pertinent Results: [**2186-7-16**] 08:04AM WBC-10.1 RBC-4.12* HGB-13.4* HCT-40.1 MCV-97 MCH-32.7* MCHC-33.5 RDW-14.9 [**2186-7-16**] 08:04AM NEUTS-70.9* BANDS-0 LYMPHS-5.1* MONOS-23.9* EOS-0.1 BASOS-0.1 [**2186-7-16**] 08:04AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2186-7-16**] 08:04AM PLT SMR-NORMAL PLT COUNT-235 [**2186-7-16**] 08:04AM GLUCOSE-142* UREA N-17 CREAT-0.9 SODIUM-136 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2186-7-16**] 08:04AM ALT(SGPT)-6 AST(SGOT)-13 LD(LDH)-163 ALK PHOS-75 AMYLASE-24 TOT BILI-0.6 [**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) WBC-92 RBC-31* POLYS-42 LYMPHS-4 MONOS-54 [**2186-7-16**] 10:40AM CEREBROSPINAL FLUID (CSF) PROTEIN-670* GLUCOSE-59 LD(LDH)-52 CT Myelogram (pre-op): Contrast flowed readily from the injected level (L3/4) through the lumbar spine and extending cephalad to the thoracic spine. There is complete block of contrast material at the thoracic [**3-23**] vertebral body level. The post- myelogram CT of the thoracic and cervical spine reconfirmed that there is complete block of contrast within the subarachnoid space at the T4/5 level. Bedside Echocardiogram: There is a moderate sized pericardial effusion most prominent anterior to the right atrium with brief right atrial diastolic collapse. A promient echogenic area is seen overlying the right ventricular free wall which likely represents epicardial fat (cannot exclude thrombus or tumor if this is clinically suggested). There is but no right ventricular diastolic collapse with relatively minimal fluid anterior to the right ventricle. There is mild eccentuation of transmitral Doppler E wave suggesting increased pericardial pressure. Serial evaluation is suggested. CXRs have shown intermittent, recurrent opacification alternately of the left and right lungs. Chest CT on [**7-18**] showed debris in the distal L mainstem bronchus consistent with aspirated material. CTA was negative for PE. Brief Hospital Course: 51 yo man with esophageal cancer s/p chemo and XRT presenting with abrupt onset lower extremity flacid paralysis found to have T4 epidural abscess, s/p operative debridement, now with acute onset respiratory distress . # Respiratory distress: acute dyspnea with severe hypoxemia and tachycardia on HD#3, now maintaining adequate saturation on high flow nebulizer mask. Ruled out DVT and PE with lower extremity dopplers and CTA. The combination of locally advanced esophageal cancer and weakened chest muscles leading to poor cough predispose to recurrent, significant aspiration. This was discussed at length with the patient, and he wishes to continue chest PT and other non-invasive measures to augment his cough and support his breathing. If non-invasive measures cease to be effective, he has stated clearly that he would want to be made comfortable. He has continued to affirm that he should not be intubated. - aggressive chest PT & nebs since cough is very weak due to T4 spinal lesion. - supplemental O2 as needed to keep SpO2>90%, currently requiring Hi Flow venti mask; titrate up to non rebreather if needed - DNR/DNI; if noninvasive means to support oxygenation are ineffective, pt would want to transition to hospice . # Pericardial effusion: given cardiomediastinal enlargement on CXR, stat echo was obtained, which showed moderate pericardial effusion with invagination of RA, equivocal respiratory variation of RV movement, but no collapse of RV. Given low/normal pulsus and no signs of tamponade by echo, this effusion is likely not the cause of his respiratory decompensation. . # T4 epidural abscess: s/p open debridement on [**7-16**], wound cultures growing Strep milleri, but wound GM stain also showed a GM Neg coccobacillus, suspect mouth flora. Ceftriaxone 2gm Q24H for once-daily dosing regimen to cover Strep milleri, and metronidazole 500mg tid for anaerobes. Will plan to continue course for 6 weeks given serious CNS infection. After 6 week course is complete, recommend suppressive therapy with amoxicillin 500mg daily indefinitely, as the locally advanced esophageal cancer will remain a risk for thoracic spine infection. - TLSO brace while out of bed, multipodis boots to prevent heel breakdown - Neurology consult indicated that patient will most likely not recover meaningful motor function of his legs, ie, ambulation is unlikely. Any recovery of motor function will be limited and gradual. . # Esophageal CA: s/p chemo and xrt, with stenting for stenosis. Pain control. Patient's goals for treatment have been to be able to eat; oncologist Dr [**First Name (STitle) **] has indicated that further chemo or xrt will likely not help in this regard but continue to follow. Pain control. . # GERD: continue protonix . # Nutrition: pt cannot tolerate solid foods. Ensure supplements, soft foods only. . # Tobacco Dependance: nicotine patch . # Prophylaxis: -heparing subcutaneous, pneumoboots, and protonix . # Code Status: DNR/DNI, discussed with patient and family including HCP (mother) Medications on Admission: -Percocet -Prilosec -Unknown BP med -Stool softener Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection DAILY (Daily). 4. Folic Acid 5 mg/mL Solution Sig: One (1) Injection DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for COPD. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for COPD. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 weeks. 12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 14. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 15. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML Miscellaneous Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 17. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 18. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: esophageal cancer T4 epidural abscess, polymicrobial, with spinal cord compression and paraplegia Discharge Condition: fair, although with tenuous respiratory status. Discharge Instructions: You had surgical decompression of a T4 epidural abscess and will need 6 weeks of antibiotics to treat this. You may or may not regain much motor function in your legs because of the spinal cord compression injury. For your respiratory status, the combination of esophageal cancer and weakness have predisposed you to aspirating and prevent you from coughing effectively. Continue with aggressive chest physical therapy and MIE as long as patient feels subjective benefit. Supplemental O2. Followup Instructions: Dr [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 92277**], Friday [**7-28**], 2:00pm. (Oncology) [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "530.81", "420.90", "518.5", "324.1", "507.0", "150.8", "344.1", "305.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "03.09", "03.4" ]

icd9pcs

[ [ [] ] ]

10634, 10713

5740, 8766

311, 327

10855, 10905

3727, 5717

11443, 11726

2023, 2040

8869, 10611

10734, 10834

8792, 8846

10929, 11420

2055, 2379

236, 273

355, 1382

2599, 3708

2394, 2583

1404, 1773

1789, 2007

13,263

101,794

26102

Discharge summary

report

Admission Date: [**2194-12-16**] Discharge Date: [**2194-12-20**] Date of Birth: [**2150-10-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: diffuse exfoliating rash Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: 44 year old female with h/o HTN initially admitted to [**Hospital 1562**] Hospital on [**2194-12-11**] with 7 days of cough, fever, and 1 day of change in mental sttatus. Her family/friends noted she had slurred speech, few episodes of talking out of contexted causing them to bring her to the ED. She was covered with ceftriaxone/vancomycin for presumed meningitis (LP attempts unsuccessful) and admitted to the ICU, where she was subsequently intubated for hypoxia (O2 sat 80s RA) and change in mental status. CXR should multifocal opacities, and antibiotics were broadened to CTX/vanco/levo/doxy/ayclovir/metronidazole. Over the course of the next few days, she developed transaminitis (LFTs 600s), ARF (attributed to ATN, initiated dialysis [**12-15**], [**12-16**]), thrombocytopenia (plt 23 from 90s on admit), lactic acidosis (lactate 5). All bcx, spcx, ucx, BAL NGTD. Antibiotics narrowed to levofloxacin/linezolid/doxycycline (?when). On [**12-12**], pt was noted to be diffusely mottled. Over the course of the next 4 days, she developed diffuse, dependent purpura with areas of necrosis/skin sloughing. She was transferred to [**Hospital1 18**] [**12-16**] given concern for TEN. Currently, the patient is intubated and sedated. Past Medical History: 1) HTN 2) obesity 3) s/p C-section 4) s/p cholecystectomy 5) Osteopenia 6) ?glucose intolerance Social History: 1) HTN 2) obesity 3) s/p C-section 4) s/p cholecystectomy 5) Osteopenia 6) ?glucose intolerance Family History: Father with CAD and diabetes. Mother healthy Physical Exam: T Gen: obese, middle-aged female, intubated, sedated HEENT: anicteric, pinpoint pupils, symmetric bilaterally, pale conjunctiva, oral mucosa moist, neck supple, JVP ~ 7 cm Cardiac: tachycardic, no M/R/G appreciated Pulm: Decreased lung sounds at bases bilaterally, coarse ronchi throughout Abd: Obese, soft, hypoactive bowel sounds, no apparent tenderness Extremities: anasarca, cool extremities and fingers bilaterally, cyanosis/blackening of all 10 finger tips. 1+ DP bilaterally. Poor cap refill in fingers and toes bilaterally. Skin: Diffuse, patchy, non-palpable purpura, predominately over dependent areas involving ~ 50% of skin, with bullae/sloughing of ~ 10% of skin. No clear mucosal involvement. Neuro: Pupils equal, minimally reactive, moves all 4 extremities in responsive to painful stimuli, toes mute bilaterally, 1+ DTR throughout. Pertinent Results: Micro: [**Hospital1 18**] [**12-16**] bcx pending, ucx pending . [**Hospital1 1562**] bcx: [**12-12**] NGTD, [**12-13**] NGTD, [**12-14**] NGTD, [**12-15**] pending vag cx [**12-13**] (-) ucx [**12-12**] pending spcx [**12-14**] (-) BAL [**12-15**] negative . CXR ([**Hospital1 18**]) [**12-16**]: ETT, NGT, RSC in place. bilateral airspace opacity, perihilar predominance, c/w pulmonary edema . Renal U/S (OSH) [**12-15**]: negative . Head CT (OSH) [**12-12**] (-) . EKG [**2194-12-13**]: ST @ 128 bpm w/ PVCs q II, III, avF, non-specific TW changes Brief Hospital Course: A/P: 44 yoF w/ h/o HTN presents with rapidly progressive change in mental status in the setting of fever. Course c/b multisystem organ failure (renal, respiratory, liver) with coagulopathy and diffuse purpura fulminans. . . 1) Purpura Fulminans: Seen by dermatology and biopsied upon transfer with prelim path consistent with microthrombi. The felt that findings are most consistent with purpura fulminans, most commonly seen in setting of sepsis/DIC/meningococcemia. DDx includes TEN (although minimal total-body exfoliation), toxic shock, scalded skin syndrome. Initially duoderm dressings appllied and as skin started exfoliated and denuding, was cleaned with saline and silvadene with telfa applied to denuded areas. She had significant weeping of the wounds and was supported with IVF and albumins were monitored and last albumin was 2.4. She was treated for her possible underlying infection as below. Negative vaginal exam for tampon (vag cx, speculum exam negative at OSH). As area of skin involved progressed, she will be transferred to a specific burn unit to manage and monitor her skin breakdown. she has been on heparin gtt to prevent further microemboli and per rehumatology and hematology should be started on IVIG and steroids to treat possible acute antiphospholipid antibody syndrome which may also cause this presentation of microemoli. . 2) Sepsis: Improved hypotension off pressors X >24 hrs prior to transfer and no need for pressors while here and no evidence of lactic acidosis. Potential infectious sources include menignitis (including meningococcus given rapid clinical deterioration), pulmonary source (given report of cough, patchy infiltrates on CXR). Given presentation meningococcus was leading infection although Lp attempts at OSH and unable after repeated attempts and here not attempted given antibioitcs and rash covering back with thrombocyopenia. Initially broadly coverage again per ID reccomendations with Ceftriaxone/vanco/acyclovir/ampicillin to cover meningitis, levofloxacin to cover atypicals, doxycline to cover for tick-[**Location (un) **] disease(RMSF). eventually levofloxacin, ampicillin and acycovir were stopped as not clinically consistent with those diagnoses. Ct of chest/abd/pelvis with contrast did not reveal any abscesses, large PEs or other infectious processes, although was consistent with ARDS. Crypto Ag(-), histo Ag(p), erhlichiae Ab(neg) per ID. cultures here including daily blood, urine and sputum have been negative. tissue culture with 1+PMn, but no anaerobic gorwth and aerobic cx still pending. Head MRI negative for septic emboli or temporal enhancement suggestive of herpes encephalitis, but did have scattered foci of FLAIR signal hyperintensity, nonspecific, which may relate to post infectious/inflammatory process, demyelination, or subacute or chronic infarction. TTe and TEE without signs of vegetations. IVF boluses used to maintain CVP >12, MAP >65. She was initially on droplet precautions, but no longer needed as has been treated over 24hrs. She was continued on sepsis dose steroids and then transitioned to steroids to treat possible auto-immune source of rash even though [**Doctor First Name **] and ANCA were negative. She is currently on ceftriaxone 2gm IV q12hrs, vanc 1 gm pre levels<15, doxycycline 100mg IV q12. . 3) Transaminitis: Most likely secondary to shock liver, trending down while here Hepatitis A, B, C serologies (-) at OSH; EBV serologies indicating prior infection, and again repeated here although still pending. RUQ U/S did not shouw evidence of portal thrombosis and unremarkeable liver and s/p ccy. . 4) Thrombocytopenia: Plt 21 on admission and prior to d/c back up to 40. thought to be secondary to DIC (although PT/PTT wnl, D-dimer high, FDP and fibrinogen normal here) vs sepsis, consumption in the setting of widespread purpura. HIT was negative. Also initially concern for TTP, given ARF, MS change, fever, but with no shistocytes on smear, no haptoglobin less likely. . 5) ARF: Sediment at OSH c/w ATN, likely secondary to sepsis/renal hypoperfusion. Renal U/S at OSH (-). she continued to require daily HD here for fluid management. As infection resolves, she may recover renal function, although currently seems unlikley. . 6) CHF: Grossly total body fluid overloaded (in the setting of aggresive fluid resuscitation) although CVP 7, however given concern for sepsis/lactic acidosis, would not actively diurese at this time, particularly as patient is ventilated. normal EF on TTE, and as started weeping from wounds, slowed down diuresis attempts. She was started on afterload reduction with hydralazine, isordil and low dose metoprolol. . 7) Rahbdo: she had persistently elevated CKs likely from mircoemboli to muscles as well. Continued on IV hdration and remained stable. . 8) Anemia: HCT 28.8, microcytic. Likely secondary to volume resuscitation in the setting of marrow-suppression (sepsis, ARF). She was only transfused 1 uPRBC during her course here. . 9) F/E/N: Tube feeds started to help support nutrition, electrolytes morinotred twice a day and replete as needed. Insulin drip for close glucose monitoring. . 10) Ppx: IV H2 blocker, heparin drip . 11) Code: Full Code . 12) Communication: Father [**First Name4 (NamePattern1) **] [**Name (NI) **] cell [**Telephone/Fax (1) 64766**]), Sister [**First Name8 (NamePattern2) 8513**] [**Name (NI) 64767**] cell [**Telephone/Fax (1) 64768**]). Family includes husband (whom she is separated from), 2 sisters, son, mother, and father. Next of [**Doctor First Name **] is adult son as separated from husband who has deferred decision making to son and father. . 13) Lines: Left radial a-line ([**12-13**]), RIJ cordis ([**12-13**]), Left IJ dialysis catheter ([**12-16**]) Medications on Admission: Meds (home): 1) metoprolol 50 mg PO TID 2) HCTZ 25 mg PO daily 3) Trazodone 50 mg PO daily 4) Wellbutrin 150 mg PO BID 5) Clarinex 5 mg PO daily 6) Motrin prn . Meds (on transfer): 1) Zyvox 600 mg IV BID 2) Protonix 40 mg IV daily 3) Procrit 1000 units after each hemodialysis 4) Doxycycline 100 mg IV q12h 5) Levofloxacin 250 mg IV daily 6) RISS 7) solumedrol 80 mg IV q8h 8) Albuterol/Atrovent MDIs prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: Three (3) units Injection TITRATE TO (titrate to desired clinical effect (please specify)). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID (3 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 7. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. Midazolam 5 mg/mL Solution Sig: Two (2) mg/hr Injection TITRATE TO (titrate to desired clinical effect (please specify)). 12. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred (100) mcg/hr Injection INFUSION (continuous infusion). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Doxycycline Hyclate 100 mg IV Q12H 15. Pantoprazole 40 mg IV Q24H 16. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1100 (1100) units/hr Intravenous ASDIR (AS DIRECTED). 17. Vancomycin HCl 1000 mg IV ONCE Duration: 1 Doses 18. Ceftriaxone 2 gm IV Q12H Dose antibiotic after dialysis Discharge Disposition: Extended Care Discharge Diagnosis: purpura fulminans sepsis multi-organ failure thrombocytopenia shock liver acute renal failure Discharge Condition: fair, stable BP and HR, intubated on Pressure support 15/5 at 355 FIO2. Discharge Instructions: please continue aggressive skin care and managing sepsis as per d/c summary. Followup Instructions: please follow up with PCP after discharged from hospital. Completed by:[**2195-1-4**]

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46517

Discharge summary

report

Admission Date: [**2174-8-13**] Discharge Date: [**2174-8-26**] Date of Birth: [**2100-4-30**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1881**] Chief Complaint: shortness of breath and productive cough Major Surgical or Invasive Procedure: Rigid bronchoscopy [**2174-8-18**] Flex Bronchoscopy [**2174-8-19**] History of Present Illness: 74F h/o anca positive vasculitis (Wegeners) with pulmonary and renal involvement, complicated by tracheobronchial disease who p/w fever. Patient visited pulm/rheum as outpatient on [**8-11**], and was believed to have evidence of worsening tracheobronchial disease vs infection. Written for levaquin but never obtained rx. CT as outpatient on [**8-12**] showed pronounced opacities at the lung bases bilaterally and stable appearance of wall thickening of the distal trachea and right and left main stem bronchi. Family reports increase in coughing with production of yellowish sputum. She denies stridor, shortness of breath, or chest pain. Has chronic DOE at baseline. The patient also reports loss of appetite. She denies abdominal pain, nausea, vomiting, or diarrhea. Currently taking prednisone 20 mg daily (decreased about 3 weeks ago) and has noticed that her chronic cough and fatigue has gradually worsened on the lower dose. . In the ED, initial vs were: temp 101.8 110 110/53 20 92% RA. EKG: sinus tach 106, LAD, QTC 450, old Q waves inferiorly. HCAP coverage started with vanco/zosyn. Review CT chest from [**8-12**] - pronounced nodules at the lung bases bilaterally likely resolving wegener's (markedly improved since [**5-/2174**]), patchy densities of bases b/l remain (also improved since [**5-/2174**]), distal trachea and r/l mainstem bronchi demonstrate wall thickening (similar [**3-/2174**]), R middle bronchus narrow. Given 2L NS. Exam notable for coarse breath sounds, A&Ox3, baseline short term memory loss and thrush. Blood cultures sent prior to abx initiation. Chest xray obtained. Access is 20g in L arm. Labs notable for WBC 29.2, bands 30, plts 507 and lactate 1.7. Most recent vitals: 98.5 103 114/56 20 94%2L. Admitted to medicine w concern for treatment failure of pna vs vasculitis flare. . On the floor, patient desatted to 86% after returning from a walk to the bathroom. She quickly recovered and was asymptomatic for the entire episode. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Wegener's granulomatosis: Followed by Dr. [**Last Name (STitle) **]; recent history detailed in progress note by Dr. [**First Name (STitle) **] [**2174-3-24**], recently complicated by tracheobronchial disease in particular bilateral bronchial stenosis status post balloon dilation with intralesional steroid therapy by [**Month/Day/Year **] pulmonology - Hypothyroidism - Osteoporosis - History of breast cancer: in [**2151**], s/p surgery and chemo - minimal short term memory Social History: Lives with her son [**Name (NI) 122**]. Quit smoking ~50 years ago. Former social drinker, no alcohol in 2 years. Family History: -Brother with [**Name (NI) 98796**] Disease -Mother passed from sudden cardiac arrest s/p "hand procedure" at age 75 -Father passed at 89 from "old age" with Parkinson's Disease -Hypertension in several family members -[**Name (NI) **] history of cancer, autoimmune diseases Physical Exam: ON ADMISSION: Vitals: 101.0 104 108/50 22 91% tent/hum w/50% O2 General: Alert, oriented (poor short term memory), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, slight supraclavicular LAD Lungs: course upper airway breath sounds and on bottom with mild end exp wheezes and diffuse rhonchi CV: Regular rate and rhythm, normal S1 + S2, high pitched holosystolic murmur heard best at the left sternal border Abdomen: soft, non-distended,non-tender, thin, bowel sounds (+), no rebound tenderness or guarding, no HSM Ext: No lower extremity edema Neuro: motor function and sensation grossly normal . ON DISCHARGE: General: Alert, oriented (poor short term memory), no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: soft crackles at L base; mildly decreased breath sounds at L base relative to R CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-distended,non-tender, thin, bowel sounds (+), no rebound tenderness or guarding, no HSM Ext: 2+ pitting edema to mid-shins bilat Neuro: motor function and sensation grossly normal Pertinent Results: LABS ON ADMISSION: [**2174-8-13**] 03:15PM BLOOD WBC-29.2*# RBC-4.05* Hgb-13.3 Hct-40.7 MCV-101*# MCH-32.9* MCHC-32.7 RDW-14.6 Plt Ct-507* [**2174-8-13**] 03:15PM BLOOD Neuts-59 Bands-30* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-1* [**2174-8-13**] 03:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+ [**2174-8-13**] 03:15PM BLOOD PT-12.6 PTT-22.6 INR(PT)-1.1 [**2174-8-13**] 03:15PM BLOOD Glucose-112* UreaN-22* Creat-0.8 Na-140 K-3.8 Cl-101 HCO3-23 AnGap-20 [**2174-8-14**] 09:15AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8 . Discharge Labs: [**2174-8-26**] 05:32AM BLOOD WBC-6.3 RBC-3.15* Hgb-10.1* Hct-30.7* MCV-98 MCH-32.3* MCHC-33.1 RDW-14.9 Plt Ct-494* [**2174-8-26**] 05:32AM BLOOD Glucose-69* UreaN-9 Creat-0.6 Na-144 K-3.5 Cl-101 HCO3-35* AnGap-12 [**2174-8-26**] 05:32AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 . LABS OF INTEREST: [**2174-8-14**] 09:15AM BLOOD B-GLUCAN-Negative [**2174-8-14**] 09:15AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Negative [**2174-8-17**] 09:33AM BLOOD ANCA-NEGATIVE [**2174-8-18**] 11:00PM BLOOD Type-ART Temp-36.7 PEEP-5 pO2-85 pCO2-55* pH-7.36 calTCO2-32* Base XS-3 Vent-CONTROLLED [**2174-8-18**] 10:48PM BLOOD CK-MB-2 cTropnT-<0.01 [**2174-8-19**] 05:56AM BLOOD-ART pO2-91 pCO2-38 pH-7.48* calTCO2-29 Base XS-4 [**2174-8-20**] 04:37AM BLOOD ALT-9 AST-27 LD(LDH)-296* AlkPhos-59 TotBili-0.2 [**2174-8-20**] 12:57PM BLOOD B-GLUCAN-Negative [**2174-8-20**] 12:57PM BLOOD ASPERGILLUS ANTIBODY-Negative [**2174-8-23**] 06:03PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM . Microbiology: [**2174-8-13**] 3:15 pm BLOOD CULTURE **FINAL REPORT [**2174-8-19**]** Blood Culture, Routine (Final [**2174-8-19**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2174-8-14**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**Doctor First Name **] LOCK #[**Numeric Identifier **] [**2174-8-14**] 0805. . [**2174-8-15**] 10:28 am SPUTUM Source: Induced. GRAM STAIN (Final [**2174-8-15**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2174-8-18**]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2174-8-16**]): NEGATIVE for Pneumocystis jirovecii (carinii).. . [**2174-8-18**] 6:55 pm BRONCHIAL WASHINGS Site: ENDOTRACHEAL **FINAL REPORT [**2174-8-20**]** GRAM STAIN (Final [**2174-8-18**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2174-8-20**]): NO GROWTH, <1000 CFU/ml. . [**2174-8-21**] 12:11 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2174-8-23**]** GRAM STAIN (Final [**2174-8-21**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2174-8-23**]): MODERATE GROWTH Commensal Respiratory Flora. . STUDIES OF NOTE: . CT Torso ([**2174-8-12**]) - IMPRESSION: 1. Small irregular densities throughout the lungs bilaterally, likely resolving changes from known Wegener's vasculitis. More pronounced opacities at the lung bases bilaterally, also likely related to prior episode of vasculitis and these too have improved since the outside hospital study of [**2174-5-26**]. 2. Stable appearance of wall thickening of the distal trachea and right and left main stem bronchi when compared to the [**Month (only) 958**] [**Hospital1 18**] chest CT study of [**2174-3-25**]. The right middle lobe bronchus remains markedly narrowed with resulting right middle lobe collapse. 3. Multiple small sclerotic foci scattered throughout the entire visualized skeleton. The lesions throughout the ribs, scapula, and thoracic spine are stable in appearance since the [**2174-3-25**] chest CT. However, there are no recent CT studies for comparison of the abdomen and pelvis. These lesions were not present on the CT torso of [**2173-4-16**]. . LUE US ([**2174-8-15**]) - IMPRESSION: No evidence of DVT. . [**2174-8-17**] CXR: Left lower lobe PNA w/ small loculated L pleural effusion. . [**2174-8-18**] ECHO: The left atrium is mildly [**Month/Day/Year 6878**]. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: No transthoracic echocardiographic evidence of valvular vegetation or abscess. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2174-7-15**], a large left pleural effusion is now seen. The absence of valvular vegetations on transthoracic echocardiogram does not preclude the presence of endocarditis. If clinical suspicion for endocarditis is high, a transesophageal echocardiogram may be considered. . [**2174-8-24**] LEFT UPPER EXTREMITY VENOUS ULTRASOUND: The Grayscale, color, and pulse Doppler son[**Name (NI) 867**] of the left internal jugular, axillary, subclavian, brachial, basilic and cephalic veins were obtained. Normal flow, compressibility, augmentation, and waveforms are demonstrated and no intraluminal thrombus is identified. A PICC is in place via the left basilic vein. IMPRESSION: No deep venous thrombosis in left upper extremity. . CXR ([**2174-8-24**]) - IMPRESSION: 1. Complete resolution of pulmonary edema. 2. Right middle lobe collapse. 3. Left lower lobe pneumonia. Brief Hospital Course: This is the brief hospital course for a 74 year-old female with a past medical history significant for Wegener's granulomatosis with pulmonary, tracheobronchial, and renal involvement who presented with worsening fever and productive cough. The [**Hospital 228**] medical issues dealt with during this hospital stay are detailed below. # Wegener's (lung) / pneumonia: The patient was found to have a left lower lobe pneumonia and a pleural effusion on chest x-ray [**8-17**], [**2174**]. Prior imaging on admission was negative for this finding. Clinically, the patient began to develop upper airway sounds the following day prompting an evaluation by [**Year (4 digits) **] pulmonary for possible bronchoscopy. In the meantime, the patient was continued on her admission course of Prednisone 20 mg daily for treatment of her Wegener's. She was also on Vancomycin/Zosyn, which was transitioned to Vancomyin/Meropenem for treatment of E. coli bacteremia which was likely caused by a pneumonia as urine cultures were negative for bacteria and sputum cultures were negative for PCP. [**Name10 (NameIs) 11063**] pulmonology took the patient for rigid bronchoscopy [**2174-8-18**] with intratracheal decadron injection and ballooning of the L main stem, with 100-200 cc of bleeding which resolved. She desated to 80%s when extubated and had to be reintubated, which was complicated by left lung collapse as well as transient hypotension (SBP to 70s) after a propofol bolus. Her SBPs corrected with NEO to 100-130s and she was admitted to the ICU for monitoring, intubated and on pressors. Her code status had been DNR on admission and was reversed for the procedure. On [**2174-8-19**], she had flexible bronchoscopy showing plaques suggestive of worsening Wegener's and had opening of left upper lobe and debridement. Pressors were weaned and CXR showed improvement of L lung. Sputum culture from [**2174-8-18**] grew Haemophilus influenzae and on [**2174-8-20**], she was switched to Ampicillin-Sulbactam 3 g IV q6hr. She was extubated on [**2174-8-20**] and on follow-up CXR had increased left lower lobe opacity, consistent with for new/worsening PNA vs. blood vs. effusion. Vancomycin was added because repeat sputum culture grew GPCs in clusters. Her respiratory status gradually improved, and she was moved to the floor on [**2174-8-22**]. Vancomycin was stopped on [**2174-8-25**], as it was felt that the GPCs in her sputum were normal respiratory flora. She completed a 14 day course of antibiotics by [**2174-8-26**] and her pulmonary exam gradually cleared with less rhonchi and better air movement. She had symptomatic improvement with albuterol nebulizers. On discharge, she was oxygenating well on 1 L NC and had a non-productive cough. At discharge, she remained on 20 mg prednisone daily. She will f/u with rheum and pulmonary as an outpatient. Her flovent was held, given her recent lung infection. She should discuss whether to restart this at her pulmonary f/u appointment. . # Ecoli bacteremia: As above, a blood culture from [**2174-8-13**] grew out pan-sensitive E. coli. The patient was changed from IV Vancomycin and IV Zosyn to IV Vancomycin and IV Meropenem because on past episodes such as this, the patient grew out species of E. coli which were resistent to Zosyn. A decision was made to switch to Meropenem as the patient developed x-ray changes significant for a new pleural effusion while on the Zosyn containing regimen. Subsequent blood cultures were negative. Ultimately, as above, she was transitioned to unasyn and completed a total 14 day [**Last Name (un) 10128**] of antibiotics. . # Hypotension: As above, was hypotensive during rigid bronchoscopy [**2174-8-18**] after propofol bolus and was briefly supported with pressors while in the intensive care unit. She had a brief episode of hypotension on [**2174-8-20**] which responded to 500 cc NS bolus. . # Aspiration risk: She had a video swallow on [**2174-8-22**] that showed aspiration of thin liquids and she was changed to a nectar diet. Of note, she had had recent speech/swallow evaluation on [**2174-5-30**] showing silent aspiration of thin liquids. . # Hypothyroidism: She has known hypothyroid (TSH 0.7 on [**7-2**]) and was maintained on home levothyroxine while in house. . . TRANSITIONAL ISSUES: - PICC line in place at time of discharge, as pt still receiving last few doses of IV unasyn. PICC should be discontinued after IV antibiotics are complete. - Flovent on hold at time of discharge, as pt with recent pulmonary infection. Can likely be restarted at pulm follow-up appointment. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) inhaled twice a day - No Substitution ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 ml by mouth daily CITALOPRAM - 20 mg Tablet - One Tablet(s) by mouth daily DIAZEPAM - 5 mg Tablet - 1 Tablet by mouth [**Last Name (un) **] 12 hours as needed FLUTICASONE [FLOVENT DISKUS] - 250 mcg Disk with Device - 2 puffs inh twice a day - No Substitution FUROSEMIDE - 40 mg Tablet - [**1-23**] Tablet(s) by mouth once a day LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE [SYNTHROID] - 150 mcg Tablet - 1 Tablet(s) by mouth once a day NYSTATIN - 100,000 unit/mL Suspension - 10 ml by mouth swish and swallow 3 times a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth at night PREDNISONE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1 Tablet(s) by mouth in the morning , half a tablet at night; [**First Name9 (NamePattern2) 98798**] [**2083-7-16**] mg daily. - No Substitution SIMVASTATIN - 20 mg Tablet - 1 Tablet by mouth DAILY (Daily) . Medications - OTC B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE [TUMS E-X] - (Prescribed by Other Provider) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (OTC) - 400 unit Tablet - 2 Tablet(s) by mouth daily DEXTROMETHORPHAN HBR [COUGH SUPPRESSANT] - 15 mg/5 mL Syrup - [**1-23**] tsp by mouth up to every four hours as needed for cough OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other Provider) - Dosage uncertain VIT C-VIT E-LUTEIN-MINERALS [OCUVITE LUTEIN] - (Prescribed by Other Provider) - Capsule - 1 (One) Capsule(s) by mouth once a day Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 2. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) Injection TID (3 times a day). 3. atovaquone 750 mg/5 mL Suspension [**Month/Day (2) **]: Ten (10) mL PO DAILY (Daily). 4. prednisone 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 5. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Ten (10) ML PO TID (3 times a day) as needed for thrush. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. furosemide 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QAM (once a day (in the morning)). 8. alendronate 70 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a week. 9. levothyroxine 150 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 10. citalopram 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 11. simvastatin 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 12. ampicillin-sulbactam 3 gram Recon Soln [**Month/Day (2) **]: Three (3) grams Injection Q6H (every 6 hours): For 1 more day, to complete a 14 day course of antibiotics, ending on [**2174-8-27**]. 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 14. B complex vitamins Oral 15. calcium carbonate Oral 16. cholecalciferol (vitamin D3) 400 unit Tablet [**Date Range **]: Two (2) Tablet PO once a day. 17. omega-3 fatty acids-vitamin E Oral 18. vit C-vit E-lutein-minerals Capsule [**Date Range **]: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: Primary: Pneumonia Secondary: Wegeners granulomatosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 98795**], it was a pleasure to take care of you during your hospital stay here. You were admitted for worsening shortness of breath and cough. You were found to have infections in your lungs and blood. Because of the infection, and your underlying lung disease (from Wegeners), you required treatment in the intensive care unit including intubation. During your admission, you also underwent bronchoscopy (insertion of a camera into your lungs to get a better look at your lungs). Your breathing has improved and the infection has been treated with a two-week course of antibiotics. CHANGES IN MEDICATIONS: - You are being given heparin injections to prevent blood clots when you are spending a lot of time in bed. When you are moving around at your rehabilitation facility, this can be stopped. - You will continue the IV antibiotics that we started (AMPICILLIN-SULBACTAM) for one more day, to complete a total 14 day course of antibiotics, ending on [**2174-8-27**]. - We STOPPED your flovent while you are recovering from a pulmonary infection. You should discuss with your lung doctors when [**Name5 (PTitle) **] should restart this medication. - We STOPPED your valium. You should discuss with your doctor when you should restart this medication. You are being discharged to a rehabilitation facility. You have follow-up appointments with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**2174-9-15**], a CT scan on [**2174-9-19**], and flexible bronchoscopy on [**2174-9-21**] the [**Hospital3 **] (details are below). Followup Instructions: Department: MEDICAL SPECIALTIES When: THURSDAY [**2174-9-15**] at 3:00 PM With: DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RHEUMATOLOGY When: MONDAY [**2174-9-19**] at 9:30 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage *The office is going to call you at the rehab facility if they get any cancellations for sooner appointments. Date/Time:[**2174-9-22**] 2:40 Department: PULMONARY FUNCTION LAB When: THURSDAY [**2174-9-15**] at 2:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]

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icd9cm

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[ "96.04", "33.24", "33.91", "38.93", "32.01", "96.71" ]

icd9pcs

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2829, 3312

3328, 3444

11,957

146,617

50671+50672

Discharge summary

report+report

Admission Date: [**2133-12-19**] Discharge Date: [**2134-1-5**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left lower extremity cellilits x 1 day, CP and chills. Major Surgical or Invasive Procedure: Diagnostic angiogram via right femoral artery access [**2133-12-23**] left fem-akpop with PTFe, akpopto peroneal w left arm vein [**2133-12-28**] left #2 toe amp [**2134-1-1**] History of Present Illness: 87 yo M with hx of CAD s/p MI/CABG, HTN, PVD/PAD, DM with hx L toe osteo with 1d of L 2nd toe swelling/erythema/pain. Also, episode of anginal CP 1hr before presentation, resolved with rest/nitro. In ED, temp to 101.2. Exam with cellulitis of L 2nd toe (same toe with previous osteo) with extension up lower leg. Given cipro/vanco. CXR no PNA, L foot x-ray no osteo. EKG unchanged. Continued to have cp in the ED which resolved with SLNG x 1. No n/v/d/abdominal pain, dysuria/no sob. Increase LLE swelling and erythema. He uses SLNG 1/month. ROS per HPI otherwise all other ROS negative. No increase in frequency of use of SLNG. Past Medical History: -CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD, SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat cath [**7-12**] showed inoperable disease. During admit [**10-12**], had CP a/w some dynamic ST segment depressions in anterior leads, medically managed with aspirin, plavix, ACE, imdur, and betablocker. LVEF >55% on Echo done [**12/2131**] -Incarcerated paraesophageal hernia s/p laparoscopic repair with fundoplication in [**10-12**]; associated gastric outlet obstruction resolved with surgical repair -Lower gastrointestinal bleed secondary to hemorrhoids and colonic polyps, admit [**2129-11-20**] -Hypertension with mild symmetric LVH -Afib, first noted post-op during [**10-12**] admission post op after paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off coumadin [**2-7**] significant bleeding issues. -Hyperlipidemia -Diabetes type II -By MRI/MRA: left posterior parietal infarct, chronic periventricular microvascular ischemic changes, moderate disease resulting in 60-70% stenosis of the right precavernous and cavernous ICA -s/p bilateral carotid endarterectomy -Peripheral vascular disease status post left toe amputation, followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 105256**] of prostate cancer status post radiation therapy -Cataracts Social History: No history of tobacco, no illicit drugs, no EtOH use. Walks without a walker at home. Lives with his wife [**Name (NI) 1446**] and son [**Name (NI) **] who is active in his care. Retired physical therapist, musician and barber. Independent of ADLs except for showering. Wife does the bills. He does his own medications and his son supervises. 3 children, 3 grandchildren and 7 great grandchildren. Last fell [**10-18**] and was admitted to [**Hospital 2940**]. Family History: History of MI in mother (death 89), father (death 67). Physical Exam: VS: T = 97.8 P = 56 BP = 100/46 RR = 18 O2Sat = 96% on RA Wt = GENERAL: Frail elderly male sitting up in bed Nourishment: At risk Grooming: Well groomed Mentation: Alert, slightly sleepy but when he wakes up he is able to participate in the conversation. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: RLL crackles Cardiovascular: RRR, nl. S1S2, loud blowing holosystolic murmur. Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: deferred Rectal: No stool in vault. Smear of stool is guiac negative. Skin: L second toe with hemtoma present. Pulses not appreciated on exam. Dopplers: No pressure ulcer Extremities: 2+ radial, pulses b/l. LLE with erythema, edema, more swollen than the right. L 2nd toe amputaion site dry and intact. Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. +DOYB. No evidence of delirium on exam. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Full affect with appropriate brightening. Pertinent Results: [**2133-12-19**] 09:47PM VoidSpec-[**Doctor First Name **] CLOT [**2133-12-19**] 09:30PM GLUCOSE-218* UREA N-35* CREAT-1.2 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-16 [**2133-12-19**] 09:30PM estGFR-Using this [**2133-12-19**] 09:30PM CK(CPK)-72 [**2133-12-19**] 09:30PM CK-MB-NotDone cTropnT-<0.01 [**2133-12-19**] 09:30PM ALBUMIN-3.9 CALCIUM-8.9 MAGNESIUM-2.0 [**2133-12-19**] 09:20PM WBC-10.9# RBC-2.93* HGB-8.9* HCT-26.4* MCV-90 MCH-30.4 MCHC-33.7 RDW-14.5 [**2133-12-19**] 09:20PM NEUTS-81.6* LYMPHS-11.9* MONOS-5.5 EOS-0.6 BASOS-0.4 [**2133-12-19**] 09:20PM PLT COUNT-211 Admission foot X ray: IMPRESSION: Stable radiographic appearance of partial amputations of the first and second digits. No radiographic evidence for osteomyelitis or subcutaneous gas. Conclusions The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately 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 ([**1-7**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2133-4-29**], the findings are similar. Portable TTE (Complete) Done [**2133-12-25**] at 11:54:31 AM The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately 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 ([**1-7**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. ECG Study Date of [**2133-12-28**] 4:37:14 PM Atrial fibrillation, mean ventricular rate 70. Right bundle-branch block. Inferior myocardial infarction. Compared to the previous tracing of [**2133-12-23**] cardiac rhythm is now atrial fibrillation. ECG Study Date of [**2133-12-29**] 2:31:48 PM Normal sinus rhythm. Right bundle-branch block. Prolonged A-V conduction. Inferior myocardial infarction which is old and marked notching across the precordium suggetes old anterior wall myocardial infarction as well. Since the previous tracing of [**2133-12-29**] no significant change. ECG Study Date of [**2133-12-31**] 10:21:36 AM Possible ectopic atrial rhythm at rate 59 with first degree A-V block and right bundle-branch block. Probable old inferior wall myocardial infarction. Low voltage in the precordial leads. Compared to the previous tracing of [**2133-12-29**] the sinus or ectopic atrial rate is slower. Brief Hospital Course: The patient is an 87 y.o. M with DM, hypertension, CHF, PVD who presents with cellulitis of the L 2nd toe along with erythema and swelling of the left leg. Problems: 1. CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD, SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat cath [**7-12**] showed inoperable disease presenting with CP 2. Hypertension with mild symmetric LVH 3. Afib, first noted post-op during [**10-12**] admission post op after paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off coumadin [**2-7**] significant bleeding issues. 4. Hyperlipidemia 5. Diabetes type II 6. PVD 7. S/p carotid endarterectomy Plan: -Continue abx, vancomycin and cipro - Podiatry consult -ROMI/tele/cycle enzymes - f/u blood cultures - ROMI negative consider PPI. - Continue all home meds: Plavix 75 mg qd, Toprol 12.5 mg qd, Imdur 30 mg qd, Lisinopril 5 mg [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg qd, Calcium/Vitamin D 1/day, MVT qd except januvia, not available at Code status: FULL d/w patient and family in detail on admission. Access: PIVs ppx; sub Q heparin Disposition: Pending w/u in progress Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 105430**], cp [**Telephone/Fax (1) 105431**] Wife=Mrs. [**Known lastname 105255**] = HCP number: [**Telephone/Fax (1) 105432**] [**Name2 (NI) **]ar consulted [**2133-12-20**] underwent diagnositc angio without complication Transfered to Vascualr Surgery service [**2133-12-23**] [**2133-12-23**] Repeat Angiogram without complication done for assesment of tibial vessels, not well visulaized with inital angio. [**Date range (1) 69262**] vein mapping ro access vein conduit for antcipated surgery was done.IV antibiotics were continued.Preoperative ECHO: EF >55% with mild to moderate MR [**2133-12-28**] s/p left fem-akpop w PTFE+akpop-peroneal artery bpg w left arm vein. [**2133-12-29**] POD#1 required transfusion for Hct of 25.Remained in VICU with aline and Swan catheter in place. diet advanced. IV fluid discontinued and patient remained on bedrest.[**Last Name (un) **] consulted for glycemic managment. Patient iniated on Glargine and humalog.Januvia discontinued. [**2133-12-30**] No acute events, transfused 2 units of PRBCs , given Fursemide in between units. Transferred to VICU [**Hospital Ward Name 121**] 5. [**2133-12-31**] pre-op and consented for left 2nd toe amputation. Remains in VICU. [**2134-1-1**] underwent L 2nd toe amputation, recovered in the PACU. Transferred back to [**Hospital Ward Name 121**] 5 VICU. Had some atrial rythm problems. Cardia Echo was done- showing LVH with preserved EF, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. Electrolytes repleted. 12/27-28/08 No acute events, [**Last Name (un) **] following. Central line d/c'd, peripheral IV inserted. [**2134-1-4**] No acute events, now full weight bearing bilaterally, PT [**Hospital 105433**] rehab placement. Became floor status. Rehab screening initiated. [**2134-1-5**] No acute events. Discharged to Rehab in good condition, will FU with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Medications on Admission: Plavix 75 mg qd Toprol 12.5 mg qd Imdur 30 mg qd Januvia 50 mg qd Lisinopril 5 mg qd [**Last Name (STitle) **] 81 mg qd SLNG 0.4 mg prn Calcium/Vitamin D 1/day MVT qd 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. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 5. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime: 14 units. 6. Insulin Aspart 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: AC:breakfast [**Last Name (STitle) 105434**]: < 70 no insulin 71-120/2u 121-160/3u 161-200/5u 201-240/6u 241-280/7u 281-320/8u 321-360/9u 361-400/10u >400 [**Name8 (MD) 138**] MD u=units lunch/dinner AC glucoes: <120 no insulin 121-160/2u 161-200/4u 201-240/6u 241-280/7u 281-320/8u 321-360/9u 361-400/10u >400 [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) 105434**]: <160 no insulin 161-200/2u 201-240/4u 241-280/6u 281-320/7u 321-360/8u 361-400/9u >400 [**Name8 (MD) 138**] Md . 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): while taking narcotics. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Healthcare of [**Location (un) 55**] Discharge Diagnosis: Lower right extremity cellulitis angina histroy of chroinic systolic CHF on acute history of coronarary artery disease s/p 3V CABG ( SVG_D1+LAD,Svg-OM1+OM3, svg-AM) s/p PCI/'[**28**],stenting of SVG-D1+ LAD,Cardiac cath '[**31**], inoperable disease history of paraesophgeal hernia-incarcerated s/p laperscopic repair with fundoplication [**10-12**], complicated by gastric out let symdrome s /p surgical repair history of lower GI bleed [**2-7**] hemmroids and colonic polyps [**11-10**] history of hypertension with symmertical LVH history of AF, converted NSR, anticoagulated d/c'd [**2-7**] GI bleed history of dyslipdemia history of DM2, insulin dependant history of posterior paraiatal infract by MRA?Mhronic periventricular microvascular disease carotid disease of pericavenerous& cavernous ICA 60-70%,s/p bilateral CEA's history of peripheral vascular diasease s/p left toe amputation post-operative anemia requiring blood transfusions Atrial fibrillation Discharge Condition: stable Discharge Instructions: - walk essential distances untill FU with Dr. [**Last Name (STitle) 1391**] - Ace wrap leg from foot-knee when ambulating - Elevate leg when sitting - no driving till FU - may shower, no tub baths - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Continue all medications as directed - Keep all FU appointments - Call Dr.[**Name (NI) 1392**] office for FU appointment Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: 2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment, [**Telephone/Fax (1) 1393**] Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] (PCP) [**Telephone/Fax (1) 719**] Date/Time: [**2133-1-18**] 1:30 PM [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2134-1-13**] 11:30 Completed by:[**2134-1-5**] Admission Date: [**2133-12-19**] Discharge Date: [**2134-1-5**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left lower extremity cellilits x 1 day, CP and chills. Major Surgical or Invasive Procedure: Diagnostic angiogram via right femoral artery access [**2133-12-23**] left fem-akpop with PTFe, akpopto peroneal w left arm vein [**2133-12-28**] left #2 toe amp [**2134-1-1**] History of Present Illness: 87 yo M with hx of CAD s/p MI/CABG, HTN, PVD/PAD, DM with hx L toe osteo with 1d of L 2nd toe swelling/erythema/pain. Also, episode of anginal CP 1hr before presentation, resolved with rest/nitro. In ED, temp to 101.2. Exam with cellulitis of L 2nd toe (same toe with previous osteo) with extension up lower leg. Given cipro/vanco. CXR no PNA, L foot x-ray no osteo. EKG unchanged. Continued to have cp in the ED which resolved with SLNG x 1. No n/v/d/abdominal pain, dysuria/no sob. Increase LLE swelling and erythema. He uses SLNG 1/month. ROS per HPI otherwise all other ROS negative. No increase in frequency of use of SLNG. Past Medical History: -CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD, SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat cath [**7-12**] showed inoperable disease. During admit [**10-12**], had CP a/w some dynamic ST segment depressions in anterior leads, medically managed with aspirin, plavix, ACE, imdur, and betablocker. LVEF >55% on Echo done [**12/2131**] -Incarcerated paraesophageal hernia s/p laparoscopic repair with fundoplication in [**10-12**]; associated gastric outlet obstruction resolved with surgical repair -Lower gastrointestinal bleed secondary to hemorrhoids and colonic polyps, admit [**2129-11-20**] -Hypertension with mild symmetric LVH -Afib, first noted post-op during [**10-12**] admission post op after paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off coumadin [**2-7**] significant bleeding issues. -Hyperlipidemia -Diabetes type II -By MRI/MRA: left posterior parietal infarct, chronic periventricular microvascular ischemic changes, moderate disease resulting in 60-70% stenosis of the right precavernous and cavernous ICA -s/p bilateral carotid endarterectomy -Peripheral vascular disease status post left toe amputation, followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 105256**] of prostate cancer status post radiation therapy -Cataracts Social History: No history of tobacco, no illicit drugs, no EtOH use. Walks without a walker at home. Lives with his wife [**Name (NI) 1446**] and son [**Name (NI) **] who is active in his care. Retired physical therapist, musician and barber. Independent of ADLs except for showering. Wife does the bills. He does his own medications and his son supervises. 3 children, 3 grandchildren and 7 great grandchildren. Last fell [**10-18**] and was admitted to [**Hospital 2940**]. Family History: History of MI in mother (death 89), father (death 67). Physical Exam: VS: T = 97.8 P = 56 BP = 100/46 RR = 18 O2Sat = 96% on RA Wt = GENERAL: Frail elderly male sitting up in bed Nourishment: At risk Grooming: Well groomed Mentation: Alert, slightly sleepy but when he wakes up he is able to participate in the conversation. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: RLL crackles Cardiovascular: RRR, nl. S1S2, loud blowing holosystolic murmur. Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: deferred Rectal: No stool in vault. Smear of stool is guiac negative. Skin: L second toe with hemtoma present. Pulses not appreciated on exam. Dopplers: No pressure ulcer Extremities: 2+ radial, pulses b/l. LLE with erythema, edema, more swollen than the right. L 2nd toe amputaion site dry and intact. Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. +DOYB. No evidence of delirium on exam. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Full affect with appropriate brightening. Pertinent Results: [**2133-12-19**] 09:47PM VoidSpec-[**Doctor First Name **] CLOT [**2133-12-19**] 09:30PM GLUCOSE-218* UREA N-35* CREAT-1.2 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-16 [**2133-12-19**] 09:30PM estGFR-Using this [**2133-12-19**] 09:30PM CK(CPK)-72 [**2133-12-19**] 09:30PM CK-MB-NotDone cTropnT-<0.01 [**2133-12-19**] 09:30PM ALBUMIN-3.9 CALCIUM-8.9 MAGNESIUM-2.0 [**2133-12-19**] 09:20PM WBC-10.9# RBC-2.93* HGB-8.9* HCT-26.4* MCV-90 MCH-30.4 MCHC-33.7 RDW-14.5 [**2133-12-19**] 09:20PM NEUTS-81.6* LYMPHS-11.9* MONOS-5.5 EOS-0.6 BASOS-0.4 [**2133-12-19**] 09:20PM PLT COUNT-211 Admission foot X ray: IMPRESSION: Stable radiographic appearance of partial amputations of the first and second digits. No radiographic evidence for osteomyelitis or subcutaneous gas. Conclusions The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately 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 ([**1-7**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2133-4-29**], the findings are similar. Portable TTE (Complete) Done [**2133-12-25**] at 11:54:31 AM The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately 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 ([**1-7**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. Dilated ascending aorta. ECG Study Date of [**2133-12-28**] 4:37:14 PM Atrial fibrillation, mean ventricular rate 70. Right bundle-branch block. Inferior myocardial infarction. Compared to the previous tracing of [**2133-12-23**] cardiac rhythm is now atrial fibrillation. ECG Study Date of [**2133-12-29**] 2:31:48 PM Normal sinus rhythm. Right bundle-branch block. Prolonged A-V conduction. Inferior myocardial infarction which is old and marked notching across the precordium suggetes old anterior wall myocardial infarction as well. Since the previous tracing of [**2133-12-29**] no significant change. ECG Study Date of [**2133-12-31**] 10:21:36 AM Possible ectopic atrial rhythm at rate 59 with first degree A-V block and right bundle-branch block. Probable old inferior wall myocardial infarction. Low voltage in the precordial leads. Compared to the previous tracing of [**2133-12-29**] the sinus or ectopic atrial rate is slower. Brief Hospital Course: The patient is an 87 y.o. M with DM, hypertension, CHF, PVD who presents with cellulitis of the L 2nd toe along with erythema and swelling of the left leg. Problems: 1. CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD, SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat cath [**7-12**] showed inoperable disease presenting with CP 2. Hypertension with mild symmetric LVH 3. Afib, first noted post-op during [**10-12**] admission post op after paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off coumadin [**2-7**] significant bleeding issues. 4. Hyperlipidemia 5. Diabetes type II 6. PVD 7. S/p carotid endarterectomy Plan: -Continue abx, vancomycin and cipro - Podiatry consult -ROMI/tele/cycle enzymes - f/u blood cultures - ROMI negative consider PPI. - Continue all home meds: Plavix 75 mg qd, Toprol 12.5 mg qd, Imdur 30 mg qd, Lisinopril 5 mg [**Last Name (LF) **], [**First Name3 (LF) **] 81 mg qd, Calcium/Vitamin D 1/day, MVT qd except januvia, not available at Code status: FULL d/w patient and family in detail on admission. Access: PIVs ppx; sub Q heparin Disposition: Pending w/u in progress Contact: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 105430**], cp [**Telephone/Fax (1) 105431**] Wife=Mrs. [**Known lastname 105255**] = HCP number: [**Telephone/Fax (1) 105432**] [**Name2 (NI) **]ar consulted [**2133-12-20**] underwent diagnositc angio without complication Transfered to Vascualr Surgery service [**2133-12-23**] [**2133-12-23**] Repeat Angiogram without complication done for assesment of tibial vessels, not well visulaized with inital angio. [**Date range (1) 69262**] vein mapping ro access vein conduit for antcipated surgery was done.IV antibiotics were continued.Preoperative ECHO: EF >55% with mild to moderate MR [**2133-12-28**] s/p left fem-akpop w PTFE+akpop-peroneal artery bpg w left arm vein. [**2133-12-29**] POD#1 required transfusion for Hct of 25.Remained in VICU with aline and Swan catheter in place. diet advanced. IV fluid discontinued and patient remained on bedrest.[**Last Name (un) **] consulted for glycemic managment. Patient iniated on Glargine and humalog.Januvia discontinued. [**2133-12-30**] No acute events, transfused 2 units of PRBCs , given Fursemide in between units. Transferred to VICU [**Hospital Ward Name 121**] 5. [**2133-12-31**] pre-op and consented for left 2nd toe amputation. Remains in VICU. [**2134-1-1**] underwent L 2nd toe amputation, recovered in the PACU. Transferred back to [**Hospital Ward Name 121**] 5 VICU. Had some atrial rythm problems. Cardia Echo was done- showing LVH with preserved EF, mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. Electrolytes repleted. 12/27-28/08 No acute events, [**Last Name (un) **] following. Central line d/c'd, peripheral IV inserted. [**2134-1-4**] No acute events, now full weight bearing bilaterally, PT [**Hospital 105433**] rehab placement. Became floor status. Rehab screening initiated. [**2134-1-5**] No acute events. Discharged to Rehab in good condition, will FU with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Medications on Admission: Plavix 75 mg qd Toprol 12.5 mg qd Imdur 30 mg qd Januvia 50 mg qd Lisinopril 5 mg qd [**Last Name (STitle) **] 81 mg qd SLNG 0.4 mg prn Calcium/Vitamin D 1/day MVT qd 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. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 5. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime: 14 units. 6. Insulin Aspart 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: AC:breakfast [**Last Name (STitle) 105434**]: < 70 no insulin 71-120/2u 121-160/3u 161-200/5u 201-240/6u 241-280/7u 281-320/8u 321-360/9u 361-400/10u >400 [**Name8 (MD) 138**] MD u=units lunch/dinner AC glucoes: <120 no insulin 121-160/2u 161-200/4u 201-240/6u 241-280/7u 281-320/8u 321-360/9u 361-400/10u >400 [**Name8 (MD) 138**] MD [**First Name (Titles) **] [**Last Name (Titles) 105434**]: <160 no insulin 161-200/2u 201-240/4u 241-280/6u 281-320/7u 321-360/8u 361-400/9u >400 [**Name8 (MD) 138**] Md . 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): while taking narcotics. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Healthcare of [**Location (un) 55**] Discharge Diagnosis: Lower right extremity cellulitis angina histroy of chroinic systolic CHF on acute history of coronarary artery disease s/p 3V CABG ( SVG_D1+LAD,Svg-OM1+OM3, svg-AM) s/p PCI/'[**28**],stenting of SVG-D1+ LAD,Cardiac cath '[**31**], inoperable disease history of paraesophgeal hernia-incarcerated s/p laperscopic repair with fundoplication [**10-12**], complicated by gastric out let symdrome s /p surgical repair history of lower GI bleed [**2-7**] hemmroids and colonic polyps [**11-10**] history of hypertension with symmertical LVH history of AF, converted NSR, anticoagulated d/c'd [**2-7**] GI bleed history of dyslipdemia history of DM2, insulin dependant history of posterior paraiatal infract by MRA?Mhronic periventricular microvascular disease carotid disease of pericavenerous& cavernous ICA 60-70%,s/p bilateral CEA's history of peripheral vascular diasease s/p left toe amputation post-operative anemia requiring blood transfusions Atrial fibrillation Discharge Condition: stable Discharge Instructions: - walk essential distances untill FU with Dr. [**Last Name (STitle) 1391**] - Ace wrap leg from foot-knee when ambulating - Elevate leg when sitting - no driving till FU - may shower, no tub baths - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Continue all medications as directed - Keep all FU appointments - Call Dr.[**Name (NI) 1392**] office for FU appointment Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: 2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment, [**Telephone/Fax (1) 1393**] Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] (PCP) [**Telephone/Fax (1) 719**] Date/Time: [**2133-1-18**] 1:30 PM [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2134-1-13**] 11:30 Completed by:[**2134-1-5**]

[ "440.24", "250.72", "729.81", "V45.82", "440.4", "250.62", "276.2", "681.10", "V45.81", "428.22", "428.0", "682.6", "585.3", "041.11", "427.31", "413.9", "250.82", "357.2", "707.15", "412", "V58.67", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "84.11", "86.04", "88.48", "38.93", "39.29" ]

icd9pcs

[ [ [] ] ]

27986, 28081

23257, 26387

15326, 15505

29090, 29099

19460, 23234

29681, 30105

18003, 18059

26604, 27963

28102, 29069

26413, 26581

29123, 29658

19214, 19441

18074, 19077

15232, 15288

15533, 16164

19092, 19197

16186, 17507

17523, 17987

17,059

153,310

23440

Discharge summary

report

Admission Date: [**2157-10-29**] Discharge Date: [**2157-11-3**] Date of Birth: [**2083-5-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: liver mass Major Surgical or Invasive Procedure: None History of Present Illness: 74 year old retired machinist transferred from [**Hospital 1263**] hospital on [**2157-10-29**] for a transfusion requirement secondary to a liver mass. He was well until approximately 1 week prior to admission at which time he described a slowly increasing abdominal girth and abdominal discomfort. This distention continued until the day of admission to [**Hospital 1263**] hospital when he noted that his abdomen was tensly distended and uncomfortable, and in addition he had some shaking chills. A CT demonstrated a large lesion in the right lobe of the liver concerning for a hepatoma. He had a paracentesis and a hematocrit of 26.6 on admission. The following day his hematocrit dropped to 19.6, and after 3 units of transfusion, his hematocrit increased to 26. He has no nausea or vomiting, his last bowel movement was the day prior to admisson. Of not the patierns faimly stated that the patient had a recent colonscopy in [**Month (only) **] that was within normal limits. His peritoneal tap from [**10-28**] had [**2152**] wbcs, 2380 rbcs, 61 polys, albumin 1.2. Cytology was negative for malignant cells Past Medical History: Coronary artery disease status post PTCA stent 3 years ago at [**Last Name (LF) 112**], [**First Name3 (LF) **] 55% Hypertension Diet controlled diabetes Prostate cancer status post radical prostatectomy Diverticulosis History of multiple rib fractures Glaucoma History of negative hepatitis serologies History of ATN with urosepsis and pyelonephritis Past surgical history: Radical prostatectomy [**2151**] Umbilical hernia repair Left posterior chest surgery secondary to trauma Social History: Retired, wife deceased, Lives alone, history of alcohol, 3 drinks a day, quit 7 years ago. no history of IVDU Family History: 6 brothers, 2 sisters, no history of cancer or liver disease Physical Exam: Temperature 101.0, Pulse 84, Blood pressure 152/52, Respiratory rate 26, Oxygen saturation 97% on 2L NC General: well appearing stated age in no apparent distress HEENT: Sclerae non-icteric, mucous membraines moist, no lymphadenopathy Cardiac: regular rate and rythym with no murmurs Lungs: Clear to auscultation bilaterally Abdomen: Distended, tympanic with some ecchymosis periumbilical. Reducible Right inguinal hernia. No spider telangetasia. Discomfort to deep palpation in all 4 quadrants without rebound or guarding Extremities: Warm and well perfused, with good pulses bilaterally. no clubbing cyanosis or edema. Rectal: empty vault, absent prostate. Guiac negative. Pertinent Results: Admission labs: [**2157-10-29**] WBC-11.1* RBC-3.66* Hgb-11.0* Hct-32.7* MCV-89 MCH-30.2 MCHC-33.8 RDW-16.8* Plt Ct-277 PT-12.4 PTT-25.1 INR(PT)-1.0 Glucose-81 UreaN-63* Creat-2.8* Na-135 K-4.3 Cl-98 HCO3-22 AnGap-19 ALT-208* AST-326* LD(LDH)-312* AlkPhos-153* Amylase-53 TotBili-2.3* DirBili-1.2* IndBili-1.1 Lipase-34 Albumin-3.0* Calcium-8.6 Phos-4.9 Mg-1.9 Iron-25* Cholest-165 CEA-2.0 AFP-412.7 CA19-9 pending at discharge Liver Ultrasound [**2157-10-30**]: 1. Massive predominantly right-sided liver mass with extension into the medial segment of the left lobe. 2. Small amount of perihepatic ascites. 3. No identification of the main portal vein or right portal veins. 4. Multiple portal varices are seen at the porta hepatis and in the gallbladder fossa, likely indicating a cavernous transformation due to chronic occlusion. 5. Patency of the left hepatic vasculature is noted. MRI Abdomen [**2157-10-31**]: 1) Large, heterogeneous mass occupying the entire right lobe of the liver which is most consistent with a hepatoma. There is invasion of the main portal vein just distal to the portal vein/superior mesenteric vein junction, as well as the left and right portal veins. 2) Nodular mass lesion in the right lower lobe which appears to be either pleural or chest wall based and involves a posterior right rib. This is concerning for metastasis. 3) Paracholecystic varices. 4) Ascites. Brief Hospital Course: The patient was admitted to the surgical intensive care unit for hemodynamic monitoring and hematocrit monitoring. Serial hematocrits were monitored and were stable. Hepatology was consulted as well as medical oncology. He remained hemodyamically stable and was transferred to the surgical floor by hospital day 2. Hepatology suggested a paracentesis for cytology, but this was obtained at the outside hospital so this was deferred. An ultrasound and MRI were also obtained to further evaluate the mass. Medical oncology felt that a tissue diagnosis might help, but the patient has significant surgical risk and this was deferred given the picture on CT. Given that the patient was nooperative, the patient was set up for oncology follow up. They felt that the patient was not a candidate for a treatment trial nor a candidate for radioablation therapy (too large), or chemoembolization, but they would consider possible options for palliative chemotherapy. The patient was also seen by the physical therapists to assess functional ability, and they felt that the patient was safe to go home. The patient will follow up with oncology for further treatment management. A family meeting was held prior to discharge to discuss the follow up and prognosis Medications on Admission: Aspirin 81 mg qd, multiple glaucoma meds Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) **] VNA Discharge Diagnosis: Probable Hepatocellular carcinoma Hepatic mass Hypertension Diabetes History of prostate cancer status post prostatectomy Diverticulosis Ascites Discharge Condition: Stable Discharge Instructions: weakness or dizziness, intractable nausea or vomiting, inability to tolerate food. You may resume your regular diet You should continue taking any medications you were taking prior to this hospitalization. Followup Instructions: You should follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Oncology in the next week. Call his office for an appointment. You will need to meet with him for any further discussions of chemotherapy planning, so you should call shortly after discharge You can follow up with Dr. [**Last Name (STitle) 816**] only if necessary.

[ "155.0", "365.9", "560.1", "593.9", "571.2", "V10.46", "786.6", "401.9", "285.9", "250.00", "V12.01", "567.8", "568.81", "V45.82", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5922, 5978

4333, 5595

326, 333

6167, 6175

2908, 2908

6431, 6804

2134, 2196

5686, 5899

5999, 6146

5621, 5663

6199, 6408

1884, 1991

2211, 2889

276, 288

361, 1486

2924, 4310

1508, 1861

2007, 2118

6,893

145,334

30129

Discharge summary

report

Admission Date: [**2187-5-18**] Discharge Date: [**2187-6-22**] Date of Birth: [**2131-4-6**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: transferred s/p ICH Major Surgical or Invasive Procedure: Intubation Tracheostomy PEG EGD History of Present Illness: 56yo M h/o HTN non-compliant on medications and poorly controlled, who presented to [**Hospital1 **] yesterday evening with vomiting and decreased responsiveness and found to have a left BG hemorrhage. Per his records, he had N/V x one week but had not sought medical attention. Yesterday, he complained of headache and was agitated, with worse vomiting. His wife found him "acting strange" and "thrashing about in the bed" and he did not respond to voice. She denied history of alcohol or cocaine use in the patient; nor does he have h/o DM, stroke, TIA and had not had fever/chills, chest pain, SOB, abdominal pain, urinary symptoms, diarrhea, constipation, neck/back pain, flank pain or URI symptoms. On EMS arrival, bp was 270/140 and pulse 140. He was flaccid on his right side and had non-sensical speech. They applied nitropaste and gave SLNTG. At [**Hospital1 **], his neurological exam was documented as "GCS of 9 (3-eye, 2-verbal, 4-motor). He was given IV labetalol and loaded with dilantin 1g IV. Blood pressure fell to systolic 120's and antihypertensives were discontinued. He received sedation en route to our ED and had been off sedation for 30min prior to first neurological exam by Dr. [**Last Name (STitle) **]. Platelet transfusion was refused by the wife due to Jehovah witness religion. ICU course has been complicated this morning by hypertension, with pressures in the systolic 200's and MAPs 140s; coffee-grounds suctioned out of his NGT and oliguria (25cc's total). Neurologically, however, his exam has improved (see below), off sedation. Past Medical History: PMH: HTN Dr. [**Last Name (STitle) 2578**] ([**Hospital1 2025**]) last saw patient in [**2182**], with Cr in 2's and HTN, at which point he discontinued medical care and stopped taking all meds Social History: SH: no etoh/drugs/tob. jehovah's witness (refuses PRBC transfusions) Family History: FH: unknown Brief Hospital Course: Neuro: The patient was admitted to the neurologic ICU after discovery of his left-sided intracerebral hemorrhage. His blood pressure was controlled and his neurologic status remained stable; he retained full alertness throughout. On [**6-4**], he was transferred from the ICU to neurologic stepdown unit, for continued treatment and placement in rehab. His left side retained full strength and after 7-10 days, he began again to follow commands. His right was initially flaccid with no response to noxious stimuli, but began to develop some movement 2 weeks before discharge. Upon discharge, he had some antigravity strength in the biceps, triceps, wrist extensor, grasp. He was only trace at deltoid, wrist flexor and finger extensors. Right homonymous hemianopia persists. The right leg was initially flaccid. Then developed some non antigravity movement on noxious stimulation. This continued to improve, and at discharge, he was a 4 in the IP, HS, 3 at Quad, and 4+ in the Dorsi/plantar flexors. Renal: The patient was seen by renal consult and dialysis initiated, which he will be dependent upon for the forseeable future. The etiology was thought to be a combination of HTN, then hypoperfusion/ATN, and microangiopathy, the latter which would explain the patient's thrombocytopenia, which is now recovered. The patient received Hemodialysis MWF which he was tolerating well. His most recent HD was on day of discharge [**2187-6-22**]. Heme: Heme consult found no evidence of schistocytes. Work up of his iron deficiency anmeia revealed upper GI bleed with gastritis, duodenitis and [**Doctor First Name 329**]-[**Doctor Last Name **] tear. Had an episode early [**Month (only) 116**] with heme positive stool and coffee ground residuals. Hematocrit fell to the extent that he required transfusion. Although he previously refused blood-products secondary to his religious preferences, he did at this time agree and consent to 2 units PRBC. GI: Patient was scoped for chronic anemia and was found to have gastritis, duodenitis and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear. On [**6-11**] was found to have two large heme + stools and hematocrit fell moderately. Remained hemodynamically stable but was also found later to have coffee ground emesis. Repeated lavage did not produce any blood and GI was notified. He remained hemodynamically stable but with hematocrit drop did end up receiving two units PRBC. His PPI was changed from PO to IV BID per GI recs. He was not re-scoped. Heme + stools stopped spontaneously and Hematocrit remained stable. Pulm: From a pulmonary standpoint, the patient underwent tracheostomy on [**6-2**], which he needed due to a poor cough reflex. He has been successfully weaned from the ventilator. He still has tracheostomy and is tolerating trach mask and passy-muir valve well. He had large thick sputum production initially which was MRSA positive. He has now completed a 10 day course Vancomycin IV and has mild/moderate light yellow sputum production which continues to decrease. Cards: Cardiac-wise, hypertension has been well controlled now on amlodipine, lisinopril and metoprolol. There have been no arythmias. He has had no other cardiac issues. ID: From ID standpoint his course was complicated by aspiration pneumonia, which was treated successfully first with vanco/zosyn and then course completed on levaquin. BAL showed staph aureus and H.flu. Sputum production was significant and trach was maintained for patient's inability to handle secretions. Sputum cultures were sent multiple times, initially growing only oral flora, later MRSA. The patient's MRSA screen returned positive and he was put on contact precautions. On [**6-10**]: stool studies returned positive for Cdiff and the patient was started on Flagyl. On [**6-12**] sputum cultures returned positive for MRSA and Vancomycin was started for 10 day course renally dosed. At this time, he has completed 10 days vancomycin and is on day 12 of 14 for Flagyl for Cdiff. Medications on Admission: None Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Intracerebral hemorrhage Acute renal failure Anemia of chronic disease Hypertension Aspiration pneumonia Mallor-[**Doctor Last Name **] tear C diff MRSA positive recent MRSA in sputum Discharge Condition: Good. Improving right hemiparesis. Peg/trach. Discharge Instructions: You were admitted to the hospital with a left-sided bleed in your head. You also had kidney failure and will need dialysis. Your course was complicated by pneumonia, for which you were treated with antibiotics. You had a tracheostomy and PEG placed for help with breathing and eating; these may be eventually discontinued. Your bleed was caused by high blood pressure and you should see a doctor regularly for blood pressure control. Followup Instructions: [**First Name8 (NamePattern2) 2530**] [**Name8 (MD) **], MD (Stroke Neurologist): [**2190-7-24**]:30 at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) **]. # [**Telephone/Fax (1) 44**] After discharge from Rehabiliation, call [**Telephone/Fax (1) 250**] to arrange a primary care physician for yourself. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "584.9", "V09.0", "287.5", "V15.81", "507.0", "437.2", "285.29", "008.45", "403.90", "535.50", "535.60", "585.6", "431", "342.90", "427.31", "530.7", "518.81", "348.4" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95", "43.19", "96.72", "33.23", "99.04", "45.13", "96.6", "31.1" ]

icd9pcs

[ [ [] ] ]

6424, 6503

2326, 6369

335, 369

6731, 6781

7263, 7738

2289, 2303

6524, 6710

6395, 6401

6805, 7240

276, 297

397, 1968

1990, 2186

2202, 2273

25,848

142,166

13656+13657+13658+56479

Discharge summary

report+report+report+addendum

Admission Date: [**2136-11-29**] Discharge Date: [**2136-11-19**] Date of Birth: [**2072-5-19**] Sex: M Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old gentleman with a history of CAD, who on [**2136-11-22**], under a microvascular decompression for trigeminal neuralgia. Preoperatively, he was found to be in atrial flutter and underwent cardiac catheterization which showed clear coronaries. On [**2136-11-28**], he was loaded on Heparin and admitted for cardioversion. He had a negative TEE and converted to normal sinus rhythm. He was placed on Amiodarone. He was discharged on Lovenox and Coumadin after cardioversion. On [**2136-11-29**] in the morning, he complained of sudden onset of severe headache, followed by nausea, vomiting, and vertical diplopia. In the emergency room, he developed sinus bradycardia with ventricular escape beats, and he was given Atropine. He was brought into a normal sinus rhythm. He became disoriented with a severe headache. Head CT showed acute posterior fossa subarachnoid hemorrhage with fourth ventricle obstruction. On examination, the blood pressure as 240/120, heart rate was down to 12. He was sleep. He only responded to vigorous stimulation. He would fall back to sleep easily, withdraw on all four extremities. Pupils were 5-mm and minimally reactive bilaterally. He had a positive gag. Face was symmetrical. He was not moving any extremities, but to pain. His eyes were closed. He was hyperreflexic on the left. PAST MEDICAL HISTORY: History included CAD and status post CABG. He also had prosthetic valve placed and trigeminal neuralgia decompression. LABORATORY DATA: Labs on admission revealed the following: White count 7.5, hematocrit 40.7, platelet count 260,000, PT 14.4, PTT 35.1, INR 1.4. The patient was admitted to the Surgical Intensive Care Unit and a ventricular drain was placed. The patient was monitored closely. The Department of Cariology saw the patient in the Intensive Care Unit and recommended holding all beta blockers and restarting the Amiodarone. The patient remained intubated and sedation for two days. On [**2136-12-2**], all sedation was discontinued and the patient was showing some signs of improvement. Pupils were 3-mm down to 2 -mm and briskly reactive. The patient was following simple commands, showing two fingers. The patient had repeat head CT on [**2136-12-2**], which showed no change in the fourth ventricle. The patient had an episode of hypoxia on [**2136-12-3**]. The patient had a CT angiogram, which was negative for PE. The patient had spiked a temperature on [**2136-12-4**] and was started on Levofloxacin for gram-negative rods, sputum culture. The patient continued to be followed by the Cardiology Service. The patient went back into atrial fibrillation. The Department of Cardiology recommended electrocoagulation, which was done. The patient converted to normal sinus rhythm and has remained in normal sinus rhythm to date. The patient was extubated on [**2136-12-10**] and tolerated that well. He was awake, alert, oriented, following commands, moving all extremities strongly. He was transferred to the regular floor on [**2136-12-12**]. He had a swallow evaluation, which he failed. He had a G tube placed. Vital signs have remained stable. He has been afebrile. He finished a 10-day course of Levofloxacin for Klebsiella pneumonia. He current is afebrile. He was seen by physical therapy and Occupational Therapy and found to require rehabilitation prior to discharge home. MEDICATIONS ON DISCHARGE: 1. Prevacid 30 mg per NG tube q.12h. 2. Levofloxacin discontinued. 3. Captopril 25 mg per NG tube q.8h. 4. Nystatin swish and swallow 5 cc q.6h. 5. Celebrex 200 mg per NG tube q.day. 6. Lopressor 25 mg p.o.b.i.d. 7. Amiodarone 200 mg p.o. NG tube b.i.d. 8. Tums 500 mg per NG tube b.i.d. 9. Tylenol 650 q.4.h. p.r.n. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 6910**] in 10 to 14 days and with his cardiologist as needed postoperatively. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2136-12-17**] 12:04 T: [**2136-12-17**] 12:06 JOB#: [**Job Number 41194**] 1 1 1 DR Admission Date: [**2136-11-29**] Discharge Date: [**2136-11-19**] Date of Birth: [**2072-5-19**] Sex: M Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old gentleman with a history of CAD, who, on [**2136-11-22**], underwent microvascular decompression for trigeminal neuralgia. Preoperatively, he was found to be in atrial flutter and underwent cardiac catheterization, which showed clear coronaries. On [**2136-11-28**], he was loaded on Heparin and admitted for cardioversion. He had a negative TEE and converted to normal sinus rhythm. He was placed on Amiodarone. He was discharged on Lovenox and Coumadin after cardioversion. On [**2136-11-29**], in the morning, he complained of sudden onset of severe headache, followed by nausea, vomiting, and vertical diplopia. In the emergency room, he developed sinus bradycardia with ventricular escape beats, and he was given Atropine. He was brought into a normal sinus rhythm. He became disoriented with a severe headache. Head CT showed acute posterior fossa subarachnoid hemorrhage with fourth ventricle obstruction. On examination, the blood pressure as 240/120, heart rate was down to 12. He was sleep. He only responded to vigorous stimulation. He would fall back to sleep easily, withdraw on all four extremities. Pupils were 5-mm and minimally reactive bilaterally. He had a positive gag. Face was symmetrical. He was not moving any extremities, but to pain. His eyes were closed. He was hyperreflexic on the left. PAST MEDICAL HISTORY: History included CAD and status post CABG. He also had prosthetic valve placed and trigeminal neuralgia decompression. LABORATORY DATA: Labs on admission revealed the following: White count 7.5, hematocrit 40.7, platelet count 260,000, PT 14.4, PTT 35.1, INR 1.4. The patient was admitted to the Surgical Intensive Care Unit and a ventricular drain was placed. The patient was monitored closely. The Department of Cariology saw the patient in the Intensive Care Unit and recommended holding all beta blockers and restarting the Amiodarone. The patient remained intubated and sedation for two days. On [**2136-12-2**], all sedation was discontinued and the patient was showing some signs of improvement. Pupils were 3-mm down to 2 -mm and briskly reactive. The patient was following simple commands, showing two fingers. The patient had repeat head CT on [**2136-12-2**], which showed no change in the fourth ventricle. The patient had an episode of hypoxia on [**2136-12-3**]. The patient had a CT angiogram, which was negative for PE. The patient had spiked a temperature on [**2136-12-4**] and was started on Levofloxacin for gram-negative rods, sputum culture. The patient continued to be followed by the Cardiology Service. The patient went back into atrial fibrillation. The Department of Cardiology recommended electrocoagulation, which was done. The patient converted to normal sinus rhythm and has remained in normal sinus rhythm to date. The patient was extubated on [**2136-12-10**] and tolerated that well. He was awake, alert, oriented, following commands, moving all extremities strongly. He was transferred to the regular floor on [**2136-12-12**]. He had a swallow evaluation, which he failed. He had a G tube placed. Vital signs have remained stable. He has been afebrile. He finished a 10-day course of Levofloxacin for Klebsiella pneumonia. He current is afebrile. He was seen by physical therapy and Occupational Therapy and found to require rehabilitation prior to discharge home. MEDICATIONS ON DISCHARGE: 1. Prevacid 30 mg per NG tube q.12h. 2. Levofloxacin discontinued. 3. Captopril 25 mg per NG tube q.8h. 4. Nystatin swish and swallow 5 cc q.6h. 5. Celebrex 200 mg per NG tube q.day. 6. Lopressor 25 mg p.o.b.i.d. 7. Amiodarone 200 mg p.o. NG tube b.i.d. 8. Tums 500 mg per NG tube b.i.d. 9. Tylenol 650 q.4.h. p.r.n. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 6910**] in 10 to 14 days and with his cardiologist as needed postoperatively. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2136-12-17**] 12:04 T: [**2136-12-17**] 12:06 JOB#: [**Job Number 41194**] Admission Date: [**2136-11-29**] Discharge Date: [**2136-11-19**] Date of Birth: [**2072-5-19**] Sex: M Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old gentleman with a history of CAD, who, on [**2136-11-22**], underwent microvascular decompression for trigeminal neuralgia. Preoperatively, he was found to be in atrial flutter and underwent cardiac catheterization, which showed clear coronaries. On [**2136-11-28**], he was loaded on Heparin and admitted for cardioversion. He had a negative TEE and converted to normal sinus rhythm. He was placed on Amiodarone. He was discharged on Lovenox and Coumadin after cardioversion. On [**2136-11-29**], in the morning, he complained of sudden onset of severe headache, followed by nausea, vomiting, and vertical diplopia. In the emergency room, he developed sinus bradycardia with ventricular escape beats, and he was given Atropine. He was brought into a normal sinus rhythm. He became disoriented with a severe headache. Head CT showed acute posterior fossa subarachnoid hemorrhage with fourth ventricle obstruction. On examination, the blood pressure as 240/120, heart rate was down to 12. He was sleep. He only responded to vigorous stimulation. He would fall back to sleep easily, withdraw on all four extremities. Pupils were 5-mm and minimally reactive bilaterally. He had a positive gag. Face was symmetrical. He was not moving any extremities, but to pain. His eyes were closed. He was hyperreflexic on the left. PAST MEDICAL HISTORY: History included CAD and status post CABG. He also had prosthetic valve placed and trigeminal neuralgia decompression. LABORATORY DATA: Labs on admission revealed the following: White count 7.5, hematocrit 40.7, platelet count 260,000, PT 14.4, PTT 35.1, INR 1.4. The patient was admitted to the Surgical Intensive Care Unit and a ventricular drain was placed. The patient was monitored closely. The Department of Cariology saw the patient in the Intensive Care Unit and recommended holding all beta blockers and restarting the Amiodarone. The patient remained intubated and sedation for two days. On [**2136-12-2**], all sedation was discontinued and the patient was showing some signs of improvement. Pupils were 3-mm down to 2 -mm and briskly reactive. The patient was following simple commands, showing two fingers. The patient had repeat head CT on [**2136-12-2**], which showed no change in the fourth ventricle. The patient had an episode of hypoxia on [**2136-12-3**]. The patient had a CT angiogram, which was negative for PE. The patient had spiked a temperature on [**2136-12-4**] and was started on Levofloxacin for gram-negative rods, sputum culture. The patient continued to be followed by the Cardiology Service. The patient went back into atrial fibrillation. The Department of Cardiology recommended electrocoagulation, which was done. The patient converted to normal sinus rhythm and has remained in normal sinus rhythm to date. The patient was extubated on [**2136-12-10**] and tolerated that well. He was awake, alert, oriented, following commands, moving all extremities strongly. He was transferred to the regular floor on [**2136-12-12**]. He had a swallow evaluation, which he failed. He had a G tube placed. Vital signs have remained stable. He has been afebrile. He finished a 10-day course of Levofloxacin for Klebsiella pneumonia. He current is afebrile. He was seen by physical therapy and Occupational Therapy and found to require rehabilitation prior to discharge home. MEDICATIONS ON DISCHARGE: 1. Prevacid 30 mg per NG tube q.12h. 2. Levofloxacin discontinued. 3. Captopril 25 mg per NG tube q.8h. 4. Nystatin swish and swallow 5 cc q.6h. 5. Celebrex 200 mg per NG tube q.day. 6. Lopressor 25 mg p.o.b.i.d. 7. Amiodarone 200 mg p.o. NG tube b.i.d. 8. Tums 500 mg per NG tube b.i.d. 9. Tylenol 650 q.4.h. p.r.n. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 6910**] in 10 to 14 days and with his cardiologist as needed postoperatively. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2136-12-17**] 12:04 T: [**2136-12-17**] 12:06 JOB#: [**Job Number 41194**] rp12/12/[**2136**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 7440**] Admission Date: [**2136-11-29**] Discharge Date: [**2136-12-19**] Date of Birth: [**2072-5-19**] Sex: M Service: Neurosurgery The patient is being discharged to [**Hospital **] Rehabilitation today. During the remainder of his hospital course, the patient did fall out of his chair and sustained a laceration over his right eye and a fractured nose, which did not require any surgical repair; he just has stitches above his right which should be removed in two days, and his nose will not require any further treatment. He also developed an Methicillin resistant Staphylococcus aureus infection of his right elbow for which he is currently receiving Cefzil 1 gram intravenously q. eight hours, for a total of a two week course. He is actually being discharged on Vancomycin. Further culture came back with Methicillin resistant Staphylococcus aureus and so he will be switched from Cefzil to Vancomycin intravenously to complete a two week course for a right elbow infection. The remainder of his hospital stay was uneventful and he remains afebrile with stable vital signs. Neurologically, he does remain on sitters and will continue to have sitters at rehabilitation due to his lack of impulse control. His vital signs have been stable and he is in stable condition at the time of discharge. [**Name6 (MD) 7441**] [**Name8 (MD) 7442**], MD [**MD Number(1) 7443**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2137-1-4**] 13:31 T: [**2137-1-7**] 13:23 JOB#: [**Job Number 7444**]

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Discharge summary

report

Admission Date: [**2135-2-6**] Discharge Date: [**2135-2-17**] Date of Birth: [**2077-9-3**] Sex: M Service: NEUROLOGY Allergies: Aspirin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Seizure in the setting of expanding left subcortical mass lesion Major Surgical or Invasive Procedure: *Stereotactic Brain Biopsy ([**2135-2-8**]) History of Present Illness: 57-year-old RH man with PMH significant for HTN, hepatitis C, cryoglobulinemia, renal failure off HD now, migraine headaches, seizure disorder (followed by Dr. [**Last Name (STitle) 11294**], and L-BG hemorrhage [**12-15**], with unusual characteristics concerning for neoplasm (though at the time CSF neg, and pt unable to get contrast [**2-8**] renal failure), was at home this morning and per per discussion with his son [**First Name8 (NamePattern2) 74998**] [**Name (NI) 27644**] [**Telephone/Fax (1) 83376**]), he began making noises that sounded like humming, and possibly pain. When his son came into his room he noticed he was shaking his arms and legs B/L for about 2 min. His son kept calling his name, eventually the shaking stopped, but when the pt tried to open his eyes, his son noted that his eyes were rolling into the back of his head. There was no B/B loss. His son felt that his speech was completely incoherent, and called 911. He states that the pt also felt hot to the touch. His son states that the pt had been complaining yesterday of not feeling well, and had had a HA, but his son took his temperature and he was afebrile at 98F. His son also states that over the past few days, he has been dragging his RLE more than usual. He states there have been no other seizures since his last discharge from [**Hospital1 18**] [**12-15**]. He was brought to [**Hospital3 15402**] Hosp, where he was found to have a fever to 102.4 F, and repeat NCHCT showed significant L sided vasogenic edema and 6 mm shift. He was given Tylenol, 1 mg Ativan and 8 mg Decadron, and transferred to [**Hospital1 18**]. Here, he is afebrile, but was given Ceftriaxone and Vancomycin. He has a leukocytosis with left shift. Past Medical History: PMH: - L-BG hemorrhage, w/ unusual features concerning for neoplasm - Migraines - Cervical epidural hematoma - Depression - HTN - renal failure (on HD in the past, off since [**2133**]), AV fistula. - hepatitis C with cryoglobulinemia, - Appendectomy. - Seizures Type 1: Presyncope Aura: Numbness of body, darkening of vision Ictal: Last for seconds, no loss of consciousness, improves if he sits down and lowers his head. TB/incont: No Postictal: Return to baseline First: Unclear Frequency: Rare Precipitants: Standing Type 2: Staring episodes Aura: No warning Ictal: Unresponsive, behavioral arrest, stares for 15 to 30 seconds. TB/incont: No Postictal: Confused, "in slow motion" First: Unclear Frequency: Daily Precipitants: None Type 3: Simple partial Aura: Flashing circles of light, like a kaleidoscope, in the right hand corner of his vision, lasts one to two minutes. Ictal: No loss of consciousness or confusion TB/incont: None Postictal: None First: Several months ago Frequency: One to two per week?????? Social History: - On disability. - Divorced. - Lives with son and grandchildren. . HABITS . - Used to smokes marijuana. Physical Exam: ON AMDISISON: T- BP- HR- RR- O2Sat 97.3 92 108/78 20 96 Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal passive motion L/R, but unable to actively or passively touch his chin to chest. CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no c/c/e; equal radial and pedal pulses B/L. Neurologic examination: Mental status: Sleeping, eyes closed. Opens eyes to voice, but appears to have some R neglect (pt kept looking to left for my voice coming from right). Very lethargic with hypophonia and psychomotor slowing. Oriented to person, to hosp given choices, but not to date. Inattentive. Able to follow some commands (closes eyes after telling him multiple times), and moves limbs to command, but does not show thumb or 2 fingers when asked to. Speech composed primarily of one word responses, mostly yes/no. though says, "don't got any" when asked to show teeth. (+) dysarthria [**2-8**] sig R facial droop. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Pt forcibly closes eyes on attempts to view fundi. (+) BTT B/L.. Extraocular movements cross midline bilaterally, no obvious nystagmus. Sensation intact V1-V3. (+) Sig R facial droop. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 4+ 4+ 5- 0 0 0 0 4+ 4+ 5 0 5 0 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Reports sensing LT in all 4 ext and withdraws to noxious in all 4 ext. Reflexes: [**Hospital1 **], tri, and BR brisker on R than L without evidence of spread. Knees 2+ and symmetric. Achilles absent B/L.. Toes equivocal bilaterally (on R, big toe stays still/slightly moves up while other toes clearly go down, giving possible illusion of upgoing toe) Coordination: Able to do FNF in LUE without ataxia/dysmetria Pertinent Results: Admission Labs: . WBC-15.4*# RBC-3.29* HGB-9.7* HCT-29.9* MCV-91 MCH-29.6 MCHC-32.6 RDW-14.0 GLUCOSE-135* UREA N-41* CREAT-2.8* SODIUM-139 POTASSIUM-5.4* CHLORIDE-113* TOTAL CO2-17* ANION GAP-14 CALCIUM-8.0* PHOSPHATE-3.2 MAGNESIUM-1.8 TOT PROT-6.6 ALBUMIN-3.7 GLOBULIN-2.9 PHOSPHATE-3.0# MAGNESIUM-1.9 CK-MB-1 cTropnT-<0.01 ALT(SGPT)-10 AST(SGOT)-19 LD(LDH)-173 CK(CPK)-46* ALK PHOS-82 TOT BILI-0.3 ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2135-2-5**] 10:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG . URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . Discharge Labs. . IMAGING . Non-Contrast CT Head ([**2135-2-5**]) PRELIM: Interval enlargement in left basal ganglia lesion with worsening surrounding vasogenic edema and two similar appearing foci in the left frontal lobe concerning for underlying neoplasm rather than purely hypertensive hemorrhage. Mass effect with 7mm rightward midline shift. . Non-Contast CT Head ([**2135-2-8**]): IMPRESSION: Status post left basal ganglia mass biopsy, without significant hemorrhage. . TTE ([**2135-2-7**]): The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2134-12-10**], trace aortic regurgitation is now seen in the presence of normal valve morphology. If the clinical suspicion for endocarditis is moderate or high, a TEE is suggested to better define the aortic valve. . Renal Ultrasound ([**2135-2-7**]): IMPRESSION: Multiple bilateral renal cysts, some of which contains low-level internal echoes and septations. . PATHOLOGY Note: Final note: The findings in aggregate are sufficient for a diagnosis of Glioblastoma (WHO grade IV). . CT head [**2135-2-9**] FINDINGS: Again seen is left frontal burr hole with mild soft tissue swelling and associated gas in the soft tissues, biopsy tract, and within the biopsied left basal ganglia lesion. This lesion measures approximately 39 x 33 mm and again demonstrates hyperattenuating rim and hypodense center, with associated vasogenic edema. There is no large area of acute hemorrhage. There is unchanged mass effect with effacement of adjacent sulci and the left lateral ventricle, as well as unchanged rightward displacement of the normally midline structures by 7 mm. There is no evidence of transtentorial or uncal herniation. There is no large vascular territorial infarct. Two satellite lesions with similar characteristics in the superior left frontal lobe are again visualized, measuring 18 x 12 and 13 x 9 mm. Again demonstrated is an arachnoid cyst in the left posterior fossa. The paranasal sinuses and mastoid air cells are clear. There are no fractures. IMPRESSION: No new hemorrhage. Biopsied left basal ganglia mass and satellite lesions. CXR [**2135-2-11**] FINDINGS: As compared to the previous radiograph, the size of the cardiac silhouette has minimally increased. There is evidence of minimal enlargement of the perihilar vessels, potentially suggestive of mild pulmonary edema. The pre-existing subtle retrocardiac parenchymal opacities have markedly decreased. Currently, no safe evidence of focal parenchymal opacities suggesting an infectious disease are present. No evidence of pleural effusions. Brief Hospital Course: Mr. [**Known lastname 487**] is a 57 year-old right-handed man with past medical history including hypertension, hepatitis C, cryoglobulinemia, CKD, and prior left basal ganglia hemorrhage thought to be concerning for underlying malignancy who presented to [**Hospital3 **] following seizure activity and was transferred to the [**Hospital1 18**] after a non-contrast CT of the head revealed significant vasogenic edema surrounding the left basal ganglia mass lesion associated with midline shift. He was admitted to the stroke service from on [**2135-2-6**]. . NEURO Following his arrival to the [**Hospital1 18**], a non-contrast CT of the head was repeated to evaluate for evolution of the lesion. The imaging was thought to show interval enlargement in left basal ganglia lesion with worsening surrounding vasogenic edema concerning for underlying neoplasm. The Neurosurgery Team was invited to participate in the patient's care, and performed a stereotactic biopsy of the lesion on [**2135-2-8**]. Preliminary results of the frozen section indicate malignanct glioma and final pathologic review demonstrated a WHO stage 4 malignant glioma. Dr. [**Last Name (STitle) 724**] of neuro-oncology was consulted and recommended starting dexamethasone 4 mg q6h. He underwent MRI brain [**2-10**] for staging purposes, but unfortunately did not tolerate this study due to agitation. Radiation oncology are also actively participating in Mr. [**Known lastname 13396**] care and radiation therapy was initiated on [**2-11**]. Treatments are to continue every other day thereafter per radiation oncology's protocol. . He has had problems with disorientation and inattention, worsening on [**2-10**] and [**2-11**]. His keppra was increased to 1000 mg [**Hospital1 **] and was started on ativan 0.5 mg tid on [**2-10**] as he had been on a benzodiazepine at home prior to admission. A routine EEG completed on [**2-11**] demonstrated diffuse encephalopathy without evidence of seizure activity or foci. . ID There was concern for underlying infection and/or the presence of a brain abscess given the ring-enhancing apperance of the left basal ganglia lesion and the patient's recent history of strep pneumonia bacteremia ([**12-15**]). Accordingly, empiric coverage with broad spectrum acntibiotics (vancomycin, ceftriaxone, ampicillin, acyclovir, flagyl) was started pending further investigatory results. In the setting of chronic kidney disease and low suspician for HSV infection, the acyclovir was soon discontinued. No vegetations, thrombi, masses, or septal defects were noted on a trans-thoracic echocardiogram. Upon learning news of the biopsy result, the antibiotics were discontinued, as was the infectious work up. On [**2-11**], the patient's WBC increased from 8.6 to 16.6. He had diarrhea as well as mild abdominal pain. A c. dif was negative x1, LFTs were normal with the exception of an AST of 78 and lipase of 81, and a plain film of his abdomen revealed no obvious pathology. A bladder scan revealed > 1000 cc of urine. He had a low-grade temperature (100.3 axillary) [**2-11**] and was pancultured. A urinalysis and CXR showed no obvious infectious proces. Allblood cultures where negative. ONCOLOGY Given the high suspicion for malignancy, a renal ultrasound was performed. The study revealed multiple bilateral renal cysts, some of which contained low-level internal echoes and septations. . RENAL The patient has chronic renal disease and has been on hemodialysis in the past, but not recently. His creatinine this hospitalization ranged from [**2-9**] which is consistent with his baseline and has been receiving gentle hydration. All future medications should be renally dosed. Keppra is currently above the recommended renal dosing given the patient's risk of seizure, but he has tolerated this dose well. . CARDIOVASCULAR The patient has been somewhat hypertensive with blood pressures 160s-170s/100-110s. His home diovan was resumed and treatment with metoprolol was initiated. Medications may be uptitrated as needed. . Medications on Admission: Levetiracetam 1,000 mg [**Hospital1 **] Sertraline 100 mg qhs Triazolam 0.25 mg qhs Diovan 80 mg qd Furosemide 40 mg qd Oxycodone-Acetaminophen 5 mg-325 mg q6h prn pain. Renal Caps 1 mg qd . ALL: ASA Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: [**1-8**] units Injection ASDIR (AS DIRECTED): while on high dose dexamethasone per sliding scale. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for cerebral edema: Continue until completion of XRT and follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Hospital1 18**] neurooncology. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for on benzos at home: hold for sedation. 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Hold for sedation. 14. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4H (every 4 hours) as needed for seizure > 3 min or clusters of 3 or more sezizures per hour. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital Discharge Diagnosis: Malignant Left Basal ganglia/thalamic glioma Lesion based seizure disorder Discharge Condition: Severe dysarthria, inattention. Right upper motor neuron facial weakness. Right arm with flaccid plegia, right leg with mild paresis. Discharge Instructions: You were admitted after a seizure and were found to have a mass in a part of your brain called the basal ganglia. A biopsy of the mass was found a malignant glioma, a type of brain tumor. Please follow up with neuro-oncology and radiation oncology for further management. You were started on a medication called Keppra to prevent seizures, Dexamethasone to prevent swelling in your brain, and new medications to lower your blood pressure. Followup Instructions: Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in [**Hospital **] clinic for further care. Call ([**Telephone/Fax (1) 6574**] for an appointment. You should see him 4 weeks after your last radiation treatment. Completed by:[**2135-2-17**]

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icd9cm

[ [ [] ] ]

[ "01.13", "92.29", "87.03", "93.59" ]

icd9pcs

[ [ [] ] ]

15375, 15426

9478, 13545

340, 385

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53,294

160,247

22930

Discharge summary

report

Admission Date: [**2194-10-24**] Discharge Date: [**2194-10-27**] Date of Birth: [**2109-7-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization Central Line History of Present Illness: 85 y/o gentleman history of HTN, hyperlipidemia, PAD, s/p right fem-[**Doctor Last Name **] bypass and left [**Doctor Last Name **] atherectomy, CAD, sp IMI with ?angioplasty 20 years ago and BMS to RCA 2 weeks ago presented to [**Hospital1 18**] cath lab for staged intervention of known lesion secondary to continued exertional angina. A month ago pt started noticing chest pain with exertion and increased to chest pain at night. He had angiography 3 weeks ago and a cardiac cath 2 weeks ago. Recent cath 2 weeks ago revealed a 50-60% D1, a proximal Cx lesion up to 70% stenosed and a large RCA with a tight proximal lesion. A BMS was placed in the RCA. Pt continued to have chest pain (with 50 yards of walking) and returned for further intervention. Of note, pt reports that on occasion, his chest pain has resolved with prilosec which he has been taking once a day for the last few weeks. During today's cardiac cath procedure, DES was placed in diag lesion. Circ was challenging to manipulate and was hard to wire. Unable to stent. Post procedure, pt developed CP at end of case and was transfered to the CCU for close monitoring. On the CCU floor, pt denies any chest pain, no SOB, no diapharesis, no nausea, no dizziness. VSS. . 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, pt denies chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, glucose intolerance 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: IMI approximately 20 years ago, s/p rescue PTCA CAD s/p BMS to RCA on [**2194-10-7**] PVD s/p right fem-[**Doctor Last Name **] bypass [**4-5**] left popliteal atherectomy -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Mesenteric carcinoid s/p resection Vitamin B 12 deficiency Hypothyroidism Hypopituitarism d/t a benign pituitary tumor resection in the ? [**2163**]'s Right leg fracture s/p surgery Hx of hyperkeratosis Social History: Patient is married with five children. He is retired, previously working in construction. Contact upon discharge: [**First Name4 (NamePattern1) 501**] [**Known lastname **] (daughter):[**Telephone/Fax (1) 59241**] ETOH: Occasional wine or beer Tobacco: Quit 60 years ago Family History: Mom- [**Name (NI) 3730**], died of MI Dad- died of MI at age 59 No Hx of leukemia or liver problems Physical Exam: Admission exam VS: BP=93/51, HR=72, O2 sat=100% RA. GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: normal S1, S2. diminished heart sounds. 1/6 systolic murmur at left sternal border. 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: radial 2+ Femoral 2+ Left: radial 2+ Femoral 2+ Pertinent Results: **FINAL REPORT [**2194-10-26**]** URINE CULTURE (Final [**2194-10-26**]): NO GROWTH. Blood Cx [**10-26**] negative at time of discharge on [**10-27**] Brief Hospital Course: 85 y/o gentleman history of HTN, hyperlipidemia, PAD, CAD, sp IMI with angioplasty 20 years ago and BMS to RCA 2 weeks ago presented to [**Hospital1 18**] cath lab for continued exertional angina and planned cardiac catheterization. . # CORONARIES: CAD s/p BMS in RCA 2 weeks prior to admission and had DES in diagonal on this admission. Circ was not stented since it was challenging to intervene. Had chest pain shortly after procedure and sent to the CCU for close monitoring. Pt continued to have exertional chest pain and was sent home on Ranexa 500mg [**Hospital1 **] and SL Nitro prn. Continued on ASA, BB (switched from atenolol to metoprolol succinate 25 mg daily), Simvastatin, lisinopril (5mg daily), and plavix for at least 1 year. Pt's persistent chest pain likely multifactorial: 1)secondary to his Circumflex which will be managed medically as well as 2)GERD for which he is on ranitidine. . #SIRS/Sepsis: Shortly after cath, pt had rigors, fever up to 102.2, WBC 13 with left shift, hypotension with MAP 60s. Central line was placed, broad spectrum AB were given (zosyn and vanco initially and then switched to keflex) and pt given 6.5 L IVF. Pt was also started on hydrocotrisone supplementation given his history of adrenal insuficiency and dependence on prednisone. Both blood and urine cultures were negative. Pt will go home on Keflex for total 7 day course. . # HTN: BP meds initially held in setting of hypotension. After BP improved, pts anti-hypertensives were restarted. Took atenolol 50mg daily at home which was switched to metoprolol succinate 25mg daily. Continued on home lisinopril 5mg daily. . # Hypothyroidism: Continued home levothyroxine 100mcg daily . #HLD: Continued simvastatin 80mg daily and gemfibrazil 300mg daily . # Hypopituitarism: Prednisone 5mg daily. He was given supplemental hydrocortisone in setting of SIRS for 2 days and then switched back to his home prednisone 5mg daily. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 100 mg Tablet - 0.5 (One half) Tablet(s) by mouth every evening CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth every morning CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by Other Provider) - 1,000 mcg/mL Solution - once a month GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - 0.5 (One half) Tablet(s) by mouth every morning LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet - 1 Tablet(s) by mouth every morning LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily NITROGLYCERIN - (Prescribed by Other Provider) - Dosage uncertain PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth every morning RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth every evening ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 4 Tablet(s) by mouth daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 2. gemfibrozil 600 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*3* 5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: For chest pain, place 1 tablet under the tongue. [**Month (only) 116**] repeat again in 5 minues. Disp:*60 Tablet, Sublingual(s)* Refills:*0* 8. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ranexa 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 12. 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:*3* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease SIRS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a planned cardiac catheterization. A stent was placed on a vessel in your heart to keep it open. Another vessel was occluded but not able to be stented open, despite trying. This vessel is likely contributing to your angina. You will continue to be treated with medications: Ranexa, sub-lingual nitro as needed, aspirin, plavix, and statins. You were found to have signs of an infection shortly after the procedure. We gave you higher doses of steroids, antibiotics and fluids. We placed a line in a vein of your neck to carefuly monitor you. You will continue a total 7 day course of Keflex antibiotic after you leave the hospital. The following changes were made to your medications: STOP: -Atenolol 50mg dialy -Aspirin 80mg daily START: -Aspirin 325mg daily -Cephalexin 500mg every 6 hours for 6 more days -Ranexa 500mg in the morning and 500mg in the evening (take every day to help your chest pain) -Metoprolol Succinate 25mg daily Please make sure you follow up with your primary care doctor this week as well as Dr. [**Last Name (STitle) 8579**] in a few weeks. Followup Instructions: Cardiologist- please follow up with Dr. [**Last Name (STitle) 8579**]. [**Telephone/Fax (1) 59242**]. Monday, [**11-17**] at 1:30, [**Hospital 59243**] Medical Building, [**Location (un) **], [**State **], [**Location (un) **] MA. Dr. [**Last Name (STitle) 59244**] office will call you to see if you can be soon sooner then [**11-17**]. You have an appointment with you primary care doctor, Dr. [**Last Name (STitle) **], at Wednesday, [**10-29**], 9:30 AM. Office #[**Telephone/Fax (1) 8539**]

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icd9cm

[ [ [] ] ]

[ "36.07", "00.66", "00.45", "37.23", "88.56", "00.40" ]

icd9pcs

[ [ [] ] ]

8642, 8648

4163, 6091

328, 367

8721, 8721

3979, 4140

10006, 10507

3035, 3138

7245, 8619

8669, 8700

6117, 7222

8872, 9983

3153, 3960

2263, 2493

278, 290

2860, 3019

395, 2148

8736, 8848

2524, 2730

2170, 2243

2746, 2844

19,251

101,249

12232+56346

Discharge summary

report+addendum

Admission Date: [**2168-1-29**] Discharge Date: [**2168-2-1**] Service: [**Hospital Unit Name 196**]-Gold CHIEF COMPLAINT: Chest pain HISTORY OF PRESENT ILLNESS: This is an 82 year old gentleman with a history of coronary artery disease, status post coronary artery bypass graft times three in [**2150**], inferior myocardial infarction in [**2159**], status post percutaneous transluminal coronary angioplasty at [**Hospital 36653**] Clinic in [**2158**], who is transferred from an outside hospital for chest pain, left arm numbness and nausea. The patient noted the night before admission and the day of admission chest pain across his chest associated with left arm numbness and nausea. He denied shortness of breath or diaphoresis. His pain was noted by daughter who had taken him home from the nursing home for lunch and took him immediately back to the nursing home when he told her that he had chest pain. The patient is unsure of how long the chest pain lasted the day before admission but lasted one to two hours on the day of admission. The patient is an extremely poor historian secondary to his parkinsonian's dementia. Electrocardiogram on presentation showed [**Street Address(2) 4793**] elevations in 3, AVF and downsloping ST depression in precordial leads V4 through V6. His initial CPK was 30 and troponin was negative. He was started on nitroglycerin GTT, heparin GTT, Integrilin and Lopressor and was transferred to [**Hospital6 1760**] for possible catheterization at an outside hospital. On presentation to the Emergency Department at [**Hospital6 1760**] he was chest pain free and was maintained on the same GTT. In the AM while still in the Emergency Department the patient had more chest pains and associated shortness of breath and was given intravenous Lasix. He was given steroids, Zantac and Benadryl for shellfish allergy and was taken to the Catheterization Laboratory. Complicated catheterization required 300 cc of dye in order to visualize the graft. PCW 30, PA saturation 76%, V wave 35, right atrial pressure 12, right ventricular pressure 64/8, left ventricular end diastolic pressure 35. The patient had no significant left main disease but left anterior descending was occluded at the origin and severe proximal stenosis at the origin of obtuse marginal 1 was noted. Also mid left circumflex occlusion and proximal occlusion of right coronary artery. In terms of the patient's graft, the saphenous vein graft to obtuse marginal was patent with complex severe distal stenosis, the saphenous vein graft to left anterior descending was patent was 90% distal stenosis with thrombus and the saphenous vein graft to right coronary artery has 90% proximal stenosis with thrombus. Transthoracic echocardiography was performed demonstrating an ejection fraction of 20 to 30% with global reduction of left ventricular systolic function. The inferior wall was noted to be akinetic and trace aortic regurgitation was mild 11+ mitral regurgitation was noted. The patient was transferred out of the catheterization laboratory to the Coronary Care Unit for observation and consideration of further options. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft at [**Hospital3 **] in [**2150**]. Status post inferior myocardial infarction and percutaneous transluminal coronary angioplasty at [**Hospital 36653**] Clinic in [**2158**]. 2. Abdominal aortic aneurysm, stable. 3. Parkinson's disease times two years. 4. Hypertension. 5. Low back pain. 6. Status post cholecystectomy. 7. Hypercholesterolemia. MEDICATIONS AS OUTPATIENT: 1. Atenolol 25 mg b.i.d. 2. Captopril 25 mg t.i.d. 3. Aspirin 4. Digoxin 0.25 mg q. day 5. Klonopin 0.5 mg q. 6 hours prn 6. Nitroglycerin prn 7. Norvasc 2.5 mg q. day 8. Lipitor 10 mg q. day 9. Aricept 5 mg q. day 10. Celexa 10 mg q. day 11. Imdur 60 mg q. day 12. Requip 1.5 mg t.i.d. 13. Darvocet N 100 mg q. 6 hours prn MEDICATIONS ON TRANSFER: 1. Integrilin GTT 2. Nitroglycerin GTT 3. Heparin GTT 4. Lopressor 25 mg t.i.d. 5. Captopril 25 mg t.i.d. 6. Aspirin 325 mg q. day 7. Digoxin 0.25 mg q. day 8. Lipitor 10 mg q. day 9. Aricept 5 mg q. day 10. Celexa 10 mg q. day 11. Imdur 60 mg q. day 12. Requip 1.5 mg t.i.d. 13. Darvocet N 1 tablet q. 6 hours prn pain, maximum 6 tablets per day 14. Klonopin 0.5 mg p.o. q. 6 hours prn ALLERGIES: Shellfish SOCIAL HISTORY: Lives in nursing home. By patient report, quit tobacco 50 years ago. No current alcohol or tobacco use. PHYSICAL EXAMINATION: Physical examination on admission from the Emergency Room, temperature 90.6, pulse 79, blood pressure 157/86, respiratory rate 16, 95% on 2 liters. In general this is a thin elderly male in no acute distress. Oropharynx is benign. Pupils are equally round, and reactive to light and accommodation. Pupils 2 mm. Heart is regular rate and rhythm with S1 and S2, no murmurs, rubs or gallops noted. Jugulovenous pressure at 4 cm. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended with good bowel sounds. Extremities with 2+ dorsalis pedis pulses. LABORATORY DATA: Notable laboratory data on admission are BUN 18, creatinine 1.1, white blood cells 6.1 with 61 neutrophils, 23 lymphocytes, hematocrit 43, platelets 214. At an outside hospital CK is 30 and troponin is negative. Bilirubin is slightly elevated at 1.1, but ALT 25, AST 13, alkaline phosphatase 110, PT 11.4 with INR of 0.8. Electrocardiogram demonstrates at outside hospital normal sinus rhythm, axis and intervals within normal limits. Q in 2, 3 and AVF, [**Street Address(2) 4793**] elevations in 3 and AVF, [**Street Address(2) 1766**] depressions in V2, V3 and downsloping ST depressions in V4 through V6 which at [**Hospital6 256**] was similar. Chest x-ray demonstrated unusual tracheal course secondary to a possible thyroid mass and some emphysematous changes. HOSPITAL COURSE: 1. Cardiovascular - A. Ischemia, the patient proceeded to rule in for myocardial infarction with CKs of 192, 1122, 1362, 1131, and then proceeded to taper down to 739, 127 on [**1-31**]. The patient underwent catheterization with results as above and was transferred to Coronary Care Unit without intervention. Discussion ensued with family and patient who decided that high risk PCI was not desirable at this time and the patient should be medically managed. The patient was continued on Beta blocker, ACE inhibitor and Aspirin therapy as well as Plavix q. day. Lipitor and Imdur were continued and the patient underwent 48 hour course of Integrilin. Lopressor and ACE inhibitor were titrated up as an inpatient and will continue to be titrated up as an outpatient as the patient tolerates. B. Pump, the patient was noted to have an ejection fraction of 20% on transthoracic echocardiography and will continue medical management. Lasix was begun and the patient will continue Captopril and Digoxin. C. Rhythm, the patient remained in normal sinus rhythm with occasional runs of premature ventricular contractions but no more than 3 at a time were noted. Telemetry was continued during this hospitalization. 2. Neurological - The patient with a history of Parkinson's with associated symptoms of dementia. Aricept and Ropinirole were continued throughout this hospitalization with no issues. 3. Code Status - The patient is Do-Not-Resuscitate, Do-Not-Intubate. This status was temporarily suspended during the patient's catheterization but was reinstated in the post procedure period. 4. Fluids, electrolytes and nutrition - The patient was maintained on cardiac diet during this admission with no further issues. DISPOSITION: The patient will be discharged to rehabilitation once his medical management is optimized and a rehabilitation bed is available. DISCHARGE DIAGNOSIS: 1. Severe coronary artery disease 2. Abdominal aortic aneurysm 3. Hypertension 4. Parkinson's disease 5. Hypercholesterolemia MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. q. day 2. Lopressor 50 mg p.o. q. day 3. Captopril 12.5 mg p.o. q.d. (this will be titrated up as tolerated to 25 mg p.o. t.i.d.) 4. Digoxin 0.25 mg p.o. q. day 5. Aspirin 325 mg p.o. q. day 6. Imdur 60 mg p.o. q. day 7. Lipitor 10 mg p.o. q.h.s. 8. Nitroglycerin 0.4 mg sublingually prn 9. Klonopin 0.5 mg p.o. q. 6 hours prn 10. Aricept 5 mg p.o. q. day 11. Celexa 10 mg p.o. q. day 12. Requip (Ropinirole) 1.5 mg p.o. t.i.d. 13. Darvocet N 1 tablet q. 6 hours prn pain 14. Tylenol 500 mg p.o. q. 8 hours prn pain or fever 15. Dulcolax 10 mg p.o./p.r. q. 24 hours prn constipation 16. Trazodone 25 mg p.o. q.h.s. prn insomnia DISCHARGE CONDITION: Fair. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-269 Dictated By:[**Last Name (NamePattern1) 19212**] MEDQUIST36 D: [**2168-1-31**] 17:05 T: [**2168-1-31**] 18:52 JOB#: [**Job Number 38238**] Name: [**Known lastname 6916**], [**Known firstname 1340**] Unit No: [**Numeric Identifier 6917**] Admission Date: [**2168-1-29**] Discharge Date: [**2168-2-2**] Date of Birth: [**2085-7-15**] Sex: M Service: ADDENDUM: The patient continued to have chest pain with maximized medical management. Catheterization films were reviewed and discussed with family. It was felt that intervention would be too dangerous at this point so the patient will return to the nursing home with optimized medical management. Instructions were given to the nursing home that when the patient has chest pain to first given sublingual Nitroglycerin as his blood pressure tolerates and then to try oral morphine. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q. day. 2. Lopressor 100 mg p.o. twice a day. 3. Captopril 12.5 mg p.o. three times a day. 4. Digoxin 0.25 mg p.o. q. day. 5. Aspirin 325 mg p.o. q. day. 6. Imdur 120 mg p.o. q. day. 7. Lipitor 10 mg p.o. q. h.s. 8. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain. 9. Aricept 5 mg p.o. q. day. 10. Celexa 10 mg p.o. q. day. 11. Requip 1.5 mg p.o. three times a day. 12. Dulcolax 10 mg p.o./p.r. q. 24 hours p.r.n. constipation. 13. Trazodone 25 mg p.o. q. h.s. p.r.n. insomnia. 14. MS Contin 15 mg p.o. q. 12 hours p.r.n. pain; hold for sedation or mental status changes. 15. Lasix 40 mg p.o. q. day. 16. MSO4, 5 to 30 mg q. four hours p.r.n. of 10 mg/5 cc elixir. 17. Ativan (2 mg per cc), 1 to 2 mg p.o. q. six to eight hours p.r.n. DISCHARGE INSTRUCTIONS: 1. If patient has chest pain, can receive sublingual Nitroglycerin as blood pressure tolerates, then try p.o. morphine elixir, 5 to 30 cc q. four hours p.r.n. 2. The patient also noted to be hyponatremic with sodium dropping to 130 on day after admission and 127 on day of discharge. The patient is not taking significant amounts of liquids but will restrict free water. Would recommend restricting free water at nursing home and rechecking serum sodium in two to four days, or is mental status changes occur. CONDITION AT DISCHARGE: Fair. CODE STATUS: "DO NOT RESUSCITATE", "DO NOT INTUBATE" [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2526**], M.D. [**MD Number(1) 916**] Dictated By:[**Last Name (NamePattern1) 6918**] MEDQUIST36 D: [**2168-2-2**] 13:40 T: [**2168-2-2**] 13:47 JOB#: [**Job Number 6919**]

[ "414.01", "414.02", "428.0", "410.71", "401.9", "294.10", "724.2", "332.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.57", "88.56", "99.20" ]

icd9pcs

[ [ [] ] ]

8703, 9681

9704, 10472

7864, 7996

8022, 8681

5962, 7843

10496, 11021

4567, 5944

11037, 11371

136, 148

177, 3166

4000, 4420

3189, 3975

4437, 4544

71,015

113,337

3283

Discharge summary

report

Admission Date: [**2195-12-31**] Discharge Date: [**2196-1-6**] Date of Birth: [**2111-7-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Multiple blood transfusions Upper endoscopy History of Present Illness: Briefly, patient is an 84 year-old man with CAD s/p CABG, DM, and HTN who presented with 2 days of black stools and coffee ground emesis. He had been feeling lethargic and lightheaded. He has not been using any new medications and has not had a prior GIB. . In the ED, initial VS: 98.7 88 65/47 98%/RA. He had an NG lavage with coffee ground emesis that cleared with 600 cc of flushing. During the lavage he had chest pressure and an EKG showed STD in V2-4. He did not have radiation, pain, or diaphoresis. EKG was reviewed with cards. His chest pain resolved after getting 1 unit of PRBCs and 1.1 L NS. Subsequent EKGs showed resolution of changes. He was also treated with zofran and protonix bolus + gtt 80/8. Initial Hct 18.7. . In the MICU, his chest pressure and lightheadedness resolved. Patient received 4 more units of PRBCs (total of 5). Pt has not had any further bleeding. He has been hemodynamically stable in the MICU. Access: 2PIVs--18, 20. . Here, he had an upper endoscopy that revealed a duodenal ulcer with stigmata of recently bleeding. He has been hemodynamically stable. He has no complaints at this time except hunger. Past Medical History: Coronary artery disease s/p triple-vessel coronary artery bypass in [**9-/2182**] Hypertension Peripheral arterial disease Hypercholesterolemia Diabetes Osteoarthritis Gout Anemia Baseline 32-35 with unrevealing w/u by heme Right hernia repair in [**2161**] Appendectomy in [**2125**] Prostate disease Physical Exam: GENERAL: NAD, comfortable, A&Ox3 HEENT: [**Last Name (LF) 12476**], [**First Name3 (LF) 15315**] cheeks CARDIAC: RR 2/6 systolic murmur loudest at apex LUNG: CTAB no w/r/r ABDOMEN: +BS, soft, NT, ND EXT: WWP, 2+ PT/DP pulses NEURO: grossly nonfocal DERM: no rashes Pertinent Results: [**2195-12-31**] 06:15PM BLOOD WBC-9.9 RBC-1.98* Hgb-6.3* Hct-18.7* MCV-94 MCH-31.6 MCHC-33.5 RDW-15.8* Plt Ct-139* [**2196-1-1**] 11:25AM BLOOD WBC-8.9 RBC-3.36*# Hgb-10.5*# Hct-29.4*# MCV-88 MCH-31.4 MCHC-35.8* RDW-16.0* Plt Ct-100* [**2196-1-1**] 11:25PM BLOOD Hct-27.3* [**2196-1-6**] 06:50AM BLOOD WBC-6.8 RBC-3.85* Hgb-11.9* Hct-34.3* MCV-89 MCH-30.9 MCHC-34.6 RDW-16.1* Plt Ct-125* [**2196-1-3**] 07:05AM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0 [**2195-12-31**] 06:15PM BLOOD Glucose-300* UreaN-95* Creat-1.7* Na-145 K-4.6 Cl-108 HCO3-17* AnGap-25* [**2196-1-3**] 07:05AM BLOOD Glucose-175* UreaN-14 Creat-1.0 Na-143 K-4.0 Cl-112* HCO3-24 AnGap-11 [**2196-1-6**] 06:50AM BLOOD Glucose-156* UreaN-17 Creat-1.3* Na-141 K-3.2* Cl-105 HCO3-23 AnGap-16 [**2195-12-31**] 09:27PM BLOOD ALT-12 AST-13 LD(LDH)-183 AlkPhos-25* TotBili-1.0 [**2196-1-1**] 02:44AM BLOOD CK(CPK)-72 [**2196-1-1**] 11:25PM BLOOD CK(CPK)-130 [**2195-12-31**] 06:15PM BLOOD Lipase-72* [**2195-12-31**] 06:15PM BLOOD cTropnT-<0.01 [**2196-1-1**] 02:44AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2196-1-1**] 11:25PM BLOOD CK-MB-5 cTropnT-0.09* [**2196-1-5**] 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 [**2196-1-2**] 02:58PM BLOOD %HbA1c-6.1* [**2195-12-31**] 09:35PM BLOOD Lactate-2.5* **FINAL REPORT [**2196-1-4**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2196-1-4**]): POSITIVE BY EIA. (Reference Range-Negative). ECHO [**2196-1-5**] The left atrium is elongated. The left ventricle is not well seen. 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 number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation was seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild to moderate aortic stenosis (valve calculation may overestimate severity due to underestimation of outflow tract velocity). Preserved biventricular global systolic funcction. Endoscopy Report Ulcer in the apex of duodenal bulb (injection) Tortugas esophagus Otherwise normal EGD to third part of the duodenum Brief Hospital Course: ASSESSMENT & PLAN: Mr. [**Known lastname 4612**] is an 84 man with CAD s/p CABG, DM, HTN who presented with a GI bleed and developed chest pressure. . # Bleeding duodenal ulcer: Duodenal ulcer with stigmata of recent bleeding seen on EGD [**1-1**]. In total, he required 6 units of pRBC's. His hematocrit was stable prior to discharge. He was having dark stools that were gradually clearing. He was tolerating a regular diet. He had plans to re check his hematocrit shortly after discharge. His was discharged on high dose pantoprazole. His serum was positive for H. pylori. He was treated with a course of two weeks of clarithromycin and amoxicillin. . # NSVT: Patient had several runs of NSVT. These were less frequent after optimization of electrolytes. . # Chest pain: No further episodes were present during the hospitalization. Inferior/lateral EKG changes were concerning for demand ischemia. This was not ACS. We continued his home statin. No aspirin was given considering his recent bleeding. His beta blocker was restarted. An echo was repeated whiched showed mild to moderate aortic stenosis. However, the image quality was suboptimal and should be followed up. Of note, Mr. [**Known lastname 4612**] was told to stop his statin for the two weeks he is on clarithromycin. He was told to restart following completion of his antibiotic course. . # Acute renal failure: Given his significant volume depletion, he had acute renal failure. This improved by the time of discharge, but was not at his baseline. . # Diabetes: He was placed on an insulin sliding scale. His oral medications were restarted on discharge. . # Hypertension: On initial presentation all oral medications were stopped. Gradually his home regimens were titrated up. Even on his home doses, he was having blood pressures elevated to 200. His metoprolol dose was increased to 75 mg [**Hospital1 **] which resulted in improved control. . # Thrombocytopenia: Patient's platelet counts decreased to a low of 88. They gradually increased to 125 on the day of discharge. . # PPX: He received high dose pantoprazole and pneumoboots. . # CODE: He was a full code during this admission. Medications on Admission: confirmed with pharmacy on [**1-2**] at 1800 ALLOPURINOL 300 mg Tablet by mouth daily GLIPIZIDE 5 mg Extended Rel by mouth twice as day LOSARTAN [COZAAR] 100 mg by mouth [**Hospital1 **] METFORMIN 500 mg by mouth [**Hospital1 **] METOPROLOL TARTRATE 50 mg [**Hospital1 **] SIMVASTATIN 80 mg Tablet by mouth daily ASPIRIN 81 mg Tablet by mouth daily Discharge Medications: 1. Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a day for 14 days. Disp:*56 Capsule(s)* Refills:*0* 4. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO twice a day. 8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Final Diagnosis: Upper gastrointestinal bleed Duodenal Ulcer Secondary Diagnosis: Hypertension Coronary Artery Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital with bleeding in your stool. You had a procedure called an endoscopy to look at the source of bleeding. An ulcer was found in your duodenum, the first part of your intestine. A medicine was injected into the area to help stop it from bleeding. It is very important that if you notice any new blood from your rectum to notify your doctor of come to the emergency department immediately. We have changed several of your medications. We stopped your aspirin because of your bleeding. Do not restart this until you discuss it with your GI physician. [**Name10 (NameIs) **] increased your metoprolol to 75 mg twice a day. We are giving you two antibiotics: clarithromycin and amoxicillin. It is important to take these for two weeks. These are treating an infection which may have caused your ulcer to form. Please stop your simvastatin (cholesterol medicine) for two weeks. You can restart this after you are finished with the antibiotics. We started pantoprazole 40 mg twice a day. It is very important to continue to take this until you discuss it with your GI physician. [**Name10 (NameIs) **] needed to help move your bowels, you can take docusate twice a day. Followup Instructions: Appointment #1 MD: Dr. [**First Name (STitle) 15316**] [**Name (STitle) 12646**] Specialty: PCP Date and time: Monday, [**1-11**] at 1:00pm Location: [**Street Address(2) 15317**], [**Location (un) **],[**Numeric Identifier 809**] Phone number: [**Telephone/Fax (1) 4615**] Appointment #2 MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: Gastroenterology Date and time: Tuesday, [**2-9**] at 2:00pm Location: [**Last Name (LF) **], [**First Name3 (LF) 452**] Bldg [**Location (un) **], [**Location (un) 86**], MA Phone number: [**Telephone/Fax (1) 463**] Please have your blood checked at Dr.[**Name (NI) 12754**] office tomorrow ([**1-7**]) at 10 AM.

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icd9cm

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Discharge summary

report

Admission Date: [**2152-7-24**] Discharge Date: [**2152-8-1**] Date of Birth: [**2097-2-19**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1430**] Chief Complaint: 1. Left breast cancer, gene positivity 2. Abnormal appendix Major Surgical or Invasive Procedure: 1. Appendectomy 2. Bilateral immediate reconstruction with bilateral free transverse rectus abdominis myocutaneous (TRAM) flaps. History of Present Illness: Ms. [**Known lastname **] comes in with recurrent breast cancer on the left side. In fact she was felt to have a new primary. She was found to be gene positive. She had breast cancer on the left side treated by lumpectomy, radiation and now has a new tumor. She is opting for bilateral mastectomy. At the same time she is having bilateral oophorectomy. She had an abnormality found on her appendix. She is going to have an appendectomy at the same time. After careful consultation she is opting for immediate reconstruction with free TRAM flap. She does smoke and this is why I suggested the microsurgical approach to her rather than a standard pedicle TRAM. She also understands this does add more damage to her abdominal wall. She understands she will have a large abdominal scar, potential for hernia formation, abdominal wall weakness, need for revisional surgery one or both flaps could fail, fat necrosis a possibility. No guarantees could be made. Past Medical History: Asthma, hypothyroidism, MVP w/o murmur, GERD Social History: She is married and lives with her husband. She denies drug use. She does drink one alcoholic beverage per week and smokes three cigarettes per day. Family History: Sister colon cancer, dad prostate cancer. Physical Exam: Gen: NAD, comfortable Chest: CTAB; The breasts are symmetric. She has a well-healed scar in the lateral aspect of the left breast. There is no nipple retraction or skin dimpling. There are no dominant masses, no tenderness to palpation. She has no axillary lymphadenopathy on the right. On the left, just medial to the incision, she has a tissue defect and post-treatment changes. abd: soft, NT/ND ext: no c/c/e Pertinent Results: Labs on admission: [**2152-7-24**] 06:49PM BLOOD WBC-10.7 RBC-3.38* Hgb-9.7* Hct-28.7* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.8 Plt Ct-302 [**2152-7-26**] 01:00AM BLOOD PT-14.6* PTT-71.4* INR(PT)-1.3* [**2152-7-25**] 02:45AM BLOOD Glucose-140* UreaN-7 Creat-1.9* Na-143 K-3.2* Cl-108 HCO3-24 AnGap-14 Labs prior to discharge: [**2152-7-27**] 12:10PM BLOOD Hct-24.1* [**2152-7-27**] 03:35AM BLOOD Hct-23.7* [**2152-7-27**] 03:35AM BLOOD PT-14.2* PTT-45.4* INR(PT)-1.2* [**2152-7-26**] 01:00AM BLOOD Glucose-133* UreaN-7 Creat-0.9 Na-136 K-4.0 Cl-102 HCO3-30 AnGap-8 [**2152-7-26**] 01:00AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.1 Pathology: I. Left breast (A - P): Invasive ductal carcinoma, see synoptic report. II. Right breast (Q - Y): 1. Usual ductal hyperplasia. 2. Apocrine metaplasia. III. Lymph node, right axillary (Z - AB): Lymph node with no malignancy identified (0/1). IV. Lymph node, left axillary (AC- AI): Five lymph nodes with no malignancy identified (0/5). V. Costal cartilage, right (AJ): No malignancy identified. VI. Costal cartilage, left (AK): No malignancy identified. VII. Fallopian tubes and ovaries, bilateral ([**Doctor Last Name **] - AZ): 1. Left fallopian tube with no diagnostic abnormalities recognized 2. Left and right ovaries with surface adhesions and epithelial inclusion cysts. 3. Right fallopian tube with paratubal cyst. VIII. Appendix (BA - BK): Chronic appendicitis. Invasive Breast Cancer Synopsis MACROSCOPIC Specimen Type: Mastectomy. Lymph Node Sampling: 4 lymph nodes from specimen, 5 separately submitted axillary lymph nodes (9 total). Laterality: Left. Tumor Site: Upper outer quadrant. MICROSCOPIC Size of invasive component Greatest dimension: 2.2 cm. Histologic Type: Invasive ductal carcinoma. Ductal Carcinoma In Situ: Present. Nuclear Grade: High. Architectural Patterns: Comedo. Necrosis: Present, comedo type. Extensive Intraductal Component: Absent. Histologic Grade -- Nottingham Histologic Score Tubule formation: Minimal less than 10% (score = 3). Nuclear pleomorphism: Marked variation in size, nucleoli, chromatin clumping, etc. (score = 3). Mitotic count: Greater than 10 mitoses per 10 HPF (score = 3). Total Nottingham Score: Grade III: [**9-17**] points. EXTENT OF INVASION Primary Tumor: pT2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension. Lymph Nodes Number examined: 9. Number involved: 0. Regional Lymph Nodes: pN0: No regional lymph node metastasis histologically (i.e., none greater that 0.2 mm), no additional examination for isolated tumor cells. Distant metastasis: pMX: Cannot be assessed. Margins Deep margin. Uninvolved by invasive carcinoma. Distance from closest margin: 35 mm. Lymphatic (Small Vessel) Invasion: Present. Microcalcifications: Not identified. ER, PR, HER2: See prior report #: 09-[**Numeric Identifier 12820**]. Brief Hospital Course: Patient underwent appendectomy, bilateral salpingo-oophorectomy, bilat mastectomy, nd bilateral immediate reconstruction with bilateral free transverse rectus abdominis myocutaneous (TRAM) flaps on [**2152-7-24**]. Please see each respective operative note for details. Patient tolerated the procedure well and was transferred to the SICU in good condition. Her pain was well controlled with IV narcotics. Her flaps were closely monitored with serial doppler check and continuous [**Date Range 12821**] monitoring. She was given prophylactic antibiotic prophylaxis. On POD1 her left [**First Name9 (NamePattern2) 12821**] [**Location (un) 1131**] dropped. Left flap also became more pale and pulse weakened. There was a concern of arterial thrombosis. She was immediately started on heparin gtt with goal PTT of 60-80. Pulse signal and color of flap did appear to improve a few hours following use of therapeutic heparin gtt. She developed a moderate ecchymoses over the right breast. Vioptics and dopplers continued to improve once on heparin. and she was transferred to the floor on POD2. Her diet was slowly advanced pending return of bowel function. Her foley was removed after which she successfully voided. She worked with physical therapy. On POD4 show was transitioned from a heparin drip to subcutaneous heparin. Her flaps remained viable with stable vioptics and triphasic doppler signals. On POD7 patient exhibited TTP RLQ following a painful BM the prior day. Patient was assessed by Dr. [**Last Name (STitle) **] who recommended a I+/O+ abd/pelvis CT. CT was remarkable only for increase in LLL nodule from 5 to 10mm over the past two months. This finding was discussed with patient by Dr. [**Last Name (STitle) 11635**]. Plan for outpatient f/u CT chest. By the time of discharge patient was afebrile with stable vital signs, voiding/ambulating without assistance, tolerating a regular diet, and pain well controlled with PO narcotics. She was also passing flatus. She is being discharged home today with VNA care. She will follow up with Dr. [**First Name (STitle) **] in 1 week. Medications on Admission: levothyroxine, pantoprazole, citalopram Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Levothyroxine 88 mcg 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. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not drive or operate heavy machinery. Disp:*40 Tablet(s)* Refills:*0* 7. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*28 Capsule(s)* Refills:*0* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: 1. Left breast cancer, gene positivity. 2. Abnormal appendix Discharge Condition: Good Discharge Instructions: Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * No strenuous activity * No pressure on your chest or abdomen * Okay to shower, but no baths until after directed by your surgeon DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Please schedule 1 week follow up appointments with Dr. [**First Name (STitle) **], [**Doctor Last Name 11635**], and [**Doctor Last Name **]. Completed by:[**2152-8-1**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2134-11-20**] Discharge Date: [**2134-11-23**] Date of Birth: [**2058-11-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Neurontin / Codeine Attending:[**First Name3 (LF) 2024**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Pleurex placement History of Present Illness: 76 y/o female with h/o metastatic breast cancer p/w altered mental status (slurred speech, acting "funny" per daughter) after receiving two units of blood during scheduled visit. Parametics noted fever to 101.8, and she developed hypoxia to the 70%'s on RA, which responded to 100% on a NRB. In ED noted to have large Right pleural [**First Name3 (LF) 17838**] (has chronic right pleural [**First Name3 (LF) 17838**], last [**First Name3 (LF) 58770**] 1.3 L on [**10-28**]/6), with a question of underlying PNA. Given cefepime. Head CT was negative for bleed or large mass. Concern for PE, but given Cr 2.5, and inability to tolerate MRI in past, started on heparin empirically for PE. ROS: Has been getting aranesp Q4 wks(last on [**2134-11-17**]) and pamiodronate Q8wks (last [**2134-10-14**]). Received falsodex (last [**2134-9-15**]). SHe does report orthopnea, occasional leg swelling, decreased functional status. She denies, fever, chills, headache, light sensitivity, chest pain, shortness of breath, abdominal pain, diarrhea, arthralgias, or myalgias. She does reports nausea and vomiting over the last several weeks associted with a new cancer medication, which has stopped since stopping the medication. Past Medical History: Metastatic Right Breast Cancer with Mets to L4/L5 HTN Hyperlipidemia DM Depression Anxiety Social History: denies alcohol, drug use, Smoked [**12-14**] ppd x 20 yrs, quit 20 yrs ago Lives at senior living facility. Family History: NC Physical Exam: T 97.6 HR 60 BP 118/41 RR 12 O2 Sat 99% on 4L NC Comfortable, not tachypneic No scleral icterus, PERRL, EOMI, no nystagmus No cerviacl LAD, JVP to mid neck Left Axillary lymph node palpable Heart regular with systolic murmur at LUSB, S2 present Dullness and decreased breath sounds over right lower lung fields, no rales or wheezes Abd nondistended, good bowel sounds, soft, nontender No peripheral edema, good pulses Neuro exam with orientation to person, place, time. Able to do simple calulations and counbt down from 20 by 4's. Able to name objects without dificulty. Strength 5/5 throughout. Coordination intact. Toes downgoing. Pertinent Results: WBC 6.2 N:80.5 L:14.5 M:3.4 E:1.0 Bas:0.6 Hgb 12.0 Hct 34.4 Plt 150 MCV 88 . Na 141 K 4.8 Cl 105 HCO3 27 BUN 56 Creat 2.5 Gluc 147 Ca: 8.2 Mg: 1.9 P: 5.1 D Anion Gap 9 . CK: 54 MB: Notdone Trop-*T*: 0.07 . ALT: 17 AST: 28 Tbili: 0.4 Alb: 3.5 [**Doctor First Name **]: 96 Lip: 82 . PT: 13.0 PTT: 23.2 INR: 1.1 . Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . U/A: Spec [**Last Name (un) **] 1.015, Sm blood, 500 prot, 1 RBC, 1 WBC, few bact, 1 epi . Urine Cx: Pending Blood Cx x 2: Pending . [**11-20**] Lower Extremity Ultrasound ([**First Name9 (NamePattern2) **] [**Location (un) **]): No evidence for deep vein thrombosis in the bilateral lower extremities. . [**11-20**] CXR: Portable AP chest dated [**2134-11-20**] is compared to the prior [**2134-10-28**]. There has been interval development of a large right pleural [**Month/Day/Year 17838**], which obscures the right heart border. There is compressive atelectasis of the right lower lung lobe. The heart size remains enlarged. The aorta and hilar contours are stable. There is no pulmonary vascular congestion. The left lung is clear. IMPRESSION: Interval accumulation of a large right pleural [**Month/Day/Year 17838**] with compressive atelectasis of the right lung. . [**11-20**] Head CT: No evidence for hemorrhage, mass effect, or acute ischemic changes. Please note that MRI is more sensitive in the detection of acute ischemia. Discharge labs: wbc 4.1 hgb 11.1 hct 30.7 plt 82 137 103 55 -----------< 82 4.3 27 2.4 LDH 173 Tbili 0.5 B12 407, folate 9.4, haptoglovin 101, ferritin 702, TRF 167 Brief Hospital Course: 76 y/o female with metastatic breast cancer presents with altered mental staus, fever, right pleural [**Month/Day (4) 17838**]. . 1. Altered Mental Status: Now cleared. Possibly related to medication effect (?premedication with blood products). Resolved quickly while in ICU. No evidence of infection. Tox screen negative. CT head without bleed or mass. No significant metabolic alterations. Could be [**1-14**] hypoxia with pleural [**Month/Day (2) 17838**] as well. We avoided benadryl and other sedating meds while she was in the hospital. . 2. Fever: Could have been due to blood tranfusion, though no documentation of fever after blood products. Occurred several hours after transfusions. No evidence of infection and fever resolved the day after the blood transfusion without any antibiotics given except for cefepime in ED. All cultures negative. . 3.Hypoxia: Resolved after pleurex was done. This was thought to be due to malignant [**Month/Day (2) 17838**]. Pleurex in 50% of people will cause an auto-pleurodesis. Daughter instructed how to drain the device. PE ruled out with CT with gadollinium. MI ruled out with 3 sets of ces and no changes on ekg. Patient has anemia, but had just been given transfusion so this was probably not contributing. . 4. Right Pleural [**Month/Day (2) **]: Chronic, related to breast CA. Pleurex done. . 5. Breast Cancer: Metastatic Right Breast cancer. Was not due for pamidroate or arinesp at this time. We continued fentanyl patch for pain with bony mets. . 6. Diabetes Mellitus: NOt on oral meds or insulin at home. Was on sliding scale here but only required minimal insulin. No sugars above 200. On diabetic diet. . 7. HTN: well controlled in hospital. Continued lisinopril and dozaxosin. . 8. Depression/Anxiety: - cont fluoxetine . 9. Thrombocytopenia- plts trended down from 150-->82. Heparin was stopped on the third day and heparin dep ab were sent. Pneumoboots were used instead. Was not on ppi or any other abx. Scheduled appt in 2 days with Dr. [**Last Name (STitle) 79**] to have cbc checked. . 10. Anemia- based on iron studies, this is most likely anemia of chronic disease [**1-14**] breast cancer. Not due for aranesp. Hemolysis labs negative. Guaic negative. Not iron deficient and b12 and folate were normal. Will have repeat cbc in 2 days with heme-onc doctor, Dr. [**Last Name (STitle) 79**]. Medications on Admission: Lisinopril 40 mg QD Doxazosin 8 mg QHS Furosemide 10 mg QD Fluoxetine 20 mg QD Calcium and Vit D Fentanyl patch 50 mcg Q72H Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 6. CALCIUM 500+D Oral Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary 1. Pleural [**Hospital 17838**] 2. Altered mental status [**1-14**] medication Secondary 1. Metastatic breast CA Discharge Condition: HD stable and afebrile. Discharge Instructions: You were admitted to the hospital because of altered mental status and low O2 saturations. You were found to have a pleural [**Month/Day (2) 17838**]. The pulmonary doctors [**Name5 (PTitle) 58770**] this [**Name5 (PTitle) 17838**]. Please take all medications as directed. Please follow-up with all outpatient appointments. Please return to the ED or seek medical advice if you experience chest pain, fevers, shortness of breath or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 79**] to have your blood counts checked. You have an appointment with Dr. [**Last Name (STitle) 79**] on Thursday [**2134-11-25**] at 1 pm. . Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **]. You have an appointment with her nurse practioner on Wednesday [**12-1**] at 12:30 pm.

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icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

7250, 7308

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330, 350

7474, 7500

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1870, 2505

269, 292

378, 1596

3812, 3957

4305, 6513

1618, 1710

1726, 1835

15,361

113,572

7764

Discharge summary

report

Admission Date: [**2197-6-13**] Discharge Date: [**2197-6-23**] Date of Birth: [**2142-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Weakness, Cough and SOB Major Surgical or Invasive Procedure: None History of Present Illness: 54 y/oM with HIV on HAART (viral load undetectable, last CD4 in [**3-11**] 374), stage IV squamous lung CA s/p RUL s/p lobectomy, chemo/XRT, local and distal recurrence, HCV who p/w worsening fatigue, weakness, increasing dyspnea and new pleuritic chest pain. . Pt. was in USOH (able to ambulate on flat ground ~ 1mi w/o DOE, independent in majority of ADLs) until ~ 1wk ago when he develped malaise and fatigue. Over the next few days he developed a dry cough, which by 3 days PTA became productive of yellow/green sputum. At the same time he developed left sided pleuritic chest pain. He never had subjective fevers or chills, no nightsweats, though had ~ 10-12lbs of wt loss over the past month. By 2 days PTA, his dyspnea had worsened to the point that he was unable to perform ADLs and required assisstance from his mother. [**Name (NI) **] has had weakness in RUE and has had difficulty using that arm, but this is unchanged from prior. Has not been exposed to anyone with RFs for TB, no recent travel. Has not skipped any of the [**Doctor Last Name **] meds. He had respiratory distress requiring intubation for hypoxemic failure in [**2194**] after his right thoracotomy and right upper lobectomy. In the ED initial VS were 97.9 82 116/79 16 he desaturated to 88% on RA, increased to 93% with 2L NC. CTA showed a small LLL PNA with no evidence of PE, and enlarging right apical tumor. Blood cultures were drawn and was treated with zosyn, bactrim, vancomycin. He was admitted to the floor and had a slowly increasing O2 requirement to the point that this AM was satting 86% on 6L NC, requiring an NRB. He became more confused and sleepy per nursing staff. MICU evaluation was initiated. On evaluation, VS were 99.8F 106/72 88 26 93% on NRB, using accessory muscles of respiration and nasal flaring and tachypneic. STAT ABG was pH 7.40 pCO2 50 pO2 67, which was essentially unchanged from the one prior. He c/o of SOB and appeared slightly sleepy, though arousable to voice. . Review of systems: (+) Per HPI, chronic weakness and tingling in right arm, otherwise negative in detail. Past Medical History: - stage IV squamous cell lung cancer (Superior sulcus, T3, N0 at presentation) - dx [**2193**] with biopsy right lung apex squamous cell carcinoma. - s/p right upper lobectomy in [**2195-8-14**] - localized recurrence: Right lung apex in [**2196-6-1**] rx with CTX and cyberknife [**2195**]-[**2196**] - metastatic dx: T1-T2 neural foramina and nerve roots - palliative CTX w/ gemcitabine d/ced [**3-11**] due to liver dysfunction other medical history - Hx of Pulmonary Aspergillus fumigatus infection dx w/ BAL [**2195-7-10**], tx w/ voriconazole, resolution in [**2195-11-19**]. - HIV on HAART, [**3-11**]: viral load undetectable; CD4 count 374 - HCV: genotype 1a, bx [**8-8**] - pulmonary aspergillus dx on BAL [**7-9**] s/p voriconazole rx - hx of + ppd s/p rx with INH - hypotestosterone - polysubstance abuse - depressive d/o - arthritis s/p R shoulder replacement . Social History: - unemployed, disabled. Living at home with his mother - recovering addict (heroin, ETOH, other drugs) - tobacco use: formerly smoked 1ppd, now [**4-10**] cigarettes daily - not currently sexually active, partners have been female Family History: FH: [**Name (NI) 28142**] aunts w/lung cancer in 40s and 50s. father alive w/o CA, mother w/ asthma and s/p removal of breast lesion. Physical Exam: General Appearance: Thin, cachectic, appeared fatigued Eyes / Conjunctiva: Conjunctiva pale, R horners Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, No(t) Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), no m/r/g Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: right apex and laterally, Rhonchorous: throughout), no crackles appreciated Abdominal: Soft, ND, no shifting dullness Extremities: Clubbing, UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28146**]; no edema, dry, warm Musculoskeletal: Muscle wasting Skin: Warm Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed, awakened eailsy to command and answered questios appropriately, inquired about status. R horners, EOMi, face symmeteric, intact to LT b/l, symmetric smile, tongue midline, tremor. Shoulder shrig intact. Mild biceps and finger flexion weakness. Otherwise full. LUE full. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28147**] weak, muscle wasting throughout. Toes down b/l. normal tone. sensory exam deferred. Pertinent Results: [**2197-6-15**] 04:42AM BLOOD WBC-12.6* RBC-3.55* Hgb-13.4* Hct-40.1 MCV-113* MCH-37.8* MCHC-33.5 RDW-14.1 Plt Ct-148* [**2197-6-16**] 01:45AM BLOOD WBC-12.0* RBC-3.29* Hgb-12.3* Hct-36.9* MCV-112* MCH-37.3* MCHC-33.2 RDW-14.1 Plt Ct-129* [**2197-6-16**] 04:23PM BLOOD WBC-11.6* RBC-3.38* Hgb-12.8* Hct-39.3* MCV-116* MCH-38.0* MCHC-32.7 RDW-14.4 Plt Ct-132* [**2197-6-13**] 03:54PM BLOOD Lactate-2.2* [**2197-6-13**] 11:14PM BLOOD Lactate-1.2 [**2197-6-14**] 08:59AM BLOOD Lactate-1.5 [**2197-6-14**] 10:28AM BLOOD Lactate-1.4 [**2197-6-15**] 06:51AM BLOOD Lactate-1.2 [**2197-6-13**] CXR: FINDINGS: Portable AP upright view of the chest is obtained. Post-surgical changes related to prior right upper thoracotomy and reconstruction as well as right upper lobectomy are again noted. There is subtle increased nodular opacity at the left lung base, which raises concern for pneumonia. No large pleural effusions are seen, though the right CP angle is excluded. Cardiomediastinal silhouette appears grossly stable. Left humeral head prosthesis is noted. IMPRESSION: Findings concerning for left basilar pneumonia. Brief Hospital Course: Mr. [**Known lastname 28145**] was a 54 yo man with HIV on HAART (viral load undetectable, last CD4 in [**3-11**] 374), stage IV squamous lung CA s/p RUL s/p lobectomy, chemo/XRT, local and distal recurrence, HCV who presented with worsening fatigue, weakness, increasing dyspnea, new pleuritic chest pain, sputum production and confusion. . # Stage IV lung CA: On presentation, Mr. [**Known lastname 28145**] had an apical mass expanding, adrenal mass on CTA suspicious for metastasis and radicular symptoms in right arm likely [**1-3**] nerve compression but per Pain Clinic. On hospital day six, Mr. [**Known lastname 28145**] reported significnt concern over a new foot drop on the right which progressed to include right leg paralysis and numbness. An MRI of the Spine revealed metastatic tumor cord compression at C7 to T3 with significant stenosis at T2. Neuro-Surgery determined that he was a poor surgical candidate because of the extensive surgical debridment required or and high-risk nature of the surgery. Radiation Oncology evaluated him and determined that re-radiation was unlikely to improve his symptoms because of poor tumor response in the past. Pain control was maintined and he with his mother decided that inpatient hospice with a change of code status to DNR/DNI would be best for Mr. [**Known lastname 28145**]. . # HYPOXIC RESPIRATORY FAILURE, CHRONIC - He was found to have a LLL consolodation consistent with a LLL pneumonia. The pneumonia was believed to be aspiration vs. CAP and sputum culture failed to identify a pathogen. He recieved 7 days of imperic antibotics with azithromycin, ceftriaxone and flagyl which seemed to have resolved the pneumonia, but he continued to [**Known lastname 28148**] difficulty oxygenating. A PE was ruled out w/ CTA. And a Bubble study and Echo did not further identifying cause of hypoxia. He was aided by albuterol nebs Q2 hours and ipratropium nebs Q6H PRN. In the setting of his lobectomy and recurrent lung cancer, his new hypoxia was believed to represent a new baseline oxygen need. . # ALTERED MENTAL STATUS ?????? Mr. [**Known lastname 28145**] [**Last Name (Titles) 28148**] several paroxysmal episodes of profound agitation and combativeness that responded best to zyprexa 5mg. These may have occured due to metabolic derangement in setting of tumor burden or possibly brain mets. . # HCV: unknown VL. Synthetic function at baseline. Bx in [**2193**] -chronic viral hepatitis C with grade 2 inflammation and stage 2 fibrosis. No stigmata of acute liver failure or cirrhosis. - HCV VL = 9,060,000 . # HIV/AIDS on HAART: CD4 374 in [**3-11**] with undetectable VL. Has had apthous ulcers recently. Had CD4 count resent. - cont current antiretroviral medications - f/u CD4 count. - nystatin swish and swallow . # Code status: DNR/DNI comfort measures only # Communication: Patient and mother [**Name (NI) 382**] [**Telephone/Fax (1) 28149**] [**Doctor First Name 1258**]) FYI: Pain medications over the last 24 hours, patient required a total of morphine 52mg IV, morphine SR 60mg po, morphine IR 105mg po and a one-time dose of morphine SR 90mg at noon. Of note, patient's home narcotic regimen prior to admission included: METHADONE [**Male First Name (un) **] 10MG/5ML 75 mg daily MS CONTIN 200 MG XR12H-TAB (MORPHINE SULFATE) 1 tab po bid HYDROMORPHONE HCL 8 MG TABS 1 tab po every 6 hours prn Medications on Admission: Methadone 75 mg PO/NG QAM Albuterol 0.083% Neb Soln 1 NEB IH Q4H Amitriptyline 25 mg PO/NG HS Multivitamins 1 TAB PO/NG DAILY CefePIME 2 g IV Q12H day 1 = [**6-13**] Nystatin 500,000 UNIT PO/NG Q8H Pregabalin 50 mg PO/NG [**Hospital1 **] Clonazepam 0.5 mg PO/NG QAM:PRN anxiety Sertraline 100 mg PO/NG DAILY Docusate Sodium 100 mg PO BID Senna 1 TAB PO/NG [**Hospital1 **] Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY Fosamprenavir 1400 mg PO Q12H Sulfameth/Trimethoprim DS 2 TAB PO/NG Q8H HYDROmorphone (Dilaudid) 2-4 mg PO/NG Q6H:PRN pain Vancomycin 1000 mg IV Q 12H day 1 = [**2197-6-13**] Ipratropium Bromide Neb 1 NEB IH Q6H ValACYclovir 1 gm PO BID Lactulose 30 mL PO/NG Q8H:PRN constipation Discharge Disposition: Extended Care Facility: [**Hospital1 656**] House Discharge Diagnosis: Pneumonia Stage IV metastatic squamous cell lung cancer Cervial Spine Metastasis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with fatigue, weakness and difficulty breathing. You were treated for a pneumonia which improved your breathing. You were found to have a spinal metastatic cancer causing right leg weakness. You and your mother considered available options and decided to pursue hospice care. Please take all medications as prescribed. Followup Instructions: Please consult Dr. [**First Name (STitle) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] or Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] with questions about your condition. Completed by:[**2197-6-26**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10350, 10402

6219, 9598

339, 345

10527, 10527

5079, 6196

11089, 11354

3629, 3764

10423, 10506

9624, 10327

10712, 11066

3779, 5060

2376, 2465

276, 301

373, 2357

10542, 10688

2487, 3364

3380, 3613

78,662

100,225

41075

Discharge summary

report

Admission Date: [**2146-12-22**] Discharge Date: [**2146-12-28**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: ICH s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 89562**] is an 89 year-old right-handed woman with a history of hypertension who was initially evaluated at BIDN following a fall and was transferred to the [**Hospital1 18**] after she was found to have a right thalamic hemorrhage with intraventricular extension. . The patient is high-functioning at baseline. She lives independently. According to the patient's daughter, Ms. [**Known lastname 89562**] was in her usual state of health until at least the day prior to presentation. This morning, there was no answer at the patient's door when the meal service came to deliver food. Emergency services were contact[**Name (NI) **]. The patient was reportedly found on the floor of a bathroom. The patient's daughter shares that prior to transfer to the BIDN, the patient was "groggy" but could identify family members. She was, however, disoriented (eg she thought she was in the living room when she was actually in the bathroom) and was speaking "rag-time." . She was transferred to the BIDN for evaluation. There she was given morphine for head, left shoulder, and left hip pain from the fall. Imaging of the left hip, shoulder, c-spine, facial bones and head was performed. She was transferred to the [**Hospital1 18**] when the non-contrast CT of the head was discovered to show right thalamic hemorrhage. Past Medical History: - hypertension - hypothyroidism - macular degeneration - bilateral cataracts s/p repair Social History: - lives independently - 2 living children - previously worked in a high school cafeteria - avid reader prior to [**First Name8 (NamePattern2) **] [**Last Name (un) **] Family History: - negative for stroke, sz, migraine Physical Exam: NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Sleeping, arouses to loud voice and tactile stim. States she is in the hospital for a "boo boo on my ear." * Orientation: Oriented to person, birthay (except year), indicates the current year is 1829 * Attention: inttentive. Able to name the days of the week forwards x 3 days * Memory: able to correctly identify day, month of birthdate. * Language: Language is fluent with semantic paraphasic errors and neologisms. Often makes statements that are grammatically correct but completely unrelated to context (eg "what should I get you for your brithday?") Repetition is intact. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. Prosody is normal. Pt unable to name high (pen= "pediwinkle", knuckles = "cars") and low frequency objects (knuckles) without difficulty. * Calculation: Pt able to calculate number of quarters in $1.50 Cranial Nerves: * I: Olfaction not evaluated. * II: Pupils surgical, left slightly more reactive than right. * III, IV, VI: EOMI in horizontal plane * VII: Face grossly symmetric * VIII: Hearing intact to voice * IX, X: Palate difficult to visualuze * XII: Tongue protrudes in midline. Strength: * Left Upper Extremity: less voluntary movement tnan on right, able to grip * Right Upper Extremity: lifts at least versus gravity, offers some resistance to push, pull, grip strong * Left Lower Extremity: moves at least in plane of bed (difficult to further evaluate) * Right Lower Extremity: able to lift versus gravity Sensation: * Intact to tickle in all extremities Neuro exam on discharge/ changes from admit: Alert. Oriented to self and sometimes to hospital. Able to move right side against gravity and able to hold for >5 seconds. On the left her bicep was [**1-21**]. Delt /5 and IP /5 Pertinent Results: [**2146-12-22**] 08:40PM GLUCOSE-171* UREA N-24* CREAT-1.1 SODIUM-140 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [**2146-12-22**] 08:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-2.1 [**2146-12-22**] 08:40PM WBC-15.8* RBC-4.57 HGB-13.7 HCT-39.7 MCV-87 MCH-30.0 MCHC-34.5 RDW-13.4 [**2146-12-22**] 08:40PM PLT COUNT-325 [**2146-12-22**] 08:40PM PT-12.2 PTT-23.1 INR(PT)-1.0 CT head [**2146-12-25**] IMPRESSION: No change in the right thalamic hemorrhage extending into the ventricles, with no significant change in ventricular size and shape to suggest developing hydrocephalus. No new hemorrhage. CXR [**2146-12-24**] Lungs are clear. Heart size is normal. There is no pulmonary edema, pleural effusion or pneumothorax b/l Hip XR IMPRESSION: Degenerative changes throughout the imaged field of view as detailed above. No definite traumatic injury of the pelvis or bilateral hips identified. Left Wrist XR IMPRESSION: 1. No definite fractures. 2. Degenerative changes of the thumb CMC and STT joints, as described above. 3. Chondrocalcinosis suggesting CPPD. Brief Hospital Course: [**Known lastname 89562**] was admitted after being found down with AMS. Initial evaluation at [**Hospital1 **] [**Location (un) 620**] revealed a right thalamic bleed so transfer to [**Hospital1 18**] ICU was done. Here she was reevaluated clnically and with CT scan of the head and neck. The bleed was stable and her examination was stable so she was transferred to the floor for further care. On the wards she was stable with occasional events of A-fib with RVR to the 140's responsive to IV Beta Blocker. There were no complications and she was started on heparin SC. Her inital event was thought to be secondary to hypertension. Her blood pressure was within goal but needed some further titration IPH: Secondary to HTN. Stable with IVH extension A-fib with occasional RVR to 140's: responsive to metop 5mg IV. This has occured about once every other day. HTN: Goal less then 160 sytolic: Changed amlodipine to 7.5 mg daily on [**2146-12-28**] Speech and swallow: able to tolerate soft foods with thin liquids. ID: developed fever [**2146-12-28**]. Urine from [**2146-12-24**] grew out Klebsiella P. Sensitive to Ceftriaxone. started on [**2146-12-28**]. Medications on Admission: - toprol XL 200 mg po daily - norvasc 10 mg po daily - synthroid 88 mcg po daily - simvastatin 30 mg po daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Metoprolol Tartrate 5 mg IV Q4H:PRN SBP > 160 Hold for HR < 55 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 11. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. amlodipine Oral 15. CeftriaXONE 1 gm IV Q24H Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: New - Right Thalamic IPH - acute delirium Old - Hypothyroid - HTN - Macular degeneration - b/l cateract Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: you were admitted for a right sided thalamic bleed. You had multiple images of your brain completed which revealed a stable bleed. There was no surgical intervention that was done. You had Atrial fibrillation that was controlled most of the time but you required some PRN medications to help with control. You also were found to have a UTI and you were started on antibiotic for this. Followup Instructions: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- Neurology Location: [**Hospital Ward Name 23**] Center Floor 8. Time/Date: [**2-27**] at 3:30 Please call to ensure date/time one week prior. ([**Telephone/Fax (1) 7394**] Completed by:[**2146-12-28**]

[ "362.50", "244.9", "920", "V49.86", "721.0", "342.92", "719.45", "787.21", "401.9", "293.0", "599.0", "427.31", "E888.9", "431", "041.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7502, 7647

4990, 6152

276, 282

7795, 7795

3884, 4967

8379, 8654

1970, 2008

6313, 7479

7668, 7774

6178, 6290

7970, 8356

2023, 2023

223, 238

310, 1656

2983, 3865

7810, 7946

2048, 2048

1678, 1768

1784, 1954

15,974

164,341

44780

Discharge summary

report

Admission Date: [**2122-1-12**] Discharge Date: [**2122-2-11**] Date of Birth: [**2060-11-22**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old male, who was admitted to the hospital on [**2122-1-12**] with right upper quadrant pain x3 days. The patient had followup. Last temperature was 102.8, upper respiratory symptoms, myalgias, and abdominal pain. Appetite was impaired and prior to admission patient had epigastric pain, which radiated into the right scapula and back pain. Patient had emesis x2, positive shortness of breath. Noted white bowel movements and dark urine. He was thirsty. PAST MEDICAL HISTORY: 1. Mitral valve mechanical, which was placed in 02/[**2113**]. 2. GERD. 3. Paroxysmal atrial fibrillation. 4. High cholesterol. 5. Benign prostatic hypertrophy. MEDICATIONS: 1. Amiodarone at home. 2. Proscar at home. 3. Lipitor at home. 4. Prilosec. 5. Potassium chloride. 6. Folate. 7. Atenolol. 8. Multivitamin. 9. Coumadin. ALLERGIES: Codeine. SOCIAL HISTORY: No alcohol, quit 35 years ago. Smoking. Administrative worker at [**Hospital6 1129**]. On presentation, he was AVSS, mildly uncomfortable. Right upper quadrant and left upper quadrant tenderness. Patient was admitted what was likely to be a gallstone pancreatitis. CT, chest x-ray, patient was NPO, and IV fluids were done, Foley, INR was done, old EKG. Admitted to Dr. [**Last Name (STitle) 468**]. Patient was seen by chief resident, who assessed this 61 year old with cholangitis versus pancreatitis secondary to gallstones. Abdominal CAT scan and ERCP were consulted. Patient was placed on Unasyn. Event note on postoperative day #1, patient was for ERCP. ERCP was performed. Patient was given stent. Coumadin was held. ERCP was performed. Patient was seen by Hepatobiliary attending post ERCP. Was seen to be dyspneic. Had a fever of 102. Lungs sounded tight. Surgery was called for shortness of breath with patient had been given 4 units of FFP. Had known coronary artery disease status post mitral valve replacement. Patient was status post ERCP stenting. He denied chest pain. He was saturating 94% on nonrebreather. Patient was given Lasix. Chest x-ray and ABG were performed. Chest x-ray looked as if he was in CHF. Cardiac Surgery was consulted as per request of Dr. [**Last Name (STitle) 468**], whose impression was CHF, fluid overloaded. Patient was transferred to CCU. Admitting diagnosis was pancreatitis for further management. His respiratory status continued to go poorly. Patient was transferred to the Surgical ICU. Echocardiogram was used to evaluate. Patient was on Heparin with a goal of 60-80. Zosyn was continued. Patient's breathing got slightly better. Patient had a Swan-Ganz catheter placed in order to better manage his fluid status. Patient was followed by Nutrition and ICU management. Patient continued to need ICU level of care. Central venous line was needed. Patient continued with respiratory failure and worsening oxygenation, fever spikes, and was sedated. Patient's mental status was depressed. Infectious Disease were consulted, who assessed this 61 year old with severe pancreatitis with collections by CT with increased fevers, symptoms of URI initially, pulmonary congestion and infiltrates, and receiving Zosyn. Pancreatitis: Patient was seen again and his pancreatitis increased in severity. His creatinine increased. He was nonoliguric renal failure. Progressive end organ renal failure occurred. His hematocrit was dropping down to 23. Renal was consulted for his nonoliguric renal failure. On [**2122-1-23**], patient was hospital day #12, Zosyn day #10, Vancomycin day #5. Patient had pancreatitis, severe ARDS, and had very complicated medical staff in the ICU. Patient was in shock, questionable ARDS and new Swan-Ganz catheter was placed. [**Hospital **] hospital course continued in ICU level of care, respiratory disease, end-organ failure of the renal system. Patient was transfused as needed. Current problems on hospital day #16, postoperative day #14, he had cholangitis and pancreatitis. He was status post ERCP with transpapillary balloon dilatation. He was intubated for ARDS. He had ATN and was on CVVHD. On [**1-25**], had undergone an arrhythmia and A flutter, and was bolused with IV amiodarone. Throughout the hospital course, the patient was waxing and [**Doctor Last Name 688**]. His cholangitis and pancreatitis and ARDS continued as well as his renal failure, and ATN continued to deteriorate. The patient was acidotic, hypertensive, white blood cell count to 50,000, had a left pneumothorax, which responded well to a chest tube. Patient was placed on Vasopressin, and patient continued pancreatic necrosis. Patient's complicated medical status continued to deteriorate. He continued to remain acidotic. Cortical stimulation test was performed as well as units were transfused. On hospital day #25, postoperative day #23, patient by systems: Neuro was sedated. HEENT: PERRLA. CVS: Regular, rate, and rhythm. Respiratory: CTA. Abdomen: Soft and nontender. No bowel sounds. Amiodarone was being used to support him. Patient with a FIO2 of 60%. CVVHD was used for hemodialysis. Patient continued critical care level of care. On [**2122-2-10**], the patient was critically ill with multiorgan failure, necrotizing pancreatitis, and discussions with the family were undertaken for CMO measures. Patient was continued on Vancomycin, levofloxacin, Flagyl, meropenem, and fluconazole. A family meeting was undertaken and his chances at meaningful recovery were discussed. Family members understood the patient was critically ill and it was discussed DNR/DNI, and to make the patient CMO. On [**2122-2-11**], all supportive therapies were ongoing. Family arrived at 1:30 in the afternoon. All members were present. Dr. [**Last Name (STitle) 468**] and Dr. [**Last Name (STitle) 95812**] spoke with the family and confirmed wishes for CMO status and withdraw of life support measures. The hemodialysis D/C'd. All other supports were D/C'd including extubation. Sedation therapy remained ongoing. Patient became pulseless at 14:15. ICU attending and house officer were notified, and patient expired on [**2122-2-11**]. This is Dr. [**Last Name (STitle) **] dictating a medical record from the patient's chart only. I have never met the patient. Had no clinical contact with this patient. Dictated for Dr. [**Last Name (STitle) 468**]. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. Dictated By:[**Last Name (NamePattern1) 740**] MEDQUIST36 D: [**2122-4-27**] 15:52 T: [**2122-4-29**] 09:25 JOB#: [**Job Number 95813**]

[ "038.9", "574.51", "V66.7", "518.82", "576.1", "512.0", "584.9", "428.0", "577.0" ]

icd9cm

[ [ [] ] ]

[ "51.87", "38.95", "34.04", "51.88", "96.04", "99.15", "51.84", "38.93", "96.72", "39.95", "93.90" ]

icd9pcs

[ [ [] ] ]

157, 639

661, 1012

1029, 6752

80,983

159,592

51768

Discharge summary

report

Admission Date: [**2125-8-10**] Discharge Date: [**2125-8-16**] Date of Birth: [**2047-2-22**] Sex: M Service: MEDICINE Allergies: Lisinopril / Norvasc Attending:[**First Name3 (LF) 1943**] Chief Complaint: Sepsis, hyponatremia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 78 year-old male with hx of DM, htn, hypothyroidism presented with intermittent SOB for the past week and low back pain. Prior to admission the patient noted generalized malaise, weakness and dysuria. Over the past 24 hours he reports clear cloudy urine, without any hematuria or unusual orders. At the same time, he felt unsteady on his feet, and he noted a low grade temp ~ 100, as well as high blood sugers. He has a chronic dry cough, and 2 pillow orthopnea, but denies any PND, chest pain, palpitations, or CHF exacerbations. He reported no numbness or tingling in the feet, or changes in LE strength. In the ED, initial vs were: T 99.7 P 74 BP 200/68 R 22 100% O2 sat. UA was consistent with a UTI. Blood and urine cultures were sent. Labs were notable for a WBC of 14, sodium of 118, Cr of 1.3, and K of 5.7. Patient was given 100 mg phenazopyridine and ciprofloxacin 400 mg IV. Got 500 cc NS in the ED. Guaiac negative on rectal exam. 184/100 On the floor, he had some minor abdominal pain and nausea. He was also thirsty. His VS were 100.4, 99, 188/68, 16, 98%. Past Medical History: 1. Diabetes mellitus type II 2. Hyperlipidemia 3. Hypertension 4. Hypothyroidism 5. Rosacea 6. Renal artery stenosis Social History: - Tobacco: 15 pack year history - Alcohol: 15 year drinking history with 3 shots/day, six days a week - Illicits: None Family History: No history of kidney problems or bleeding diathesis Physical Exam: T 96.7, HR 181/75, HR 65, RR 20, O2 100% on room air General - well appearing; lying in bed watching 60 minutes; in good spirits HEENT - anicteric; no pallor; JVP not appreciable CV - regular; no murmurs PULM - clear; no rales ABD - soft and obese; non-tender, even in region that was previously extremely tender EXT - warm; trace edema NEURO - alert; oriented to "[**Hospital1 18**], [**Location (un) 442**], [**Apartment Address(1) 107213**]" and "the 23th, [**2124**]"; he remembered my name from 2 hours earlier when I met him in the ICU Pertinent Results: [**2125-8-10**] 07:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2125-8-10**] 07:40PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.007 [**2125-8-10**] 07:40PM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2125-8-10**] 07:39PM LACTATE-1.4 K+-5.6* [**2125-8-10**] 07:35PM GLUCOSE-173* UREA N-24* CREAT-1.3* SODIUM-118* POTASSIUM-5.7* CHLORIDE-84* TOTAL CO2-22 ANION GAP-18 [**2125-8-10**] 07:35PM cTropnT-<0.01 [**2125-8-10**] 07:35PM CK-MB-2 cTropnT-<0.01 [**2125-8-10**] 07:35PM OSMOLAL-262* [**2125-8-10**] 07:35PM WBC-14.0* RBC-3.78* HGB-12.3* HCT-34.9* MCV-92 MCH-32.7* MCHC-35.4* RDW-12.0 [**2125-8-10**] 07:35PM NEUTS-81.1* LYMPHS-11.1* MONOS-5.3 EOS-2.2 BASOS-0.3 [**2125-8-10**] 07:35PM PLT COUNT-439# [**2125-8-10**] 07:35PM PT-12.1 PTT-24.5 INR(PT)-1.0 WBC: 14 --> 14.9 HCT: 34.9 Na: 116 -> 119 Chemistry URINE CHEMISTRY Hours UreaN Creat Na K Cl Uric Ac [**2125-8-13**] 18:19 RANDOM 20 38 10 36 Source: CVS [**2125-8-12**] 22:20 RANDOM 38 23 22 23.81 Source: CVS [**2125-8-11**] 00:55 RANDOM 238 30 40 31 44 [**2125-8-16**]: Glucose UreaN Creat Na K Cl HCO3 AnGap 56*1 29* 1.1 128* 5.0 91* 29 13 Blood culture [**2125-8-10**]: SENSITIVITIES: MIC expressed in MCG/ML _____________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 64 I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2125-8-11**]): GRAM NEGATIVE ROD(S). Urine culture [**2125-8-10**]: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s)uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML. --------- Images: CXR - Extensive pleural plaques from prior asbestos exposure. No acute pulmonary process. L-Spine plain film: There are extensive degenerative changes of the entire lumbar spine with loss of intervertebral disc height in all levels. There are moderate osteophytes in all vertebral bodies in the anterior and lateral aspects. The [**Last Name (un) **] of the vertebral bodies is preserved. There is vacuum phenomenon in almost all the disc spaces. The aorta is calcified. There is no evidence of fracture. There is mild rectification of the lumbar lordosis. EKG: Low voltage, but no peaked T waves or ST segment or T wave abnormalities. Renal ultrasound [**2125-8-11**]: 1. No ultrasound evidence of pyelonephritis (son[**Name (NI) 867**] is insensitive for this diagnosis), stones, abscess, or hydronephrosis. 2. Partially collapsed bladder. Equivocal wall thickening of the posterior aspect of the bladder may be reflective of known UTI, however this can also be seen in the collapsed bladder. Chest CT w/contrast [**2125-8-14**]: 1. Calcified pleural plaques consistent with asbestos exposure without evidence of interstitial lung disease. No masses or evidence of intrathoracic malignancy. 2. Multiple pulmonary nodules measuring up to 5 mm, given size, and asbestos exposure, a 6 month followup is recommended. 3. Coronary calcifications. Brief Hospital Course: This is a 78-year-old male presenting with fatigue, malaise, fevers, chills, and dysuria with lower abdominal pain and leukocytosis, a positive urine culture, and blood cultures with ESBL-producing E.coli. #. ESBL Urosepsis: The patient presented with subjective fevers and dysuria, and was noted to have a leukocytosis and positive urine and blood cultures with gram negative rods. His blood culture from [**8-10**] subsequently grew ESBL-producing E.coli. A surveillance blood culture from [**8-13**] had no growth. The patient was initially treated with ciprofloxacin, but was transitioned to meropenem on [**8-12**] once sensitivities were revealed and the E.coli species was found to be resistant to all oral antibiotic regimens. A renal ultrasound was done which showed no evidence of pyelonephritis or abscess. On day of discharge, the patient was transitioned to ertapenem due to its once daily dosing properties and ease of administration at home through a VNA service. His WBC had returned to within the normal range, and the patient remained afebrile during his admission. A PICC line was placed, and the patient will need to complete a 14-day course of ertapenem until [**2125-8-27**]. #. Shortness of Breath: The patient initially described some progressive shortness of breath over the past week prior to admission. A CXR only showed evidence of previous asbestos exposure with no areas of consolidation. His EKG was baseline. Cardiac biomarkers were negative x 2. The patient's lungs were also clear on exam, and his O2 sats were normal on room air. On the floor and after beginning appropriate therapy for his ESBL urosepsis, the patient no longer endorsed malaise and SOB. He did describe some episodic coughing, and was treated symptomatically with benzonatate PRN. #. Hyponatremia: The patient's sodium at admission was 118. The patient did not manifest any confusion or changes in mental status. His baseline sodium, last checked in [**2124-9-21**] had been normal, so this was a new finding for the patient. He was intially treated with IVF for volume depletion. His home doses of chlorthalidone and spironolactone were also held during his admission. The patient was treated with salt supplementation and free water restriction, and his Na slowly trended up; his Na was 128 on day of discharge. To work-up this patient's hyponatremia, we checked a TSH and cortisol level which were within the normal range. We also checked multiple serum and urine chemistries after stopping his home diuretic medications. His lab work-up, including his serum and urine osmolality, sodium, and urate levels seemed to suggest SIADH. Because of this patient's history of asbestos exposure, we decided to check a Chest CT to rule out a lung lesion or intrathoracic malignancy that could be causing his SIADH. This patient had prior CXR imaging which showed calcified pleural plaques consistent with a history of asbestos exposure, but no other previous chest imaging. The chest CT revealed multiple calcified pleural plaques, and multiple pulmonary nodules of up to 5mm. There was no evidence of intrathoracic malignancy. The patient should have a follow-up chest CT in 6 months to evaluate for progression of his pulmonary nodules. The chest CT did not reveal a cause of his SIADH, so following his sodium levels and a further workup as an outpatient would be advised. #. Hyperkalemia: The patient had an elevated potassium on admission. We held his spironolactone andolmesartan and did not restart these medications at discharge. The patient was initially treated with kayexalate, and was then transitioned to PO furosemide. A cortisol level was also checked, as adrenal insufficiency could lead to both hyperkalemia and hyponatremia. His cortisol level was normal/high which was not consistent with a diagnosis of AI. That patient's potassium level at discharge was within the normal range. That patient was discharged on daily furosemide. #. Lower back pain: The patient reported lower back pain on admission. A lumbar XR was performed and showed extensive degenerative changes, with no evidence of fracture. #. Chronic Kidney Disease: The patient has a baseline Cre of 1.1-1.2. His admission Cre was initially elevated. It was trended during his admission, and remained stable. #. Anemia of chronic disease and CKD: The patient has a baseline low hematocrit secondary to his chronic kidney disease. His hematocrit remained stable during his admission. #. Diabetes, type II: The patient is followed at [**Last Name (un) **], and was continued on his fixed dose of humalin 70/30 [**Hospital1 **]. The patient did have one early morning episode of symptomatic hypoglycemia, which improved after drinking juice. The patient reported that his PO intake had changed since his hospitalization. Adjustments were made to the patient's PO regimen, and he had no additional hypoglycemic episodes. His insulin regimen was thus not changed. He will follow-up with his PCP and endocrinologist as an outpatient. #. Hypertension: The patient's blood pressures were stable during his admission. He was continued on his home dose of labetalol. Medications on Admission: 1. Plavix 75 mg po daily 2. Carvedilol 12.5 mg [**Hospital1 **] 3. Chlorthalidone 50 mg po daily (currently HELD) 4. Spironolactone 25 mg po bid (currently HELD) 5. Labetalol 100 mg po bid 6. Pravastatin 80 mg po daily 7. Insulin 70/30 35 am/28 pm 8. Levothyroxine 50 mcg po daily 9. Clonazepam 0.5 mg po bid 10. Miralax daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO qAM. 5. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*30 Capsule(s)* Refills:*0* 10. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day: Please administer until [**2125-8-27**]. Disp:*QS * Refills:*0* 11. Humulin 70/30 Pen 100 unit/mL (70-30) Insulin Pen Sig: as directed Subcutaneous twice a day: 35 units every morning and 25 units every evening . 12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 14. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Miralax 17 gram/dose Powder Sig: Seventeen (17) grams PO once a day. 16. Outpatient Lab Work Please check sodium, potassium, chloride, bicarbonate, BUN, creatinine, and CBC on Monday [**8-20**] and Monday [**8-27**]. Please fax results to PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**], at [**Telephone/Fax (1) 7922**]. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: PRIMARY DIAGNOSES: - E. coli (ESBL) bacteremia - Gram negative rod urinary tract infection - Hyponatremia secondary to SIADH - SIADH, undetermined etiology SECONDARY DIAGNOSES: - Hypertension - Diabetes mellitus - Hyperlipidemia - Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for fevers, generalized weakness, and burning with urination. After your evaluation in the hospital, the cause of these symptoms was likely due to a urinary tract infection, and an infection in your bloodstream. You were started on an antibiotic called meropenem to treat this infection. You were started on this IV antibiotic because the particular bacteria in your bloodstream is resistant to every type of oral antibiotic. You will need to complete a full 2-week course of ertapenem (the once daily version of meropenem) for your infection. You were also found to have low sodium levels. There are many causes of low sodium levels. One reason could be due to use of certain medications, and this is why we stopped your hydrochlorothiazide. Your sodium will be rechecked as an outpatient, and if it remains low your PCP may recommend further studies. We also looked at a CT scan of your chest, because certain lung lesions can lead to low sodium levels. This CT showed no evidence of malignancy, some evidence of prior asbestos exposure, and several small lung nodules. You should have a follow-up CT in 6 months to make sure that these lung nodules have not changed in size or character. The following changes were made to your home medication regimen: -We discontinued your home hydrochlorothiazide because of your low sodium levels. -We also discontinued your spironolactone, because of your high potassium levels. -You were started on furosemide 20mg daily. -You were started on sodium chloride tablets, 1 gram tablet per day. -You were started on IV ertapenem to treat the urinary tract infection and the infection in your bloodstream. You will need to complete a full 2-week course of this antibiotic ending [**2125-8-27**]. -You were also started on benzonatate for cough which you can continue taking three times daily as needed. Please take all of your medications as prescribed, and keep all of your follow-up appointments. Followup Instructions: Department: [**State **]When: FRIDAY [**2125-8-31**] at 9:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13151, 13203

5924, 11067

302, 308

13493, 13493

2363, 5901

15672, 15975

1733, 1786

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13224, 13381

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140

165,618

1220

Discharge summary

report

Admission Date: [**2160-9-21**] Discharge Date: [**2160-9-23**] Date of Birth: [**2107-3-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: GI bleeding. Major Surgical or Invasive Procedure: Endoscopy. History of Present Illness: 53M with hx of HepC, Hepatitis C, thrombocytopenia, and CAD s/p CABG, with cardiac cath with stenting 1 week ago at which time he was started on plavix. Tx'd from OSH for 2 episodes each of black stool/BRBPR and cola colored emesis. No abd pain. . In the ED patient was noted to have frankly bloody guiaic with 300cc NG aspirate of cola fluid and coffee grounds; lavage was clear, HD stable. HCT was noted to have dropped 36 to 26 over past 8 days. Past Medical History: CAD s/p [**2153**] CABG with subsequent Bell's palsy, cath w stent [**2160-9-12**] Hypertension Hx of Hepatitis C. Patient's primary care provider states that the patient underwent treatment approximately 10 years ago, and then additional "incomplete" treatment several years ago. Unclear re: specifics. Thrombocytopenia. [**Month/Day/Year 7699**] have been running 60's-80's. Gout Hx of binge drinking Appendectomy Social History: Single, works construction. Lives with son, [**Name (NI) **] age 21. Has sister in area, [**Name (NI) 17**] [**Name (NI) 7700**] (# [**Telephone/Fax (1) 7701**].) Patient smoked 2-3 packs a day for approximately 30 years, quitting in [**2153**]. Family History: Mother with an enlarged heart. Physical Exam: Physical Exam: VS: Temp: AF BP: 118/57 HR: 90 RR: 20 O2sat: 100% 2 LPM GEN: middle-aged man in NAD, pale appearing HEENT: EOMI, PERRL RESP: Non labored and clear anteriorly CV: RRR no MRG ABD: Soft, ND, NT, pos BS EXT: No edema Skin: No rash Pertinent Results: Labwork on admission: [**2160-9-21**] 06:00AM WBC-5.6 RBC-2.48*# HGB-8.9*# HCT-26.4*# MCV-106*# MCH-35.7* MCHC-33.6 RDW-13.8 [**2160-9-21**] 06:00AM PLT COUNT-86* [**2160-9-21**] 06:00AM NEUTS-71.7* LYMPHS-21.8 MONOS-6.0 EOS-0.2 BASOS-0.3 [**2160-9-21**] 06:00AM PT-14.5* PTT-31.5 INR(PT)-1.3* [**2160-9-21**] 06:00AM GLUCOSE-154* UREA N-23* CREAT-0.7 SODIUM-139 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-12 . [**2160-9-21**] 06:00AM BLOOD cTropnT-<0.01 [**2160-9-21**] 06:00AM BLOOD CK-MB-4 . [**2160-9-21**] 12:44PM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative . [**2156-4-14**] Echo: LVEF 60% with mild LVH. Mild MR, TR. . [**2160-9-5**] ETT ([**Hospital1 2025**]): 5 minutes 15 seconds [**Doctor First Name **] protocol, 54% max PHR. + chest pain and EKG changes with exercise (ST elevation). Imaging: mild inferior scar with mild inferior and inferolateral ischemia. LVEF 68%. FINAL DIAGNOSIS: 1. Severe native 3 vessel coronary artery disease. 2. Moderate systemic arterial hypertension. 3. Patent LIMA-LAD and radial artery-diagonal grafts. 4. SVG-RPDA with 80% stenosis; SVG-OM with 30% stenosis. 5. Successful stenting of the SVG (to RPDA) (Drug eluting) . ECG [**2160-9-21**] Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2160-9-13**] no change. . EGD [**2160-9-21**] Impression: Normal mucosa in the duodenum Ulcers in the antrum and stomach body [**Doctor First Name **]-[**Doctor Last Name **] tear . Labwork on discharge: [**2160-9-23**] 04:10AM BLOOD WBC-4.7 RBC-3.45* Hgb-11.2* Hct-32.7* MCV-95 MCH-32.4* MCHC-34.3 RDW-16.9* Plt Ct-67* [**2160-9-23**] 04:10AM BLOOD Glucose-116* UreaN-15 Creat-0.8 Na-138 K-4.3 Cl-107 HCO3-24 AnGap-11 [**2160-9-23**] 04:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1 Brief Hospital Course: A/P: 53 y/o man with CAD s/p recent stent ([**2160-9-12**]), history of Hepatitis C, EtOH abuse who presented from OSH with melena, coffee ground emesis; found to have hematocrit drop from 36 to 26 over past 8 days prior to admissin. Admitted to MICU for monitoring prior to endoscopy. . 1. GI bleed. The patient was transfused three units packed red blood cells with appropriate bump in hematocrit. The hematocrit remained stabled after transfusion with hematocrit in low 30s hospital days [**2-29**]. The patient had two episodes of melena the night of hospital day one; no further episodes of hematemesis or melena during hospitalization. Hematocrit 32.7 on discharge. Aspirin and Plavix were initially held but were restarted the second day of admission per GI recommendations. Patient was initially treated with Protonix 40 mg IV bid; this was changed to po prior to discharge. EGD with results as above; no further treatment as tear and ulcer were no longer actively bleeding. H. pylori serum antigen was negative. The patient was taking high-dose indomethacin for one week prior to admission for gout. The patient is scheduled to have a repeat endoscopy in 4 weeks as below to assess for healing of the ulcers. . 2. CAD. Remained asymptomatic throughout hospitalization. Aspirin and Plavix were initially held but were restarted the second day of admission per GI recommendations. Antihypertensives were restarted the second day of admission. Patient to make follow-up appointment with cardiology. . 3. Hepatitis C. No varices seen on endoscopy. Further work-up and management deferred to the primary care doctor. . 4. ETOH use/abuse. Patient evaluated with CIWA scale but showed no signs of withdrawal. . 5. Thrombocytopenia. Stable, chronic. Heparin products held as primary care doctor [**First Name (Titles) 7702**] [**Last Name (Titles) **] have dropped in the past in response to heparin. HIT Ab negative. [**Last Name (Titles) 7699**] in 60s on discharge. Medications on Admission: Aspirin 81mg daily every morning Lisinopril 40mg daily every morning Folic acid 1mg daily every morning Norvasc 5mg daily every morning Atenolol 100mg daily every morning Plavix Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Pantoprazole 40 mg IV Q12H 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Upper GI bleed, [**Doctor First Name **]-[**Doctor Last Name **] tear on endoscopy 2. Ulcers in stomach body and antrum . Secondary: 1. CAD s/p [**2153**] CABG with subsequent Bell's palsy, cath w stent [**2160-9-12**] 2. Hypertension 3. Hepatitis C 4. Thrombocytopenia- [**Month/Day/Year 7699**] have been running 60's-80's 5. Gout 6. Hx of binge drinking 7. s/p Appendectomy Discharge Condition: Afebrile, vital signs stable. Hematocrit stable. Discharge Instructions: Please contact a physician if you vomit blood, experience black stools, bloody stools, chest pain, shortness of breath, or any other concerning symptoms. . Please take your medications as prescribed. Take Protonix 40 mg twice a day for the rest of your life. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up endoscopy: Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7703**] Date/Time:[**2160-11-5**] 9:00 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2160-11-5**] 9:00 . Please call your primary care doctor and arrange follow-up within the next two weeks. . Please make a follow-up appointment with your cardiologist.

[ "V45.81", "530.7", "414.01", "401.9", "287.5", "274.9", "531.90", "070.54" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

6464, 6470

3634, 5605

335, 348

6902, 6953

1862, 1870

7312, 7720

1551, 1583

5833, 6441

6491, 6881

5631, 5810

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1613, 1843

3337, 3611

283, 297

376, 828

1884, 2764

850, 1269

1285, 1535

11,860

102,196

22992

Discharge summary

report

Admission Date: [**2205-10-13**] Discharge Date: [**2205-10-18**] Date of Birth: [**2134-9-28**] Sex: F Service: MEDICINE Allergies: Dapsone / Cyclosporine / Cefepime / Aztreonam / Azithromycin / Vancomycin Attending:[**First Name3 (LF) 1185**] Chief Complaint: Diarrhea and weakness Major Surgical or Invasive Procedure: thrombectomy History of Present Illness: 70-year-old woman with a history of non-Hodgkin's lymphoma s/p SCT in [**2199**] with complications of chronic GVHD and nephrotoxicity, ESRD on HD (T/Th/S), who presented with diarrhea and weakness. She has had URI this past week with a sore throat, mild cough, malaise associated with worsening pain in her left eye (has chronic post-herpetic neuralgia which can be worse w/ colds) for which she saw her PCP and was prescribed an eye ointment. Patient had fever Thursday to 100.4, otherwise afebrile but having chills. . Also had watery, non-bloody diarrhea starting on Wednesday and continuing through today. Initially improved some, but was worse again today and after large volume diarrhea she felt weak/faint and needed support from her husband to walk. She called the oncology office and was told to come into ED for eval. In addition, the patient's AV graft could not be accessed yesterday at HD so she did not have dialysis. . In the ED, initial VS were: 98.0 100 107/66 20 98%. Labs were remarkable for a K of 5.2. CXR showed clear lungs, Patient initially spiked fevers to 100.4. Blood cultures were sent and patient recived linezolid 600 mg IV x1. She then spiked a fever to 102 degrees and developed a new oxygen requirement (89% on RA, came up to 97% on 4L NC) and became hypotensive (SBPs 70s - 80s). Given fever, antibiotics were broadened to IV zosyn, patient received tylenol 1 gram PO x1, 300 cc bolus of NS. Her blood pressure remained low - patient received a total of 1.3L NS, but required levophed gtt at 0.3. On transfer vitals were 102, 120, 18, 120/57 on 0.3 of Norepinephrine. . On arrival to the MICU, patient feels better than she did earlier today. She complains of sore throat. No nausea, vomiting, abdominal pain, melena, BRBPR, cough, chest pain, shortness of breath. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: PMH: - Large Cell Lymphoma: Diagnosed [**2197**], initially received RCHOP and ICE then relapsed and now s/p allogeneic SCT in [**6-12**], c/b GVHD. - Chronic Graft vs Host Disease, mild (cutaneous, liver) - ESRD: Unclear if secondary to chemo, cyclosporine, or GVHD. Had LUE AV fistula placed but has occluded L brachiocephalic vessel on fistulagram then had graft placed in RUE which required required angioplasty in [**1-/2205**] - s/p thyroidectomy for thyroid mass, pathology was benign - herpes zoster c/b post-herpetic neuralgia s/p nerve block - hyperlipidemia - prior moderate-to-severe mitral regurgitation and nonischemic cardiomyopathy (EF 30-40%). Possible etiologies include focal myocarditis, coronary artery disease (although coronary disease on catheterization did not fit a coronary territory), cardiotoxic chemotherapy - E Coli bacteremia - Parainfluenza Type 3 Virus bronchitis [**4-/2204**] Social History: 18-pack-year smoker, quit 40 years ago. She drinks alcohol rarely. She is married and lives with her husband. She has two adult children. She is now retired. Formerly worked in human resources at a department store. Family History: No fam history of blood clots. Mother deceased age 87 of cerebral hemorrhage. Father deceased age 48 of malignant hypertension. Aunt deceased from breast cancer. Brother deceased of massive MI at the age of 66. Additional brother with hypertension and emphysema. Physical Exam: Vitals: T: 98.2 BP: 127/40 P: 115 R: 18 18 O2: 100% on 4L NC, CVP of 4 General: Alert and oriented x3, appears slightly uncomfortable HEENT: Sclera anicteric, slightly dry mucus membrane, PERRLA, EOMI, left eyelid droop (documented in prior notes) Neck: supple, JVP not elevated, no LAD CV: Tachy, S1, S2, [**1-13**] apical systolic murmur, nonradiating Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, RUE graft with no thrill Neuro: CNII-XII grossly intact, 5/5 strength upper/lower extremities, grossly normal sensation . On discharge patient's tachycardia had resolved. The thrill had returned in her fistula. He overall plume status was euvolvemic with resolution of lower extremity edema. Pertinent Results: [**2205-10-17**] 10:29AM BLOOD WBC-9.8 RBC-2.76* Hgb-9.0* Hct-27.0* MCV-98 MCH-32.7* MCHC-33.5 RDW-15.2 Plt Ct-286 [**2205-10-13**] 07:25PM BLOOD Neuts-82.8* Lymphs-7.6* Monos-3.1 Eos-6.3* Baso-0.1 [**2205-10-14**] 04:39AM BLOOD PT-14.0* PTT-36.4* INR(PT)-1.2* [**2205-10-17**] 10:29AM BLOOD Glucose-127* UreaN-40* Creat-6.0*# Na-133 K-3.6 Cl-99 HCO3-20* AnGap-18 [**2205-10-13**] 12:20PM BLOOD ALT-12 AST-26 AlkPhos-65 TotBili-0.2 [**2205-10-17**] 10:29AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.4 [**2205-10-13**] 07:25PM BLOOD Cortsol-20.6* [**2205-10-14**] 04:58PM BLOOD IgG-741 IgA-LESS THAN IgM-30* [**2205-10-15**] 06:30AM BLOOD Type-ART Temp-35.8 Rates-/20 O2 Flow-2 pO2-111* pCO2-37 pH-7.52* calTCO2-31* Base XS-7 Intubat-NOT INTUBA . C difficile Toxin PCR POSITIVE Semi-Urgent Result Specimen Source: Stool This test was developed and is performance characteristics determined by Laboratory Medicine and Pathology, [**Hospital3 14659**]. This test has not been cleared or approved by the U.S. Food and Drug Administration. Special Information Specimen received in transport media. Report Status: Final Result reported to Dr [**Last Name (STitle) **] [**10-17**] am. . PA AND LATERAL CHEST, [**10-16**] HISTORY: 71-year-old woman with cough, rule out pneumonia. IMPRESSION: PA and lateral chest compared to [**10-13**] through 8: There is still residual consolidation in the left lung, close to the posterior heart border and lower lobe, but probably improved since the yesterday's examination. Lungs are otherwise clear. Heart size is normal. Small left pleural effusion has increased since [**10-14**]. Heart size is normal. Right jugular line ends in the mid SVC. [**Month (only) **] clips denote prior surgery in the region of the thyroid. . Final Report CT TORSO DATED [**2205-10-14**] INDICATION: A 71-year-old woman with history of non-Hodgkin's lymphoma status post stem cell transplant, presenting with diarrhea, fevers, and hypertension. The patient also with new oxygen requirement. Evaluate for pneumonia. Evidence of GI infection. Evaluate for possible GI source of infection, colitis or abscess. TECHNIQUE: Axial MDCT images acquired from the thoracic inlet to the pubic symphysis following oral and uneventful IV Optiray administration. Coronal and sagittal reformats were obtained. COMPARISON: Comparison is made to multiple previous PET-CTs most recently [**2204-12-26**]. FINDINGS: Previous thyroidectomy noted. The previously noted 2-mm right lower lobe nodule is not identified on the current study. There is no pathologically enlarged axillary, mediastinal, hilar or supraclavicular adenopathy. There are small bilateral pleural effusions which are new with overlying atelectasis. NG tube with tip within the stomach. Right-sided internal jugular central venous catheter with tip at the distal SVC. There is diffuse ground-glass opacity within both lungs with interlobular septal thickening which may be due to pulmonary edema. There is diffuse peribronchial wall thickening involving the lower lobe bronchi bilaterally which is more marked than previously. CT ABDOMEN: The liver, spleen, and both adrenal glands are normal in appearance. Stable gallstone within the gallbladder. There is no gallbladder wall thickening or pericholecystic fluid. Both kidneys are atrophic in appearance. There are bilateral hypodensities in both kidneys, which are too small to characterize. The common bile duct measures 6.5 mm within the head of the pancreas which is unchanged from previous CTs. The pancreas is normal in appearance. The spleen is normal in appearance. There is an oblong area measuring 1.9 x 0.5 cm in the left periaortic region (3:57), which may represent a vessel or less likely a lymph node and is unchanged in appearance from previous CTs. There is no free fluid. There is no free air. There is fluid within the ascending colon. There is no evidence of colonic wall thickening or edema. There is no evidence of obstruction or free air. CT PELVIS: There is a persistent area of thickening along the left side of the anorectal junction (3:123), which is unchanged from previous and poorly delineated by CT. There is a Foley catheter within the bladder. There are bilateral fat-containing inguinal hernias. There is no free fluid. VASCULATURE: There is 50% stenosis at the origin of the celiac artery. The SMA is patent. There is mild-to-moderate atherosclerotic calcification of the intraabdominal aorta which is of normal caliber. The IVC is of normal caliber. OSSEOUS STRUCTURES: There are degenerative changes throughout the lumbar and thoracic spine without evidence of suspicious osseous lesions. IMPRESSION: 1. Diffuse ground-glass opacity with interlobular septal thickening, most likely due to pulmonary edema. No evidence for pneumonia. 2. Bilateral lower lobe peribronchial wall thickening, which may be due to infection including severe bronchitis, although neoplastic involvement (lymphoma) cannot be excluded. This appears worse than previous CT of [**2204-12-26**]. 3. Small bilateral pleural effusions with overlying atelectasis. 4. Atrophic kidneys with bilateral hypodense areas, which are too small to characterize. 5. Persistent apparent thickening of the left anorectal junction, which is unchanged from previous CTs, and could be better assessed with MRI, US or direct visualization if clinically indicated. 6. 50% stenosis of the origin of the celiac artery. 7. Cholelithiasis without evidence of acute cholecystitis. Wet read provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4033**] on [**2205-10-14**] at 2:13am on CCC. 1. No definite radiographic explanation for patient's fever/hypotension. 2. Fluid in the ascending colon is consistent with provided history of diarrhea, although there is no associated bowel wall thickening or significant pericolonic fat stranding to suggest colitis. 3. No evidence of pneumonia. Bilateral lower lobe bronchial wall thickening and bronchiectasis could be due to small airways disease or chronic aspiration. 4. Cholelithiasis, as on CT from [**2204-12-26**]. 5. Atrophic kidneys, as before. Small right renal hypodensity is too small to characterize. . [**10-14**] Echo The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. Mild mitral regurgitation. Pulmonary artery hypertension. Compared with the prior study (images reviewed) of [**2204-10-29**], aortic regurgitation is not seen on the current study (may be due to technical issues) and PA systolic hypertension is now identified. The remaining findings are similar. CLINICAL IMPLICATIONS: Based on [**2200**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . Head CT INDICATION: 71-year-old woman with head trauma to the occiput status post fall, evaluate for trauma. COMPARISON: CT head with and without contrast [**2203-12-7**]. FINDINGS: There is no evidence of intracranial hemorrhage, masses, mass effect, or shift of normally midline structures. Ventricles and sulci are prominent consistent with age-related involutional changes. Mild periventricular and subcortical white matter low-attenuating regions are consistent with sequelae of chronic small vessel ischemic disease. There is no evidence of acute fracture. Bilateral mastoid air cells are clear. Mild mucosal thickening is noted in bilateral maxillary sinuses, right greater than left as well as within the anterior ethmoid air cells. Calcifications are noted within the carotid siphons. Minimal scalp hematoma over the left fronto-parietal region is noted. IMPRESSION: Minimal scalp hematoma over the left fronto-parietal region is noted. Otherwise normal examination. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 8575**] [**Name (STitle) 8576**] . Sputum Culture GRAM STAIN (Final [**2205-10-14**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2205-10-18**]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- R Brief Hospital Course: 70-year-old woman with a history of NHL s/p SCT in [**2199**] with complications of chronic GVHD and nephrotoxicity, ESRD on HD, who initially presented with diarrhea and weakness, now with hypotension requiring pressors. . # Hypotension: The patient had hypotension. She was started on broad spectrum antibiotics. Although initial imaging was negative, subsequent films showed a pneumonia and a sputum grew MSSA. A Cdiff PCR was positive. The patient was treated with dicloxacillin and flagyl and discharged for a total 21 day course. She completely stabilized on this regimen. Her antihypertensives were held during this stay and her primary outpatient team should consider restarting them if clinically indicated. . # Altered Mental Status: Patient presented with confusion in ED in setting of fever. Likely toxic metabolic encephalopathy in setting of possible infection. CT scan of head in ED showed no acute intracranial process. No evidence of seizure. Patient with slight confusion on admission to ICU, but was A&Ox3. This cleared completely as her infections resolved. . # Thrombosis of AV fistula: The patient had a thromboses fistula. IR was unable to remove the thrombus and left a piece of wire in the fistula. Transplant surgery subsequently removed the foreign body and the thrombosis. The fistula was used successfully prior to discharge. . # ESRD on HD: Continued on HD. . # Hypothyroidism: Continued levothyroxine 112 mcg daily . # Dyslipidemia: Continued simvastatin 60 mg daily . CODE STATUS: DNR, ok to intubate Medications on Admission: Dexamethasone 0.5 - 1 mg TID as needed for GVHD Epoetin with dialysis Gabapentin 100 mg QID Levothyroxine 112 mcg daily (except [**12-9**] tab on sunday) Lidocaine-prilocaine 2.5% - 2.5% cream apply as directed before dialysis Lisinopril 2.5 mg daily (hold on day of dialysis) Metoprolol succinate 12.5 mg qPM Nortriptyline 10 mg qHS Oxycontin 10 mg daily Oxycodone 5 mg Q6 - 8 H PRN Prednisone 2.5 mg daily Simvastatin 60 mg qHS Zolpidem 5 - 10 mg qHS Aspirin 81 mg daily Nephrocaps Calcium carbonate 2 tabs TID Cholecalciferol 400 units [**Hospital1 **] Discharge Medications: 1. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) lozenge Mucous membrane five times a day as needed for sore throat. 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO once a day as needed for pain. 9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): take [**12-9**] tab on Sunday. 10. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO four times a day as needed for pain. 12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 17 days. Disp:*51 Tablet(s)* Refills:*0* 13. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO four times a day for 17 days. Disp:*68 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: MSSA pneumonia C diff infection hypotension thrombosed fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with low blood pressure and diarrhea. You were found to have a pneumonia and an infection in your colon, and both have improved with antibiotics. Your fistula was shown to have a clot in it that was removed by our transplant surgeons. Medication changes: 1) START Metronidzole 500mg orally 3x a day for 17 days 2) START Dicloxacillin 500mg 4x a day for 17 days. 3) STOP Lisinopril 4) STOP Metoprolol Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please follow up with your providers as below. Followup Instructions: Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2205-10-29**] 10:00 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2205-11-29**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2206-3-31**] 11:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2205-10-20**]

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icd9cm

[ [ [] ] ]

[ "86.05", "39.95", "39.49" ]

icd9pcs

[ [ [] ] ]

18234, 18240

14781, 15516

359, 374

18347, 18347

4979, 12434

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3817, 4082

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297, 321

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78,708

128,524

4641

Discharge summary

report

Admission Date: [**2177-2-5**] Discharge Date: [**2177-2-19**] Date of Birth: [**2095-1-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin / Cefazolin / Opioids-Morphine & Related Attending:[**First Name3 (LF) 2751**] Chief Complaint: Diarrhea, abdominal pain, upper GI bleed Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 82 y/o F w/ dementia, CAD s/p CABGx3 [**7-/2158**], DM2 and HTN w/ recent admit to [**Hospital 882**] Hospital for UTI, and discharged from [**Hospital1 18**] on [**1-31**] after treatment for [**Last Name (un) **] who now returns with 3 days of abd pain, green, loose stool and emesis x1. Of note, per last d/c summary, she was treated fort 4 days with levaquin for a UTI at [**Hospital 882**] Hospital. . In the ED, VS: CBC with leukocytosis to 22. Cr 1.3 (bl 1.2), hyponateremia, hypocalcemia. UA negative. CT showing sigmoid colitis. Treated with iv flagyl, IVF, zofran and dilaudid. No cdiff sent. Also had urinary retention with 600cc out after foley placement. . On arrival to the floor, daughter reported patient is tolerating po's. . ROS: Per daughter, pt unable to give history. + per HPI. No fever, chills, SOB, cough, CP, palpitations, myalgias or arthralgias, headache, change in vision or depressed mood. . Past Medical History: diabetes mellitus type II s/p coronary artery bypass graft h/o coronary artery disease x 3 in 7/92 vasculopathy status post laminectomy at L4-L5 for spinal stenosis on [**2166-6-7**] ventral hernia since [**2159**] s/p repair in 6/93 Hashimoto's hypothyroidism HTN s/p appendectomy cholecystectomy via paramedial incision s/p total abdominal hysterectomy via the same paramedial incision s/p bilateral salpingo-oophorectomy via midline incision osteoarthritis irritable bowel syndrome esophageal stricture s/p dilation times one s/p benign polypectomy right nephrolithiasis. Social History: remote tobacco history, no etoh, lives with husband in [**Name (NI) 3786**]. Daughter and son very involved in her care. Family History: mom MI at 74. dad cancer at 79. 3 brothers with MI in 40-50s. Sister MI [**16**]. Physical Exam: VS: 98 156/76 101 15 97% RA GEN: well appearing F in NAD HEENT: EOMI, dry mucous membraines, cracked lips CV: regular rate, 3/6 SEM with radiation to carotids Lungs: CTAB, no wheezes ABD: hyperactive BS, soft but diffusely TTP throughout, no R/G RECTAL: deferred EXT: 1+ [**Location (un) **] NEURO: altert, oriented only to self Pertinent Results: Labs on Admission: [**2177-2-5**] 05:49PM LACTATE-1.8 [**2177-2-5**] 05:45PM GLUCOSE-85 UREA N-50* CREAT-1.3* SODIUM-129* POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-20* ANION GAP-21* [**2177-2-5**] 05:45PM estGFR-Using this [**2177-2-5**] 05:45PM ALT(SGPT)-11 AST(SGOT)-26 ALK PHOS-81 TOT BILI-0.2 [**2177-2-5**] 05:45PM ALBUMIN-2.7* [**2177-2-5**] 05:45PM WBC-22.8*# RBC-3.59* HGB-10.8* HCT-33.2* MCV-93 MCH-30.2 MCHC-32.6 RDW-14.6 [**2177-2-5**] 05:45PM NEUTS-85.8* LYMPHS-9.7* MONOS-3.1 EOS-0.8 BASOS-0.6 [**2177-2-5**] 05:45PM PLT COUNT-633*# [**2177-2-5**] 05:45PM PT-12.2 PTT-32.8 INR(PT)-1.0 [**2177-2-5**] 04:58PM PH-7.44 [**2177-2-5**] 04:58PM GLUCOSE-118* LACTATE-1.7 NA+-130* K+-5.4* CL--96* [**2177-2-5**] 04:58PM HGB-11.6* calcHCT-35 [**2177-2-5**] 04:58PM freeCa-1.00* [**2177-2-5**] 04:00PM URINE [**Year/Month/Day 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2177-2-5**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 Labs on Discharge: 139 101 25 --------------<120 4.1 32 0.8 Ca: 8.9 Mg: 2.2 P: 4.8 Source: Line-PICC 9.8 9.8>---<378 29.2 PT: 13.1 PTT: 28.1 INR: 1.1 Microbiology: [**2177-2-5**] 4:00 pm URINE - NO GROWTH. [**2177-2-5**] 5:45 [**Year/Month/Day **] Culture, Routine (Final [**2177-2-11**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S TETRACYCLINE---------- 4 S VANCOMYCIN------------ 1 S [**2177-2-5**] 6:34 pm [**Year/Month/Day 3143**] CULTURE **FINAL REPORT [**2177-2-8**]** [**Month/Day/Year **] Culture, Routine (Final [**2177-2-8**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S [**Month/Day/Year **] cultures from 1/14,15,17,18,20/11 Negative FINAL [**Month/Day/Year **] cultures from 1/21-22/11 PENDING [**2177-2-9**] 12:07 am STOOL CONSISTENCY: SOFT **FINAL REPORT [**2177-2-11**]** FECAL CULTURE (Final [**2177-2-11**]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2177-2-11**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [**2177-2-11**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2177-2-11**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2177-2-11**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2177-2-9**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). 1/16,17,19/11 C. Diff [**Doctor First Name **] NEGATIVE [**2177-2-14**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2177-2-14**]): NEGATIVE BY EIA. [**2177-2-13**] 3:04 pm URINE - NGTD Imaging: - ECG Study Date of [**2177-2-5**] 3:43:54 PM Sinus bradycardia with left bundle-branch block and secondary ST-T wave abnormalities with occasional premature ventricular contractions. Compared to the previous tracing of [**2177-1-27**] the occasional ventricular premature beats are new. Clinical correlation is suggested. - CT ABD & PELVIS WITH CONTRAST Study Date of [**2177-2-5**] 3:52 PM IMPRESSION: 1. Thickened, enhancing wall of the sigmoid colon concerning for colitis; infectious or inflammatory causes most likely, less likely ischemic 2. Hyperemic small bowel, in some places may be minmally thickened, with normal caliber IVC, may indicate enteritis less likely sequela of hypovolemia. 3. Mildly thickened, hyperemic gastric wall, may be due to gastritis. Recommend clinical correlation and consider endoscopy if not performed recently to exclude a more aggressive process. 4. 24 x 15 mm hypodensity near the pancreatic head, difficult to discern whether pancreatic in origin vs duodenal/gastric diverticulum vs biliary(if there is a history of prior pancreatitis, pseudocyst would be another consideration). Second hypodensity in the pancreatic body may be a cystic neoplasm (IMPN). Recommend MRCP for further evaluation. 5. Ventral wall hernia without evidence of obstruction, but with small amout of fluid in hernia sac, new since the prior study, may be reactive - CHEST (PA & LAT) Study Date of [**2177-2-5**] 4:26 PM FINDINGS: Frontal and lateral views of the chest are obtained. No focal consolidation, pleural effusion, or pneumothorax is seen. The patient is status post median sternotomy and CABG. Aorta is calcified and tortuous. The cardiac silhouette is top normal. - CHEST (PA & LAT) Study Date of [**2177-2-9**] 12:00 N IMPRESSION: No active disease. - TTE ([**2177-2-12**]): The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. - CXR ([**2177-2-15**]): As compared to the previous radiograph, the bilateral parenchymal pulmonary opacities are of unchanged extent and severity. Unchanged mild cardiomegaly, unchanged blunting of the left costophrenic sinus, potentially suggesting a small pleural effusion. No newly occurred focal parenchymal opacities. Unchanged monitoring and support devices. - CXR ([**2177-2-16**]): Report PENDING - CHEST PORT. LINE PLACEMENT Study Date of [**2177-2-17**] 9:16 AM IMPRESSION: PICC line should be retracted by 4 cm. - VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2177-2-17**] 2:02 PM Penetration to thin liquids and nectar. For full details, please refer to speech and swallow division note in OMR. - CHEST (PORTABLE AP) Study Date of [**2177-2-17**] 5:37 PM FINDINGS: The PICC line has been pulled back to either the left brachiocephalic vein or the junction with the superior vena cava. Retrocardiac opacification persists, as does the apparent elevation of pulmonary venous pressure. - UNILAT LOWER EXT VEINS LEFT Study Date of [**2177-2-18**] 1:16 PM IMPRESSION: No evidence of deep vein thrombosis in the left leg. Brief Hospital Course: 82 F with dementia with recent admission here for acute renal failure and abdominal pain and found to have Coag Negative Staph Bacteremia, as well as an upper GI bleed. # Upper GI Bleed: On admission, the patient was noted to have abdominal pain, but stable HCTs around 30. Overnight from [**Date range (1) 19674**], the patient HCT was noted to drop from 28.5 to 22.9; this was not a spurious value, as on repeat it was 21.6. The patient's lisinopril was decreased to 2.5 mg, the patient given 2 large bore IV access, and gastric lavage was performed, which revealed Gastroccult positive findings. The patient was started on a PPI gtt, and was transfused with 2 uPRBC. In Heparin and Aspirin were discontinued, and pneumoboots were started. The patient was placed on telemetry. Patient was transferred to the MICU, where she was transfused another 4 units of packed red [**Date range (1) **] cells over 36 hours with esophagogastroduodenoscopy performed by gastroenterology showing giant duodenal ulcer in bulb which was not actively bleeding and no visible vessel was seen. H. Pylori antibody was negative. Her hematocrit has remained stable around 29 with last transfusion being on [**2177-2-13**]. She was continued on IV pantoprazole, which was ultimately switched to dissolvable lansoprasole 30 mg [**Hospital1 **]. Family would not want surgical intervention but are still ok with temporary reversal of DNR/DNI for endoscopy with GI or IR intervention should she have an upper GI bleed in the past. She was restarted on her home dose of aspirin, and will likely require lifetime proton-pump inhibitor therapy, although this may be able to be titrated downward in the future. Additionally, the patient was given a prescription for sucralfate for ulcer coating as well. GI had asked for a gastrin level to be sent to assess for possible ZE Syndrome, and this was still pending at the time of discharge. # Abdominal Pain: On admission, the patent was found to have a leukocytosis, abdominal pain, and reported history of diarrhea, all of which were consistent with C. Difficile. A CT scan of the abdomen also reported sigmoid colonic inflammation, also in keeping with C. Diff (see report for full detail). Additionally, the patient has received Levaquin recently in the past for a urinary tract infection. Given the clinical picture, the patient was started on PO Vancomycin, which for 1 day was broadened to include IV Cipro/Flagyl (but these medications were subsequently DC'ed following ID consult). ID was consulted, and also felt this picture was most consistent with C. Diff; microbiology specimen of the stool, however, for C. Diff toxin was negative x 3. PO Vancomycin was DC'ed after a total course of 7 days. The patient's sigmoid colitis was presumed to be secondary to ischemia from a small upper GI bleed, given the localization of the colitis and the lack of findings from C. Diff analysis. # Bacteremia: The patient was found to have 3/4 bottles with CoNS. Per ID, the patient was started on a 7 day course of IV Vancomycin. Unknown source but urine is possibility as urine culture from [**2177-1-31**] showed Alpha hemolytic colonies consistent with alpha streptococcus or lactobacillus. However, urine on this admission was clean; it was although though that the CoNS might represent contamination of [**Month/Day/Year **] samples drawn in the emergency department. Regardless, IV Vancomycin therapy was initiated, and the patient was placed in cue for a TTE to rule out the possibility of endocarditis. TTE showed LVEF of 20-25% but no vegetation. She completed 7 days of IV Vancomycin on [**2177-2-13**]. ID has recommended that she have repeat [**Year (4 digits) **] cultures two weeks after the discontinuation of her antibiotics to ensure that she remains without bacteremia. # Nutrition/DMII: The patient was initially able to tolerate solid foods on her admission. After her transfer to the ICU, she was evaluated by speech and swallow, who did not feel comfortable clearing her from an aspiration risk standpoint. A video swallow study was performed after a few more days of medical management, and S&S cleared the patient for swallowing. However, nutrition was also consulted on the Patein, and indicated that the patient was not taking in enough via PO to sustain her nutritionally. The family was made aware of this finding, but elected to carefully monitor the patient's intake upon her discharge, writing down all foods that she takes for the next four days until she sees a nutritionist. At that time, the nutritionist will re-evaluate if the patient is taking an appropriate amount in by mouth, and recommend for or against PEG tube placement. In house, our nutritionists have recommended a PEG tube placement. The patient in the ICU was started on TPN given her NPO status, but her TPN was discontinued on the day of her discharge, as was her PICC line. The patient's sliding scale was adjusted appropriately in house, and the patient was DC'ed on her home insulin regimen. # Acute renal failure: On presentation, Cr was 1.3. However, given likely poor PO intake and slow IVF resuscitation secondary to concerns of the patent's' newly understood and diagnosed heart failure, the patient's creatinine increased to 1.9 during admission. IVF were administered more aggressively, and the Creatinine improved to 0.8 on discharge. During acute kidney injury, the patient's allopurinol, furosemide, and lisinopril were held, but as the acute kidney injury improved, these medications were subsequently added back on. Additionally, the patient required diuresis post-ICU transfer as she received a great deal of [**Year (4 digits) **] and fluid, and given her decreased EF. # Systolic congestive heart failure: Patient has a known TTE with EF 25-30%, during the course of her hospitalization was volume overloaded after tranfusion with 6 u PRBC. She was diuresed with Lasix, and was discharged on a home regimen of a BB, Statin, ASA, Furosemide and ACE-I. # Supraventricular tachycardia: During the patient's drop in HCT, she was on telemetry and was noted to have SVTs. Patient was started on prior admission on 3.125 mg Carvedilol, and was transitioned to IV metoprolol during her ICU stay. She was transitioned back to PO Metoprolol upon discharge. # Anion gap metabolic acidosis: On admission, the patient had an AG acidosis at 20, which was presumed to be secondary to acute renal injury, as the remaining MUDPILES differential were worked up, without any obvious source. The patient did not have an elevated serum osm, leading away from ethylene glycol or methanol toxicity, uremia was not particularly high, other ingested medications did not appear to pay a role, and the patient's lactic acid was only 1.8 on admission. The patient's AG resolved to normal after the administration of aggressive IVF. # Hyponatremia: Resolved with IVF, and with urine lytes was found to be pre-renal, and so most likely hypovolemic hyponatremia. This improved with aggressive IVF. # LLE swelling: patient noted on prior admission and though old notes to have L > R lower extremity edema, on last admission had DVT U/S of that extremity that was negative. DVT U/S from yesterday is also negative. # CAD: No active issues in the hospital. Low concern for ACS. Continue home BB, statin. # Dementia: Continued Aricept; we also used Tylenol PRN for pain control, as we tried to avoid masking a fever that might indicate further infection. # HLD: Home pravastatin, Zetia # CODE STATUS - Patient was DNR/DNI per HCP daughter [**Name (NI) 717**]. # PENDING RESULTS - Gastrin level # PCP [**Name9 (PRE) **] ISSUES - Optimize sCHF failure regimen - TTE in 4 weeks per cardiology recs - Consider hospice care; discuss with patient the benefits and risks of ICD placement post TTE findings - Please follow up Gastrin level from our hospital records to assess for ZE Syndrome - Please discuss the risks/benefits of a PEG tube placement; thus far, family has been reluctant to pursue, but nutritionist appointment shortly should help clarify matters - Please discuss the need for possible PT rehabilitation at a dedicated facility; understandably the family does not want their mother to leave home, but she may ultimately benefit from more close and intensive therapy than can be provided at home. - Please have your PCP draw [**Name9 (PRE) **] cultures [**2177-2-27**] to see if there are still any bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] our infectious disease team's recommendation Medications on Admission: allopurinol 100 mg qd aspirin 325 mg qd Ca/Vit D carvedilol 3.125 mg [**Hospital1 **] donepezil 10 mg qd ezetimibe 10 mg qd furosemide 20 mg qd glipizide 2.5 mg QPM. glipizide 5 mg QAM. levothyroxine 100 mcg qd lisinopril 10 mg qd memantine 10 mg [**Hospital1 **] metformin 500 mg [**Hospital1 **] multivitamin 1 qd pravastatin 40 mg qd Discharge Medications: 1. allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 3. carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 4. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 5. metformin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 6. donepezil 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 7. ezetimibe 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 9. glipizide 2.5 mg Tablet Extended Rel 24 hr [**Hospital1 **]: One (1) Tablet Extended Rel 24 hr PO at bedtime. 10. glipizide 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM. 11. levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 12. lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 13. memantine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 14. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 15. pravastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 16. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 17. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO four times a day. Disp:*120 Tablet(s)* Refills:*0* 18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: - Upper GI Bleed - Urinary Retention Secondary Diagnosis: - Systolic Heart Failure - Type II Diabetes - Hashimoto's hypothyroidism - Hypertension - Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname 19672**], it was a pleasure taking care of you in the hospital. You were admitted because you had been having some nausea, vomiting, and diarrhea. You came to our emergency room, where a CT scan of your abdomen showed that you had some inflammation in your large intestine. It also showed some areas of irritation in an area of your stomach, which was likely the source of your pain. We started to treat you with antibiotics for what we presumed was an infection in your colon. In addition, during your hospitalization we discovered that you were growing bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] we started you on antibiotics for this as well. You completed antibiotic courses for both of these infections. During your hospital stay, your [**First Name3 (LF) **] count had dropped very low, and you were found to have [**First Name3 (LF) **] in your stool. This bleeding was so severe that it required you to receive 6 units of [**First Name3 (LF) **], as well as for you to be transferred to the intensive care unit. Our GI doctors looked with a camera into your stomach and saw that you had an ulcer, which was likely the source of your bleeding, in addition to the source of your pain. We started you on two medications which should lessen the risk of your ulcer re-bleeding. You came back to the medical floor, and our speech and swallow team and nutritionist evaluated you. Our speech and swallow team felt safe with your swallowing, but your nutritionists were concerned that you were not taking enough food in by mouth, and that this was affecting your nutritional status. After speaking with your family, we agreed that your family would monitor your intake over the next few days by writing down exactly what you eat every day, and you have an appointment with the nutritionists to see if you still require a PEG tube, which is what our nutritionists have recommended you have placed. A PEG tube is a tube from the skin to the stomach which allows a person to be fed without giving food through the mouth. Finally, our physical therapists evaluated you as well, and agreed that you were somewhat weaker than you had been on your previous admission; they recommended that you go to rehabilitation or have 24 hour care and PT at home in order to get stronger. After discussion with your family, we agreed to have you evaluated at home. When you leave the hospital: - START Tylenol 650 mg every 6 hours as needed for pain - START Lansoprazole 30 mg twice a day - START Sucralfate 1 gm by mouth four times a day We did not make any other changes to your medications, so please continue to take them as you normally do. Please have your primary care physician [**Name9 (PRE) 702**] two laboratory values which are still pending at the time of your discharge - Gastrin level - Please have your PCP draw [**Name9 (PRE) **] cultures on [**2177-2-27**] to see if there are still any bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] our infectious disease team's recommendation - Please have your PCP check [**Initials (NamePattern4) **] [**1-31**] 2:00pm in order to make sure that your electrolytes are stable Followup Instructions: You have an appointment with your primary care doctor, as below Name: [**Last Name (LF) **],[**First Name3 (LF) **] A. Location: [**Hospital1 641**] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 1701**] Appointment: Friday [**2177-2-21**] 2:00pm You have an appointment with the nutritionists, as below Department: BE WELL CENTER When: TUESDAY [**2177-2-25**] at 11:00 AM With: [**First Name11 (Name Pattern1) 8826**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 8021**], RD [**Telephone/Fax (1) 3681**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Hospital 1422**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2189-3-19**] Discharge Date: [**2189-3-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: urinary tract infection, pneumonia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 59190**] is an 89 year old man with a history of coronary artery disease, congestive heart failure, atrial fibrillation, and prostate cancer who presented to the [**Hospital1 18**] [**Location (un) 620**] ED with two days of profuse nausea, vomiting and diarrhea. On arrival there, he was found to have rapid a fib and was rate controlled with Lopressor. His temperature spiked to 100.9F and his blood pressure dropped to the 70's. He was fluid resuscitated with 8L and his blood pressure stabilized to the ~100s. He had been having persistent brown diarrhea for two days but no melena or BRBPR. He also noted a cough productive of clear sputum and subjective fevers. He has had increase urine output and no dysuria. Past Medical History: 1. CAD s/p CABG in [**2183**] at [**Hospital3 2358**] 2. CHF w/ EF of 40% on TEE in [**2187**], 1+ AR, 2+MR 3. Hypothyroidism 4. L THR [**5-/2182**] 5. Prostate CA s/p resection+XRT 6. AFib s/p d/c cardioversion [**2182**], on coumadin 7. GERD 8. Hiatal hernia 9. OA 10. Hypertension 11. Dyslipidemia Social History: Widower, former furniture washer. Smoked 3ppd until 20 years ago. No alcohol use. Family History: non-contributory Physical Exam: VS: T:98.0 HR: 125 (90-125) BP: 109-136 / 65-82 RR: 16 Sat: 97% on 2LNC I/O: 1830/670: +1160 Gen: Man in bed in NAD HEENT: MMM CV: irregular, +HSM at LUSB PUL: +crackles at bases Abd: soft, nt, nd, +bs Ext: 1+ LE edema b/l Neur: A&Ox3 Pertinent Results: [**2189-3-20**] 03:38AM BLOOD WBC-3.1* RBC-4.16* Hgb-13.0* Hct-40.5 MCV-97 MCH-31.3 MCHC-32.1 RDW-14.4 Plt Ct-104* [**2189-3-20**] 03:38AM BLOOD PT-20.4* PTT-36.9* INR(PT)-2.6 [**2189-3-20**] 03:38AM BLOOD Glucose-80 UreaN-33* Creat-1.1 Na-146* K-4.3 Cl-117* HCO3-21* AnGap-12 [**2189-3-20**] 03:38AM BLOOD Albumin-3.2* Calcium-7.9* Phos-2.4* Mg-1.9 [**2189-3-24**] 08:00AM BLOOD WBC-5.3 RBC-4.11* Hgb-12.7* Hct-39.8* MCV-97 MCH-30.8 MCHC-31.8 RDW-14.3 Plt Ct-104* [**2189-3-24**] 10:20AM BLOOD PT-23.6* PTT-31.8 INR(PT)-3.5 [**2189-3-24**] 08:00AM BLOOD Glucose-82 UreaN-21* Creat-1.3* Na-141 K-4.3 Cl-105 HCO3-30* AnGap-10 CXR PA/Lat [**2189-3-19**]: The patient is status post CABG with median sternotomy. Note is made of cardiomegaly. Thoracic aorta is tortuous. Again, note is made of mild congestive heart failure, associated with bilateral effusion and patchy atelectasis. IMPRESSION: Cardiomegaly with mild CHF, small pleural effusion and patchy atelectasis. CXR AP [**2189-3-20**]: Upright AP chest: The patient is post-median sternotomy. There is stable cardiomegaly, and the aorta is tortuous. Heart failure persists and is possibly mildly worsened, with slightly increased central edema and [**Last Name (un) 16765**] lines. There is a left pleural effusion. In addition, there is worsening opacity of the left lower lung zone consistent with pneumonia. ECG [**2189-3-19**]: Atrial fibrillation, Left axis deviation - anterior fascicular block. Possible old septal infarct, Inferior/lateral ST-T changes may be due to myocardial ischemia or left ventricular hypertrophy, Repolarization changes may be partly due to rhythm, Left ventricular hypertrophy FECAL CULTURE (Final [**2189-3-21**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2189-3-21**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2189-3-20**]): NO E.COLI 0157:H7 FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2189-3-21**]): NO YERSINIA FOUND. FECAL CULTURE - R/O VIBRIO (Final [**2189-3-21**]): NO VIBRIO FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2189-3-19**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. OVA + PARASITES (Final [**2189-3-19**]): Brief Hospital Course: This is a 89 year old man with a history of coronary artery disease, congestive heart failure and atrial fibrillation who presented with nausea, vomiting, diarrhea and was found to have hypotension, pneumonia and a urinary tract infection. For his community acquired pneumonia, he was given ceftriaxone and azithromycin. Prior to discharge, the ceftriaxone was discontinued and will be discharged on five more days of azithromycin. For his urinary tract infection, he was found to have a positive UA with nitrites, leukocyte esterase, +blood) but urine culture was negative. His nausea/vomiting/diarrhea was likely due to a viral gastroenteritis. O&P, fecal cultures for campylobacter, e.coli 0157:H7, yersinia, cholera and c.diff were negative. O&P noted the presence of charcot-leiden crystals in his stool- this is suggestive of a parasitic infection. His diarrhea resolved prior to his arrival on the medical [**Hospital1 **]. For rhythm, his atrial fibrillation had been treated with coumadin and atenolol as an outpatient. His beta-blocker was initially held due to his hypotension, and was restarted as metoprolol while he was in the ICU. After being transferred to the medical service, his atenolol was restarted. He continued to have high heart rates in the 90-100's. His atenolol dose should be titrated up as tolerated as an outpatient. His coumadin dose should be watched carefully as his azithromycin will have significant effect on his INR once it is stopped. For ischemia, he has a history of CAD s/p CABG. He ruled out for MI by serial cardiac enzymes. Beta-blocker was given as above. For pump, he presented to the ICU with exacerbation of his CHF. This may have been secondard to aggressive hydration in the emergency department. He responded well to boluses of lasix. On the medical service, he was given several more boluses of IV lasix for some orthopnea and shortness of breath with good response. He was ultimately re-started on his home dose of lasix and will continue this after discharge. For endocrine, he was continued on his home dose of levothyroxine. For hypertension, his lisinopril was initially held and was restarted on [**3-24**]. He was also re-started on his standing potassium supplementation. For F/E/N, he was kept on a cardiac diet For prophlyaxis, he was kept on subcutaneous heparin. His code status is DNR/DNI. Medications on Admission: Atenolol 25mg po qd Coumadin Lasix 40mg po qd Lisinopril 10mg po qd Levoxyl 88 mg po qd KCl 10meq qd Discharge Medications: 1. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 5 days. Disp:*5 Capsule(s)* Refills:*0* 3. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Pneumonia Diarrhea Urinary tract infection Congestive heart failure Hypothyroidism Discharge Condition: Stable, afebrile. Discharge Instructions: Please take your medications as directed. Please seek medical attention for fevers>101.4, or for anything else medically concerning. Please do not take your dose of coumadin today, please take 2mg starting tomorrow ([**2189-3-25**]). Your dose will be adjusted by your PCP. Followup Instructions: Please see your PCP at your appointment on Thursday for follow up. Visiting nurse service will see you at home, tomorrow. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4775**]

[ "785.52", "427.31", "995.92", "038.9", "V10.46", "008.8", "244.9", "396.3", "V45.81", "401.9", "599.0", "276.5", "486", "398.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7155, 7204

4106, 6487

296, 302

7331, 7350

1808, 4083

7675, 7912

1518, 1536

6638, 7132

7225, 7310

6513, 6615

7374, 7652

1551, 1789

222, 258

330, 1076

1098, 1401

1417, 1502

5,193

171,808

16107

Discharge summary

report

Admission Date: [**2133-1-13**] Discharge Date: [**2133-2-10**] Date of Birth: [**2067-9-19**] Sex: F Service: SURGERY Allergies: Codeine / Morphine / Tape Attending:[**First Name3 (LF) 668**] Chief Complaint: Admitted for surgery: Ventral hernia with Marlex mesh repair Takedown ileostomy Major Surgical or Invasive Procedure: [**2133-1-13**]: Exploratory laparotomy, lysis of adhesions, removal of anterior abdominal wall skin graft, take-down ileostomy mucous fistula, component separation, ventral hernia repair with Marlex mesh. [**2133-1-19**]: Exploratory laparotomy, drainage of intra-abdominal abscess, primary repair of colotomy and abdominal closure. History of Present Illness: Patient is a 65-year-old female, with history of ruptured AAA complicated by a gangrenous right colon and necrotizing pancreatitis, who underwent multiple operations and was ultimately left with a ileostomy and mucous fistula and an open abdomen requiring skin grafting. She has recovered well from the initial surgery, and after about a year and a half, has presented for take-down of her ostomy and repair of her ventral hernia. Past Medical History: Hypertension A Fib Visual loss in L eye Cerebral aneurysm h/o ruptured AAA with repair Necrotizing pancreatitis s/p pancreatic debridements Type II DM Abdominal wound requiring vac s/p STSG Ileostomy with mucus fistula Trache Social History: Lives in single family home w/husband Family History: NC Physical Exam: VS:99.7, 110, 142/60, 96%RA Gen: NAD Neuro: A+Ox3 Lungs: CTA bilaterally Card: RRR Abd: Obese, soft, non tender, non distended Extr: WWP Pertinent Results: ADMISSION LABS ---> [**2133-1-13**] WBC-4.5 RBC-2.58*# Hgb-9.2*# Hct-27.1* MCV-105* MCH-35.6* MCHC-34.0 RDW-12.7 Plt Ct-205 Glucose-136* UreaN-18 Creat-0.9 Na-138 K-4.2 Cl-112* HCO3-18* AnGap-12 Calcium-7.9* Phos-3.9 Mg-1.5* [**2133-1-18**] 03:00AM BLOOD TSH-0.69 Brief Hospital Course: This patient was admitted on [**1-13**] for her procedure as described below (please see operative note for furthur detail). In the recovery room, her pain was controlled with a Dilaudid PCA, and her urine output was closely monitored. Her systolic blood pressure was low, ranging from 80-100s; for this reason, she was kept in the PACU overnight. She received fluid boluses to maintain her SBP and urine output. On POD1, she was transfered to the floor, where her pain was only moderately controlled with her PCA. She remained in bed and spiked temperatures up to 101.7; her chest xray showed atelectasis and she was encouraged to use her IS. . On POD2 ([**1-15**]), she received 2 units of pRBC for a postoperative anemia. Her urine output varied between 20-50cc/hour. Her systolic BP's improved but her pain was again only moderately controlled. Her NGT was removed and she was started on sips; she continued to have low-grade temp's. . On POD3 ([**1-16**]), the pt was transfered to the SICU for rapid AFib. She did not respond to IV metoprolol. She was started on an amiodarone drip; She had a recurrence of her AFib on [**1-17**] and was seen by the Cardiology service. Her AFib then became persistent despite IV amiodarone 150mg bolus and gtt, then 400mg po bid; also received IV metoprolol 30mg total and 50mg po bid, and diltiazem IV bolus and gtt. She refused cardioversion on [**1-18**] and converted into NSR on amiodarone. Heparin iv was initiated then coumadin. Heparin was d/c'd once inr was therapeutic on [**1-29**]. On [**1-19**], the pt was taken back to the OR, where they found a hole in the colon at ileocolic ligament, which was subsequently oversewn. The patient was taken back to the SICU with an NGT in place and VAC in the abdomen. TPN was started on [**1-20**]. On [**1-22**], she remained in NSR. . On [**1-23**] (POD10/3), Drain fluid sent for culture which grew Pseudomonas aeruginosa sensitive to Imipenem, and pansensitive proteus. Zosyn was d/c 'd on [**1-25**] and Imipenem/Cilastin was started and she remained on Vanco. Patient was treansferred back to [**Hospital Ward Name 121**] 10 on [**1-25**]. On [**1-26**] Plastics came by to evaluate the abdominal wound. At this time the VAC will remain in place and options for closing wound will be discussed at a future date. Coumadin was started today. On [**1-27**] a dual lumen PICC line was placed with IR. This was fluoroscopically guided PICC line placement via the right brachial vein with the tip positioned in SVC. The total length of the catheter is 33 cm. On [**1-28**] patient c/o SOB, received a dose of lasix. Chest x-ray unremarkable except for persistent left lower lobe atelectasis. She does have bilateral effusions, however these are stable. Later in the day patient received one unit RBC's for Hct 23% and an additional dose of Lasix. There were no overnight events and she was about 1L negative for the day and respiratory status was improved. On [**1-30**] she spiked at temp to 101.6. Pan cultures were done. Bl cx are pending. She remained on vanco/imipenum/fluconazole. The JP cx grew pseudomonas sensitive to imipenum, proteus and GNR. The abd wound was I&D'd at the bedside. She experienced frequent BMs that were c.diff neg x5. On [**2-1**] an abd/pelvic CT with contrast demonstrated interval dehiscence of the patient's anterior abdominal wall with overlying VAC seen. Ileocolonic anastomosis appeared intact with surgical drain seen surrounding inflamed loops of bowel. No drainable fluid collection was seen. No free oral contrast within the peritoneal cavity was seen to suggest an anastomotic leak. Stable 4 cm suprarenal abdominal aortic aneurysm. The vancomycin and fluconazole were stopped at this point as it was felt the imipenem was providing adequate antibiotic coverage. AFter that time she remained afebrile and continued to have VAC changes every third day. Her strength slowly improved and her coumadin dose was adjusted to keep her INR between 2 and 3. On [**2-9**] the imipenem was stopped and she remained afebrile for 24 hours. On [**2-10**], POD 28/21, her VAC was changed, her PICC line was removed and she was discharged to home with VNA for home vac changes. Of note, the amylase level from her JP drain was over 9000. She will follow up with Dr. [**First Name (STitle) **] as an outpatient in 1 week. She will continue all of her home medications, and add amiodarone, digoxin, and coumadin 1 mg. She will be followed by her cardiologist, Dr. [**Last Name (STitle) 1016**], for the atrial fibrillation, and will have her INR checked as an outpatient at the [**Hospital1 **] [**Location (un) **] coumadin clinic. Her INR on discharge was 3.1. Medications on Admission: Neurontin, Florinef, Metoprolol, Zetia, Zoloft, Ativan, Ambien, Darvon, Wygesic, Centram, Metamucil Discharge Medications: 1. Fludrocortisone 0.1 mg Tablet Sig: [**12-23**] Tablet PO DAILY (Daily). 2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Psyllium Packet Sig: One (1) Packet PO BID (2 times a day). 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): as directed by coumadin clinic. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Ileostomy takedown complicated by colotomy Atrial Fibrillation Pancreatic fistula Hypertension Discharge Condition: Good Discharge Instructions: * Increasing pain or persistent pain that is not relieved by pain medications * Inability to urinate * Fever (>101.5 F) * Nausea or Vomiting that last longer than 24 hours * Inability to pass gas or stool * Other symptoms concerning to you Please take all your medications as ordered. Please continue all your home medications. Continue amiodarone, digoxin, and coumadin. No lifting more than 10 lbs or abdominal stretching exercises for 4 weeks. A visiting nurse will come to your home for the VAC changes. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-2-19**] 2:10 CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2133-7-2**] 1:30 [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2133-7-2**] 2:15 Follow up with Dr. [**Last Name (STitle) 1016**] in 1 month, call to make an appointment. Please report to [**Hospital1 **] [**Location (un) 620**] coumadin clinic on Thursday [**2133-2-12**] to have your INR checked. Completed by:[**2133-2-10**]

[ "998.59", "567.22", "997.4", "401.9", "577.8", "998.6", "998.32", "682.2", "568.0", "V55.2", "250.00", "553.21", "427.31" ]

icd9cm

[ [ [] ] ]

[ "45.93", "53.61", "99.04", "99.15", "54.59", "93.59", "46.51", "45.73", "38.93", "46.75", "86.22", "03.90" ]

icd9pcs

[ [ [] ] ]

7684, 7733

1944, 6635

364, 700

7871, 7878

1656, 1921

8436, 9061

1480, 1484

6785, 7661

7754, 7850

6661, 6762

7902, 8413

1499, 1637

245, 326

728, 1160

1182, 1409

1425, 1464

45,457

114,522

35426

Discharge summary

report

Admission Date: [**2149-5-16**] Discharge Date: [**2149-5-20**] Date of Birth: [**2100-1-17**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3984**] Chief Complaint: Altered mental status/TCA overdose Major Surgical or Invasive Procedure: CVL, attempted a lines History of Present Illness: 49F sent in by ambulance to ED after found with altered mental status s/p likely suicide attempt by medication overdose. Patient was found at home after friends found suicide note, transported by ambulance to [**Hospital1 18**] ED altered, agitated. Per EMS report, there were two empty desipramine bottles in her apartment (total likely 50 pills) leading to high suspicion of TCA overdose. . In the ED, vitals on arrival were T 99.3, HR 91, BP 89/72 RR23 O2 sat 99% on 100% NRB. On exam in the ED she was found to be delirious and agitated and to have intermittent nystagmus and myoclonic jerking. Her pupils were reactive 4->2. Her tox screen came back positive for TCA, negative for all other substances on serum screen. Lactate:1.8. Patient intubated for airway protection, then weaned down to 100% on FiO2 of 50, PEEP 5, TV 450, propofol used for sedation. Also started on neosynephrine 1.5mcg/kg, after her hypotension not responsive s/p 7L fluid in total (NS). Also given bicarb - 2 to 3amps push, then 150/hr 3amp bicarb gtt, 200cc/hr with multiple ABGs. Patient with multiple EKGs with wide complex tachycardia, QRS 128-148. . Full history and ROS unable to obtain as patient intubated/sedated on arrival to MICU. Past Medical History: clonazepam 1mg TID - full bottles lamictal 300mg daily- full bottles desipramine 250mg PO - per records, was filled on [**5-14**] and there were two empty bottles in apartment (30 pills/bottle) Social History: Unknown Family History: Unknown Physical Exam: On admission GENERAL: intubated, sedated HEENT: sluggish but reactive, 6->4mm, evidence of small laceration in anterior tongue, +Horiz/vertical nystagmus Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. JVP=7 LUNGS: soft, decreased BS EXTREMITIES: Hyperreflexic bilaterally, with intermittent myoclonic symmetric jerks in all extremities. Equivocal toes, without clonus Pertinent Results: [**2149-5-16**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS . CT head [**2149-5-17**] IMPRESSION: No evidence of acute intracranial hemorrhage or major territorial infarct detected. MRI is more sensitive for the detection of acute ischemia. . CXR [**2149-5-19**] The endotracheal tube is seen with the tip 5.3 cm above the carina. The NG tube is seen traversing the esophagus with tip and side port in the expected location of the stomach. The cardiac silhouette, mediastinal and hilar contours are unchanged. There is no pneumothorax. An interval decrease of bilateral pleural effusions is noted, along with an artificial appearance of increased interstitial markings, representing otherwise unchanged moderate fluid overload. Retrocardiac atelectasis is unchangeed. No new focal parenchymal opacity is identified to suggest pneumonia. IMPRESSION: Interval decrease of bilateral pleural effusions. Unchanged moderate fluid overload. No new focal parenchymal opacity to suggest pneumonia. Brief Hospital Course: 49F with prescribed desipramine at home found with altered mental status at home with likely TCA overdose. . #. TCA overdose: TCAs were the likely cause of her altered mental status on presentation given positive TCA serum tox screen and the empty bottles in her apartment. On admission the patient had evidence of both cardiotoxicity with widened QRS, and neurotoxicity with myoclonus and hyper-reflexia. Toxicology followed the patient closely. She was started on a HCO3 gtt in the ED and her EKGs were followed closely and had a prolonged QRS. Her electrolytes were aggressively repleated. A head CT was negative for bleed. An EEG was done but the results were pending at the time of her death. She was on benzos as part of her sedation and also to help with seizure prophylaxis. She was hypotensive likely secondary to her overdose and required pressors. A central line was placed and multiple A lines were attempted but difficult given how edematous the patient had become. Given no further progression of her EKGs (although QRS was still wide) approximately 60 hrs into her hospital course her HCO3 gtt was discontinued (TCA toxicity typically resolves in 24hrs). On [**5-19**] the patient began to exhibit difficulty with oxygenation. Her CXR had air bronchograms and concern for ARDS. She was put on PEEP and low TV per ARDS protocal. She was started on vancomycin and ceftriaxone for PNA coverage given that she was spiking fevers and with difficult to read CXR. Her EKG deteriorated overnight from [**Date range (1) 26511**]/09 and she was restarted on her bicarb gtt. She was given hypertonic saline as well as fat emulsion. Her EKG continued to progress to a ventricular rhythm with widened QRS and slurring of the S wave in AVR. She was continued on levophed and phenylephrine with plans to switch to an epinephrine gtt and isoproterenol. At this time, she went into a pulseless ventricular rhythm and CPR was initiated with-in seconds. She was given a lidocaine push and started on lidocaine gtt given that lidocaine is preferable in TCA overdose. She was coded for approx 20-25 minutes with an initially shockable rhythm, but then remained refractory to resussitation efforts. She expired on [**2149-5-20**] at 9:13 am. Dr. [**Last Name (STitle) **], her attending, was present for the entire length of the code. Her psychiatrist Koldzic was on vacation but the covering psychiatrist was contact[**Name (NI) **]. Our only contacts at the time of death were Rabbi [**First Name8 (NamePattern2) **] [**Last Name (Titles) 37791**] and her friend [**Name (NI) 1022**] [**Name (NI) 80762**] were both contact[**Name (NI) **]. [**Name2 (NI) **] case was sent to the medical examiner. Medications on Admission: clonazepam 1mg TID - full bottles lamictal 300mg daily- full bottles desipramine 250mg PO - per records, was filled on [**5-14**] and there were two empty bottles in apartment (30 pills/bottle) Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2149-5-20**]

[ "E950.3", "275.3", "296.80", "427.89", "276.8", "285.9", "333.2", "792.1", "507.0", "785.50", "969.0", "427.41", "796.1", "518.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6395, 6404

3404, 6118

331, 355

6455, 6464

2352, 3381

6520, 6684

1867, 1876

6363, 6372

6425, 6434

6144, 6340

6488, 6497

1891, 2333

257, 293

383, 1608

1630, 1826

1842, 1851

20,373

172,070

51638

Discharge summary

report

Admission Date: [**2183-12-1**] Discharge Date: [**2183-12-9**] Date of Birth: [**2128-8-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy and lysis of adhesions on [**2183-12-1**] History of Present Illness: The patient is a 55 year old male, status post splenectomy after a fall two months ago who has had discomfort and bloating periodically since. Emesis in [**Month (only) 359**], then again since last night with dull pain without fevers, chills, chest pain, shortness of breath, hematuria, bright red blood per rectum, strange foods, sick contacts or travel. Has had bowel movements three times in the last day but does no think he has passed gas today. Emesis he reports as being clear. Past Medical History: hypothyroidism hernia splenectomy Social History: no tobacco, no EtOH, denies drugs, state worker/programmer Family History: sister with type I diabetes Physical Exam: Temperature 99.9 degrees, heart rate 65. Blood pressure 144/69, respiratory rate 18, saturation 96 percent on room air. Alert and oriented times three, no apparent distress. Cranial nerves 2 through 12 intact. Regular rate and rhythm. Lungs clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended with a well healed midline scar. No clubbing, cyanosis or edema of the extremities. Pertinent Results: [**2183-12-1**] 11:40PM GLUCOSE-184* UREA N-18 CREAT-0.8 SODIUM-140 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-29 ANION GAP-13 [**2183-12-1**] 11:40PM CALCIUM-9.1 MAGNESIUM-1.7 [**2183-12-1**] 11:40PM WBC-27.3*# RBC-4.38* HGB-13.0* HCT-38.4* MCV-88 MCH-29.7 MCHC-33.8 RDW-13.8 [**2183-12-1**] 11:40PM PLT COUNT-448* [**2183-12-1**] 08:45AM GLUCOSE-152* UREA N-20 CREAT-0.7 SODIUM-141 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [**2183-12-1**] 08:45AM ALT(SGPT)-15 AST(SGOT)-15 LD(LDH)-176 ALK PHOS-99 AMYLASE-59 TOT BILI-0.5 [**2183-12-1**] 08:45AM LIPASE-31 [**2183-12-1**] 08:45AM ALBUMIN-4.8 CALCIUM-10.4* PHOSPHATE-2.2* MAGNESIUM-2.2 [**2183-12-1**] 08:45AM WBC-17.9* RBC-4.85 HGB-14.5 HCT-42.6 MCV-88 MCH-29.9 MCHC-34.1 RDW-13.6 [**2183-12-1**] 08:45AM NEUTS-86.3* BANDS-0 LYMPHS-9.0* MONOS-2.7 EOS-1.5 BASOS-0.5 [**2183-12-1**] 08:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2183-12-1**] 08:45AM PLT COUNT-489* [**2183-12-1**] 08:45AM PT-12.7 PTT-35.4* INR(PT)-1.0 Brief Hospital Course: The patient was admitted on [**2183-12-1**] and taken to the operating room for an exploratory laparotomy and lysis of adhesions. He tolerated the procedure well with minimal blood loss. He was transferred to the floor. He experienced a fever on POD 1 that was attributed to atelectasis and resolved on the evening of POD 2. On POD 5 his bowel function returned and his anti-biotics were stopped. He continued to have good bowel function and good pain control and tolerated a regular diet on POD 6. He was discharged home in good condition on POD 8. Medications on Admission: Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) colace milk of magnesia Discharge Medications: 1. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p exploratory laparotomy and lysis of adhesions on [**2183-12-1**] partial small bowel obstruction hypothyroid s/p splenectomy Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. Leave the steri strips on until they begin to peel, then you may remove them. Staples and stitches will remain until your follow-up appointment. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. Be sure to take your complete course of antibiotics. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Call and schedule a follow up appointment in [**12-20**] weeks with Dr. [**Last Name (STitle) **]. His phone number is ([**Telephone/Fax (1) 2047**].

[ "560.81", "244.9", "780.6", "998.89", "E878.4" ]

icd9cm

[ [ [] ] ]

[ "54.59" ]

icd9pcs

[ [ [] ] ]

3856, 3862

2617, 3174

329, 396

4035, 4041

1528, 2594

5059, 5213

1062, 1091

3320, 3833

3883, 4014

3200, 3297

4065, 5036

1106, 1509

275, 291

424, 912

934, 970

986, 1046

11,995

132,213

15442+15443

Discharge summary

report+report

Admission Date: [**2149-11-14**] Discharge Date: [**2149-11-20**] Date of Birth: [**2081-4-17**] Sex: M Service: CHIEF COMPLAINT: Hemoptysis. HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male smoker with a history of Stage 3A nonsmall cell lung cancer, diagnosed by bronchoscopy in [**2149-8-11**] who was admitted to the [**Hospital1 2177**] on [**2149-11-13**] after having 500 cc of hemoptysis and associated shortness of breath that morning. He denied chest pain or prior episodes of hemoptysis. Of note, the patient was treated with radiation and Taxol/Carboplatin from [**2149-10-1**] through [**2149-11-6**] with a seemingly good response; his energy level and shortness of breath were reportedly improved following these treatments. One day prior to admission at the [**Hospital1 2177**], he was seen in Hematology/[**Hospital **] Clinic for a complaint of increasing lethargy and shortness of breath; a chest x-ray done at that time demonstrated a new left lung air/fluid level. A bronchoscopy done [**2149-11-13**] at [**Hospital1 2177**] demonstrated blood in the trachea, middle right-sided blood without active bleeding, and white, friable mucosa in the left main stem bronchus with narrowing of the lumen, significant enough to prevent passage of the bronchoscope; blood was seen distal to the obstruction. At the end of this procedure, the left main stem bronchus was obstructed with bronchial balloon. On [**2149-11-14**], a bronchial artery angiogram was performed with a goal of embolizing the bleeding source. Given the complex vascular supply of the tumor, however, the procedure was aborted. On the night prior to transfer to the [**Hospital6 1760**], the patient had an additional 300 cc of hemoptysis with an associated drop in his systolic blood pressure to the 80s and was therefore started on a Dopamine drip. PAST MEDICAL HISTORY: 1. Stage 3A nonsmall cell (squamous type) lung cancer diagnosed in [**2149-8-11**]. Dictator hung up [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2149-11-19**] 16:55 T: [**2149-11-19**] 17:13 JOB#: [**Job Number 44811**] Admission Date: [**2149-11-14**] Discharge Date: [**2149-11-20**] Date of Birth: [**2081-4-17**] Sex: M Service: CHIEF COMPLAINT: Hemoptysis. HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male smoker with a history of Stage 3 nonsmall cell lung cancer who was admitted to [**Hospital1 2177**] on [**2149-11-13**] after having 500 cc of hemoptysis and associated shortness of breath that morning. Of note, the patient was treated with radiation and Taxol/Carboplatin from [**2149-10-1**] through [**2149-11-6**] with a seemingly good response. One day prior to admission at the [**Hospital1 2177**], he was seen in Hematology/[**Hospital **] Clinic for a complaint of increasing lethargy and shortness of breath; a chest x-ray done at that time demonstrated a new left lung air/fluid level. A bronchoscopy done [**2149-11-13**] at [**Hospital1 2177**] demonstrated blood in the trachea, minimal right-sided blood without active bleeding, and white, friable mucosa in the left main stem bronchus with narrowing of the lumen, significant enough to prevent passage of the bronchoscope; blood was seen distal to the obstruction. At the end of this procedure, the left main stem bronchus was obstructed with a bronchial balloon. On [**2149-11-14**], a bronchial artery angiogram was performed with a goal of embolizing the bleeding source. Given the complex vascular supply of the tumor, however, the procedure was aborted. On the night prior to transfer to the [**Hospital6 1760**], the patient had an additional 300 cc of hemoptysis with an associated drop in his systolic blood pressure to the 80s and was therefore started on a Dopamine drip. PAST MEDICAL HISTORY: 1. Stage 3A nonsmall cell (squamous type) lung cancer diagnosed in [**2149-8-11**], status post Taxol/Carboplatin as above, status post radiation, status post bone scan [**2149-9-15**] (no metastases), pulmonary function tests with a FEV 1 of 1.0 (not a surgical candidate); 2. Hypothyroidism; 3. Hypercholesterolemia; 4. Gastroesophageal reflux disease; 5. Congestive heart failure; 6. Blood loss anemia secondary to gastritis. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Midazolam GTT titrated to sedation; Dopamine GTT at 10 mcg/hr; Metronidazole 500 mg intravenously q. 8 hours; Ceftriaxone 1 gm intravenously q. day; Ranitidine 50 mg intravenously q. 8 hours; Albuterol metered dose inhaler 10 puffs q. 1 hr prn; Epotropium 10 puffs q. 4 hours prn. SOCIAL HISTORY: 100 pack year smoking history, no ethyl alcohol. Lives in [**Location 8391**], retired supermarket clerk. Married with four children. FAMILY HISTORY: Mother died of lung cancer at age 57, father died secondary to coronary artery disease at age 70, brother died secondary to coronary artery disease at age 55, sister with breast cancer. PHYSICAL EXAMINATION: On initial physical examination the patient's temperature was 98.0?????? F., his temperature maximum from earlier in the day was 102, heartrate 69 to 97, blood pressure 99 to 110/50 to 60, and mean blood pressure of 66 to 99. He was on a mechanical ventilator set at assist control 350/20/0.50/5, and arterial blood gases done on those settings was 7.34/38/82. His peak pressure was 20 and his plateau pressure was 14. In general, he was sedated, and on a ventilator. Head, eyes, ears, nose and throat examination, his conjunctivae were clear, and his pupils were pinpoint. His neck was soft and supple and there was no lymphadenopathy. His heart was regular rate and rhythm, there were normal S1 and S2 heartsounds. There was a II/VI systolic ejection murmur at the bilateral upper sternal border and there were no rubs or gallops. His lung sounds were coarse anteriorly. There were faint breathsounds over the left anterior chest wall. His abdomen was soft, nontender, nondistended, and there were normoactive bowel sounds. His extremities were warm, there were 2+ radial pulses. Dorsalis pedis pulses were dopplerable, and there was no edema. He had no skin rashes or lesions, LABORATORY DATA: Initial laboratory evaluation demonstrated a white blood cell count of 4.4, hematocrit of 34.8 and platelets of 237,000. His INR was 1.4. Initial serum chemistries demonstrated sodium 140, potassium 3.5, bicarbonate 21, chloride 111, BUN 6, creatinine 0.5 and glucose 126. His calcium was 6.1, magnesium 1.7, phosphate 1.2 and ionized calcium 0.98. A bronchoscopy done on admission demonstrated an oropharynx within normal limits; trachea deviated to the left but otherwise within normal limits; right airways within normal limits; left main stem bronchus obstructed by tumor versus clot, this area was suctioned, and argon beam coagulation destruction and airway debridement was performed. A 10 by 40 Ultraflex left lower lobe stent and a 12 by 40 Polyflex left main stem bronchus stent were placed with visualization into good position; the patient was reintubated bronchoscopically with the endotracheal tube at 25 cm following this procedure. The post procedure chest x-ray demonstrated some aeration of the left lung, right lower lobe effusion versus infiltrate. An outside chest x-ray reportedly demonstrated left lung opacification and right lower lobe effusion versus infiltrate. HOSPITAL COURSE: 1. Hemoptysis - There was active bleeding seen at the time of initial bronchoscopy, of which the most likely source was the patient's malignancy. This bleeding likely originated either from erosion of the tumor into small pulmonary vessels or from erosion or trauma to the vascular supply to the tumor itself. The patient had some mild post procedural hemoptysis, although his bloody secretions rapidly tapered off. He had no further significant clinical hemoptysis during this hospitalization. 2. Post obstructive pneumonia - The fluid that was released following the tumor destruction and airway debridement in the initial bronchoscopy did not have the appearance of frank blood, but rather had a somewhat purulent appearance, (slightly yellowish). This gross finding raised the possibility of a post obstructive anaerobic pneumonia. Although the patient did not have an elevated white blood count, he was febrile to 102 prior to admission. He was therefore started on Clindamycin 600 mg intravenously q. 8 hours for anaerobic coverage; this antibiotic was continued throughout his hospitalization. He was also continued on the Ceftriaxone 1 gm intravenously q. 24 hours that had been started at the outside hospital. His white blood cell count remained normal throughout his admission and he also remained afebrile throughout his admission. 3. Airway obstruction - The patient had a significant airway obstruction from his tumor that was largely relieved by the tumor destruction and airway debridement during the initial bronchoscopy as noted above; in addition, two stents were placed in an attempt to maintain airway patency. A post procedural chest x-ray demonstrated increased aeration of the left lung, and breathsounds were heard over the left anterior chest wall following this initial procedure. On hospital day #4, the patient underwent a second bronchoscopy, during which his proximal stent was repositioned 1.5 cm proximally. The patient continued to have improved air movement following this repositioning of the stent. He was successfully extubated on [**2149-11-18**], and remained on oxygen by nasal cannula ranging from 4 to 6 liters following his extubation. He required minimal suction with the Yankauer catheter following his extubation; the patient was capable of clearing his own secretions with this catheter. His oxygen saturation remained between 94 and 98% on 4 to 6 liters of nasal cannula following his extubation. 4. Hypotension - The patient reportedly became hypotensive on the morning of [**11-14**], after having a second episode of massive hemoptysis at the outside hospital and he subsequently required Dopamine to maintain his blood pressure. He was transfused a total of 4 units of packed red blood cells at the outside hospital, and he did not have evidence of hypovolemia on admission to the [**Hospital6 1760**]. He was gradually weaned off of the Dopamine drip during his hospitalization and he required no further blood transfusions, as his hematocrit remained above 30 throughout this hospitalization. At the time of discharge, the patient's systolic blood pressure was stable in the 140s to 150s. 5. Blood loss anemia - The patient had a drop in his hematocrit following his hemoptysis at the outside hospital; following transfusion of 4 units of packed red cells at the outside hospital, the patient's hematocrit improved to 32.5. He remained stable throughout this admission. 6. Coagulopathy - The patient had a mild coagulopathy with an INR of 1.4 on admission. He was administered Vitamin K times one with resolution of his coagulopathy. 7. Electrolyte abnormalities - The patient required repletion of his phosphate, potassium, magnesium, and calcium on multiple occasions throughout this admission. 8. Code status - Once the patient was more awake and alert following his bronchoscopy, a discussion regarding the patient's code status was addressed with both the patient and his family at the bedside. Both the patient and the family agreed that once the patient had been taken off of the Dopamine drip and once he was prepared for extubation, the patient would be made Do-Not-Resuscitate/Do-Not-Intubate. Neither the patient nor the family wished for any further aggressive interventions in terms of his medical care. Therefore, once the patient was successfully extubated on [**2149-11-18**], his code status was changed to Do-Not-Resuscitate, Do-Not-Intubate. Arrangements were then made on [**2149-11-19**] for the patient to be transferred to Home [**Hospital **] Medical Care following his discharge from the hospital. DISPOSITION: At the time of discharge from the hospital the patient was aspirating all foods and liquids he attempted to consume, however, given that the decision had been made to transfer the patient to home hospice medical care, the patient was sent home only on medications as needed for pain as well as Scopolamine for minimization of oral secretions. He was not sent home on any oral antibiotics given his inability to take p.o. DISCHARGE CONDITION: Do-Not-Resuscitate, Do-Not-Intubate to Home Hospice Care. DISCHARGE PLACEMENT: Home [**Hospital **] Medical Care with [**Hospital 44812**] Hospice. DISCHARGE DIAGNOSIS: 1. Stage 3 lung cancer 2. Hemoptysis 3. Hypotension 4. Post obstructive pneumonia 5. Blood loss anemia 6. Status post bronchoscopy times two with placement of stent into the left lower lobe and left main stem bronchus DISCHARGE MEDICATIONS: 1. Scopolamine patch q. 72 hours prn for excessive oral secretions 2. Fentanyl patch 25 mcg/hr q. 72 hours as needed for pain 3. Sublingual Lorazepam 1 mg tablets to 2 mg tablets every 2 to 4 hours as needed for agitation 4. Yankauer suction unit as needed for excessive oral secretions INSTRUCTIONS: The patient was discharged home with Vista Care Hospice from Medicine Intensive Care Unit. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2149-11-19**] 17:20 T: [**2149-11-19**] 17:31 JOB#: [**Job Number 44813**]

[ "530.81", "458.2", "244.9", "272.0", "162.2", "286.9", "486", "786.3", "285.1" ]

icd9cm

[ [ [] ] ]

[ "33.24", "33.23", "96.05", "32.29" ]

icd9pcs

[ [ [] ] ]

12600, 12751

4896, 5083

13020, 13651

12772, 12997

7530, 12578

5106, 7512

2390, 2403

2432, 3922

4444, 4726

3945, 4418

4743, 4879

17,125

137,179

4497

Discharge summary

report

Admission Date: [**2102-9-12**] Discharge Date: [**2102-9-17**] Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is an 88-year-old female with moderate to severe chronic obstructive pulmonary disease with an FEV-1 measured at .66 liters, on home oxygen, who was admitted to the hospital for chronic obstructive pulmonary disease flare. She has multiple recent admissions over the past nine months for similar symptoms, requiring Intensive Care Unit stays. The patient now presented following several days of lethargy and upper respiratory infection symptoms accompanied by increasing shortness of breath and declining mental status to the point of obtundation. On presentation to the Emergency Room, the patient was afebrile, with heart rate in the 110s and blood pressure in the 140s/50s, breathing at a rate of 45 breaths per minute, with oxygen saturations of 69% on room air. She appeared obtunded. Her breath sounds were globally diminished. She had a white count to 13.7, with 90% neutrophils. Electrocardiogram showed sinus tachycardia with an old right bundle branch block. An arterial blood gas performed on 100% non-rebreather showed a pH of 7.17, PCO2 of 136, PO2 of 73, with a calculated bicarbonate of 52. The patient was placed on BiPAP for a period of time. A repeat arterial blood gas showed a pH of 7.31, PCO2 of 95, PO2 of 67, with a calculated bicarbonate of 50. The patient had difficulty keeping a BiPAP mask on her face, and was subsequently intubated and transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease with an FEV-1 of 0.66 and FVC of 1.36, ratio measured 78% of predicted. She is on 3 liters of oxygen at home via nasal cannula. 2. Colon cancer, [**Location (un) **] Stage A status post low anterior resection in [**2098-4-6**] 3. Status post seizure in [**2097**] from hyponatremia, serum-inappropriate antidiuretic hormone 4. Osteoarthritis 5. Low back pain 6. Osteoporosis 7. Old lacunar infarct in the right corona radiata ALLERGIES: Doxycycline MEDICATIONS: Albuterol two puffs three times a day, Atrovent two puffs three times a day, Serevent two puffs twice a day, Ranitidine 150 twice a day, Klonopin twice daily, and Ritalin. SOCIAL HISTORY: The patient lives with her children. She has a history of smoking one pack per day for 20 years. She stopped 30 years ago. She has had no occupational exposures. She is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**], her pulmonologist is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**]. FAMILY HISTORY: Positive for tuberculosis and lung cancer. PHYSICAL EXAMINATION: The patient arrived to the Intensive Care Unit febrile and hypotensive. Temperature was 101.8, heart rate 94, blood pressure 82/46. The patient was intubated on assist control ventilation 500 x 14, FIO2 of 1.00, PEEP of 5. Peak pressures measured 40, with plateau of 24. The skin was warm and dry. She was anicteric. There were no rashes noted. Head, eyes, ears, nose and throat: The patient was intubated. Pupils were reactive to light. The oropharynx appeared dry. The neck was supple. The neck veins were flat. The lungs were clear anteriorly bilaterally. No wheezes were appreciated. The heart was regular rate and rhythm, S1, S2, no murmurs, gallops or rubs. The abdomen had bowel sounds present, soft, nontender. Extremities: No edema. Neurologically, the patient moved all extremities. She withdrew to pain and blinked in response to voice. LABORATORY DATA: On admission, white count was 13.7, hematocrit 42.4, platelets 320, 90% neutrophils, 4.3% lymphocytes. Sodium 138, potassium 4.4, chloride 87, bicarbonate 48, BUN 22, creatinine 0.7, glucose 153. Arterial blood gas on the above ventilator settings showed a pH of 7.48, PCO2 of 45, and PO2 of 435. Calcium was 7.9, phosphate was 1.6, magnesium 1.6. Electrocardiogram showed sinus tachycardia at 107 beats per minute with a right bundle branch block, left atrial abnormality, nonspecific ST/T wave changes, overall stable compared to [**2102-2-13**]. Urinalysis showed a specific gravity of 1.025, protein 30, trace ketones, pH 6.0, [**7-17**] white blood cells, no bacteria, 0 red blood cells, 0-2 epithelial cells, [**4-11**] hyaline casts, 0-2 granular casts, occasional calcium oxide crystals. Chest x-ray showed emphysematous changes without focal consolidation, biapical pleural thickening, no focal consolidations. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for further management. Blood cultures were obtained, and the patient was started on levofloxacin empirically. The patient was bolused with fluids to manage her hypotension likely the result of volume redistribution in the setting of intubation and chronic obstructive pulmonary disease. Her electrolytes were repleted, and she was maintained on metered dose inhalers as well as nebulizer treatments as needed. Multiple blood cultures were drawn and grew positive for coagulase negative staphylococcus in two bottles from separate sites. She was treated with a short course of vancomycin. No skin source could be identified. The patient became afebrile. She was started on Solu-Medrol as adjunctive treatment for her chronic obstructive pulmonary disease, underwent diuresis and was successfully extubated on [**9-13**]. She required mask BiPAP for several hours following the extubation for borderline oxygen saturations in the mid-80s. The patient continued to be diuresed and was eventually maintained on 3 liters nasal cannula, with oxygen saturations in the mid-90s. An echocardiogram was obtained, which showed a left ventricular ejection fraction greater than 55%, with moderate pulmonary hypertension and trace aortic regurgitation. Her steroids were tapered. She demonstrated some restlessness and disorientation while in the Intensive Care Unit, which waxed and waned and improved over time. She did demonstrate a run of multifocal atrial tachycardia during an albuterol nebulizer treatment, which responded to oral metoprolol. A baseline arterial blood gas on 3 liters nasal cannula was obtained, which showed a pH of 7.43, PCO2 of 53, PO2 of 87, with a calculated bicarbonate of 37. Her steroids were tapered. She now awaits further evaluation by Physical Therapy and will likely require [**Hospital 3058**] rehabilitation. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease flare DISCHARGE MEDICATIONS: 1. Serevent two puffs twice a day 2. Atrovent two puffs every six hours 3. Albuterol two puffs every four hours as needed 4. Ranitidine 150 mg by mouth twice a day 5. Klonopin 0.25 mg by mouth twice a day 6. Prednisone 30 mg by mouth for three days, then 20 mg by mouth for three days, then 10 mg by mouth for three days, then stop DISPOSITION: The patient will be discharged shortly from the hospital, likely to a rehabilitation facility. She is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] as well as her pulmonologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 19215**] MEDQUIST36 D: [**2102-9-17**] 21:23 T: [**2102-9-18**] 00:00 JOB#: [**Job Number 19216**]

[ "V10.05", "518.84", "491.21", "733.00", "285.9", "790.7" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2650, 2694

6550, 7493

6478, 6527

4544, 6457

2717, 4526

122, 1551

1573, 2261

2278, 2632

3,234

123,671

4934

Discharge summary

report

Admission Date: [**2192-1-23**] Discharge Date: [**2192-1-29**] Date of Birth: [**2146-8-23**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 45 year old female who was diagnosed with mitral valve prolapse at age 18. She has been followed for severe mitral regurgitation with serial echocardiograms. A recent echocardiogram showed an increase in mitral regurgitation and she was referred for a diagnostic cardiac catheterization in [**2191-10-15**] to rule out coronary disease. The patient was admitted on [**2191-12-12**] for a mitral valve replacement but the surgery was postponed after a presumed allergic reaction on induction of anesthesia. PAST MEDICAL HISTORY: Mitral valve prolapse. PAST SURGICAL HISTORY: None. ALLERGIES: Question of vancomycin and Levaquin. MEDICATIONS ON ADMISSION: Amoxicillin. SOCIAL HISTORY: The patient lives alone and works as a software engineer. The patient denies smoking and drinks approximately three to four drinks per week. The patient's last dental visit was in [**2191-10-15**] without any problems. STUDIES: Cardiac catheterization on [**2191-10-17**] showed normal coronaries with an EF of 53% and 3+ mitral regurgitation. The echocardiogram from [**2191-3-15**] showed moderately dilated left atrium, EF 65%, 3+ mitral regurgitation and prolapsed posterior leaflet. PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 97.7, pulse 57, blood pressure 102/57, respiratory rate 18 and oxygen saturation 100% in room air. General: Young woman in no acute distress, lying comfortably in bed. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, extraocular movements intact, anicteric sclerae, moist mucous membranes, normal buccal membranes, no erythema or exudate. Neck: Supple, no jugular venous distention, no lymphadenopathy noted. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1 and S2, III/VI systolic ejection murmur. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Well perfused, no cyanosis, clubbing or edema, 2+ dorsalis pedis and posterior tibialis pulses bilaterally. HOSPITAL COURSE: On hospital day number two, the patient was taken to the Operating Room for a minimally invasive mitral valve repair with a #28 [**Doctor Last Name 405**] band and atrial septal defect repair. The patient was admitted to the CSRU. On postoperative day number one, the patient was extubated. Secondary to low blood pressure, she was on Neo-Synephrine for pressure support. The patient remained afebrile with stable vital signs and was making good urine. On postoperative day number two, the patient continued to have blood pressure issues and was continued on Neo-Synephrine for pressure support. The patient also received a bolus for low urine output. She remained afebrile with stable vital signs. The patient's chest tubes were removed and Neo-Synephrine was weaned. On postoperative day number three, the patient had atrial fibrillation and converted to normal sinus rhythm after receiving a dose of amiodarone. The patient was on an amiodarone drip and remained afebrile with stable vital signs otherwise. The patient was switched to oral amiodarone and transferred to the floor. On postoperative day number four, the patient had a low grade temperature of 101.1 and then remained afebrile with stable vital signs, with good oral intake and urine output. On postoperative five, the patient remained afebrile with stable vital signs, with good oral intake and urine output. The patient was thus discharged to home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. FO[**Last Name (STitle) **]P: The patient was instructed to follow up with Dr. [**Last Name (Prefixes) **] in four weeks and with her primary care physician and cardiologist in one to two weeks. DISCHARGE DIAGNOSIS: Mitral valve prolapse, status post minimally invasive mitral valve repair and atrial septal defect repair. DISCHARGE MEDICATIONS: Percocet one to two tablets p.o.q.4h.p.r.n. pain. Aspirin 325 mg p.o.q.d. Colace 100 mg p.o.b.i.d. Lopressor 25 mg p.o.b.i.d. Amiodarone 200 mg p.o.b.i.d. Iron and ascorbic acid. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 3118**] MEDQUIST36 D: [**2192-1-29**] 06:59 T: [**2192-1-29**] 07:47 JOB#: [**Job Number 20509**]

[ "745.5", "424.0", "427.31", "458.29" ]

icd9cm

[ [ [] ] ]

[ "35.12", "35.52", "39.61" ]

icd9pcs

[ [ [] ] ]

4108, 4552

3977, 4085

866, 880

2270, 3701

782, 839

1414, 2252

184, 711

734, 758

897, 1391

3726, 3956

50,915

182,910

37213

Discharge summary

report

Admission Date: [**2158-8-21**] Discharge Date: [**2158-8-31**] Date of Birth: [**2078-10-12**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 15397**] Chief Complaint: Malaise, weakness in legs Acute blood loss anemia Major Surgical or Invasive Procedure: LUE AV graft surgery [**2158-8-25**] History of Present Illness: 79 yo male with history of Stage 4 CKD, HTN, HL DM2, and BPH who was due to have an AV graft placed last Wednesday as he was getting ready to start HD, but was instead referred to the ED for exertional dyspnea. This was initially thought to be due to uremia and hypercalcemia as troponins were stable and not indicative of ACS. His hypercalcemia was thought to be a result of exogenous medications - potentially hctz, calcitriol, or calcium carbonate. These medications were held and his calcium trended down. Of note, he has not had any fevers at home. He has a chronic unchanged cough. He was taken on Friday [**8-25**] for placement of a left upper extremity AV graft. His preop coags were noted to have a PTT >150. Over the past two days his left arm has continuously expanded and is now tense and painful. His hand has been cool with some numbness. He had post-op serosanguinous leakage around the site with a soft thrill and a quiet bruit. He has had a 12 point hematocrit drop from 33 -> 21. Surgicel was placed by the transplant surgery team. He was given 1 pRBC and 1 FFP on the floor. He received his last dose of Hep SQ at 1pm on [**2158-8-27**]. His last dose of ddAVP was at 8pm today. On arrival to the MICU, he reports some lightheadedness today, but denies CP or SOB. He reports numbness/tingling in a cool left hand with pain upon palpation. His last bowel movement was yesterday. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -STAGE 4 CKD -DIABETES TYPE II -HYPERTENSION -HYPERCHOLESTEROLEMIA -BENIGN PROSTATIC HYPERTROPHY -CATARACTS -DRY EYES -OPEN ANGLE GLAUCOMA -S/P CCY Social History: Social History: Originally from [**Country 651**], lives with Wife and daughter currently in [**Name (NI) **]. Has two daughters, is quite active. Smoked for "many years" quit in [**2141**] - 47 pack year history. No ETOH. Worked a a cook in a Chinese restaurant. Family History: Unknown Physical Exam: Vitals: afeb 98 113/54 16 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, distended GU: no foley, using urinal Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left upper arm with swelling, fresh blood oozing out of three portals of entry, large dependent hemaomta, ecchymoses, palpable left radial pulse, dopplerable ulnar pulse, cool fingers with slow capillary refill Neuro: CNII-XII intact, 5/5 strength upper/lower extremities Discharge exam: GEN: pleasant, active, NAD HEENT: NCAT, EOMI, MMM NECK: supple LUNGS: bibasilar crackles heard up to mid-level CV: RRR, normal S1/S2, no m/r/g; no carotid bruits, no JVD ABD: soft, protuberant, non-tender, non-distended, no HSM RECTAL: stool guaiac negative, no prostatic tenderness EXT: L arm mild soft swelling throughout, bandage over newly-made fistula over L arm; warm with pulses, extensive bruising in left armpit MSK: strength grossly 5+ throughout NEURO: CNII-XII grossly intact, finger squeeze even, awake, alert, and oriented to time, place, self, and situation Pertinent Results: Admission labs [**2158-8-21**] 05:50PM LACTATE-0.7 [**2158-8-21**] 05:40PM GLUCOSE-133* UREA N-102* CREAT-6.7*# SODIUM-137 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [**2158-8-21**] 05:40PM CK(CPK)-366* [**2158-8-21**] 05:40PM cTropnT-0.07* [**2158-8-21**] 05:40PM CK-MB-5 proBNP-1037* [**2158-8-21**] 05:40PM CALCIUM-13.3* PHOSPHATE-5.2* MAGNESIUM-2.2 [**2158-8-21**] 05:40PM WBC-6.6 RBC-3.58* HGB-11.6* HCT-34.2* MCV-96 MCH-32.5* MCHC-34.0 RDW-12.7 [**2158-8-21**] 05:40PM NEUTS-60.5 LYMPHS-30.5 MONOS-6.3 EOS-1.9 BASOS-0.7 [**2158-8-21**] 05:40PM PLT COUNT-218 [**2158-8-21**] 05:40PM PT-10.3 PTT-32.2 INR(PT)-0.9 Discharge labs [**2158-8-31**] 07:48AM BLOOD WBC-6.0 RBC-3.64* Hgb-11.2* Hct-32.4* MCV-89 MCH-30.6 MCHC-34.5 RDW-15.9* Plt Ct-168 [**2158-8-30**] 05:13AM BLOOD Neuts-68.3 Lymphs-20.8 Monos-8.8 Eos-1.5 Baso-0.6 [**2158-8-31**] 07:48AM BLOOD Plt Ct-168 [**2158-8-31**] 07:48AM BLOOD PT-9.8 PTT-26.8 INR(PT)-0.9 [**2158-8-29**] 03:41AM BLOOD Fibrino-650*# [**2158-8-31**] 07:48AM BLOOD Glucose-105* UreaN-84* Creat-4.1* Na-142 K-3.8 Cl-105 HCO3-26 AnGap-15 [**2158-8-31**] 07:48AM BLOOD ALT-43* AST-60* CK(CPK)-683* AlkPhos-59 [**2158-8-31**] 07:48AM BLOOD CK-MB-3 cTropnT-0.47* [**2158-8-30**] 05:13AM BLOOD CK-MB-3 cTropnT-0.39* [**2158-8-29**] 03:41AM BLOOD CK-MB-7 cTropnT-0.36* [**2158-8-28**] 08:28PM BLOOD CK-MB-8 cTropnT-0.27* [**2158-8-28**] 05:43PM BLOOD CK-MB-8 cTropnT-0.25* [**2158-8-28**] 10:50AM BLOOD CK-MB-7 cTropnT-0.19* [**2158-8-28**] 04:50AM BLOOD CK-MB-5 cTropnT-0.13* [**2158-8-27**] 01:37PM BLOOD CK-MB-3 cTropnT-0.08* [**2158-8-23**] 07:45AM BLOOD CK-MB-5 cTropnT-0.07* [**2158-8-22**] 11:30AM BLOOD CK-MB-5 cTropnT-0.06* [**2158-8-21**] 05:40PM BLOOD cTropnT-0.07* [**2158-8-21**] 05:40PM BLOOD CK-MB-5 proBNP-1037* [**2158-8-31**] 07:48AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7 [**2158-8-29**] 03:41AM BLOOD TSH-1.5 [**2158-8-29**] 12:25PM BLOOD PEP-TRACE ABNO IgG-913 IgA-166 IgM-36* IFE-MONOCLONAL [**2158-8-27**] 06:55AM BLOOD Hapto-31 [**2158-8-22**] 02:35AM BLOOD PTH-12* [**2158-8-29**] 04:14AM BLOOD freeCa-1.26 [**2158-8-28**] 07:01PM BLOOD freeCa-1.06* [**2158-8-28**] 01:49PM BLOOD freeCa-1.02* [**2158-8-28**] 05:29AM BLOOD freeCa-0.98* [**2158-8-23**] 08:33AM BLOOD freeCa-1.49* [**2158-8-28**] 10:50AM BLOOD REPTILASE TIME-Test 15 (WNL <20) Blood cultures, urine cultures negative. [**2158-8-30**] ECHO EF 45% The left atrium is normal in size. 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 (LVEF = 45 %). There is no ventricular septal defect. Right ventricular chamber size is normal. RV with borderline normal free wall function. The ascending aorta is mildly dilated. 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. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**2158-8-28**] ct chest without contraST IMPRESSION: 1. Left upper extremity hematoma extending into the left pectoral muscles and axilla. There is no intrapleural involvement. Full extent is better evaluated on the concurrent left upper extremity CT. 2. 4-mm lung nodules in the right upper lobe and within the lingula. Recommend followup CT in one year given the presence of emphysema. 3. Atherosclerotic calcifications. [**2158-8-28**] CT UE W/O CONTRAST IMPRESSION: 1. Hematoma approximately 2 cm from the venous graft anastomosis measuring 3.1 x 2.1 x 3.9 cm. 2. Second foci of hematoma at the distal end of the graft measuring 1.2 x 1 cm. 3. Kinking of the venous portion of the AV graft concerning for partial occlusion. 4. Lytic lesion at the mid shaft of the ulna measuring 10 mm. [**2158-8-27**] subclavian vein doppler FINDINGS: There is normal compressibility and flow demonstrated in the left subclavian vein. In addition, normal flow and compressibility is demonstrated in the left internal jugular vein. [**2158-8-22**] RENAL US IMPRESSION: Small kidneys with mild cortical thinning consistent with chronic kidney disease. No hydronephrosis. [**2158-8-21**] CT HEAD W/O CONTRAST IMPRESSION: No acute intracranial process. [**2158-8-21**] CXR IMPRESSION: Patchy right lower lobe opacity concerning for pneumonia. [**2158-8-30**] EKG Atrial fibrillation. Non-specific ST-T wave changes. Compared to the previous tracing the patient is now in atrial fibrillation. [**2158-8-29**] EKG Sinus rhythm. Incomplete right bundle-branch block. T wave inversions in leads I, aVL and V4-V6. Compared to the previous tracing of [**2158-8-29**] patient is now in sinus rhythm. [**2158-8-29**] EKG Atrial fibrillation with rapid ventricular response. Q waves as well as ST segment elevation in the inferior leads. Consider prior inferior wall myocardial infarction of indeterminate age. Anteroseptal ST-T wave changes also noted. Compared to the previous tracing of [**2158-8-28**] the rate is faster. Otherwise, no diagnostic change. Brief Hospital Course: 79 yo male with a history of DM2, HTN, HL, CAD, and Stage 4 CKD that presented with malaise, weakness, and fatigue in the setting of progressive uremia and hypercalcemia. Hypercalcemia likely due to medication effect (calcitriol and calcium carbonate) and improved with hydration and gentle diuresis. Hospital course complicated by AV graft placement in the setting of greatly elevated PTT and left arm hematoma, patient was transferred to the ICU for further management. There he had multiple transfusions of pRBCs, cryoprecipitate, and FFPs. Once his hematocrit improved, he was transferred to the floor. # Left arm hematoma due to AV graft leak: s/p 5 units of PRBC, 4 units of cryoprecipitate and reversal of his PTT with protamine and FFP. HCT stable, PTT stable, patient was transferred to the floor from MICU. His exam was less concerning for compartment syndrome, with palpable left radial pulse, less arm swelling and no complaints of left arm pain. He was followed by the transplant surgery team. The likely etiology of the elevated PTT is secondary to SC heparin for DVT prophylaxis. He is very sensitive to SC heparin which should be noted in the future. # Hypercalcemia: Thought secondary to starting calcitriol. This medication was stopped and he had gentle hydration and was given furosemide with good effect. His calcium level returned to [**Location 213**]. Calcitriol was not continued on discharge. With improvement in his calcium, his original symptoms of malaise and fatigue resolved. # Afib with RVR. He spontaneously converted. CHADS2 score of 2. He converted on his own prior to 48 hours. Likely in setting of electrolyte imbalance vs volume depletion. Was in sinus on day of discharge. # Demand Ischemia in setting of RVR with ST depression in V4/V5 and Avl. Has no cardiac symptoms, including no chest pain, dyspnea, nausea, diaphoresis, or vomiting. Troponin elevated with negative CK-MB. Resolution of ST depression with sinus rhythm and transfusion initially but repeat EKG on [**2158-8-29**] AM had slight depression in Avl which was persisting. The patient will likely benefit from cardiac stress test as an outpatient. # CKD Stage 5: No indication for urgent dialysis. Normal electrolytes and volume balance. Continue to monitor. He was followed by Nephrology team in house. His AVG had a bruit without a thrill at discharge. Per transplant surgery, it seemed to be functioning well. # DM-2: humalog 75/25 mix and HISS # Hyperlipidemia: continued rosuvastatin # BPH: continued tamsulosin Outpatient Follow up - 4-mm lung nodules in the right upper lobe and within the lingula. Recommend followup CT in one year given the presence of emphysema. -Lytic lesion at the mid shaft of the ulna measuring 10 mm- f/u SPEP/UPEP and consider PSA Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/CaregiverPharmacy. 1. Calcitriol 0.5 mcg PO DAILY 2. Carvedilol 12.5 mg PO BID hold for SBP<100, HR<60 3. Rosuvastatin Calcium 40 mg PO DAILY 4. Guaifenesin-CODEINE Phosphate [**6-15**] mL PO Q6H:PRN cough 5. econazole *NF* 1 % Topical [**Hospital1 **] 6. Humalog 75/25 12 Units Breakfast Humalog 75/25 14 Units Dinner 7. Tamsulosin 0.4 mg PO HS 8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 9. Lisinopril 5 mg PO DAILY hold for SBP<100 10. Hydrochlorothiazide 25 mg PO DAILY 11. Calcium Carbonate 600 mg PO TID 12. Fish Oil (Omega 3) 1000 mg PO TID Discharge Medications: 1. Carvedilol 12.5 mg PO BID hold for SBP<100, HR<60 2. Humalog 75/25 12 Units Breakfast Humalog 75/25 14 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *Humalog 100 unit/mL Up to 10 Units per sliding scale four times a day Disp #*200 Milliliter Refills:*1 3. Rosuvastatin Calcium 40 mg PO DAILY 4. Tamsulosin 0.4 mg PO HS 5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 6. Nephrocaps 1 CAP PO DAILY RX *Nephrocaps 1 mg 1 capsule(s) by mouth one per day Disp #*30 Capsule Refills:*2 7. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 8. sevelamer CARBONATE 800 mg PO TID W/MEALS RX *Renvela 800 mg 1 tablet(s) by mouth three times per day with meals Disp #*90 Tablet Refills:*2 9. Fish Oil (Omega 3) 1000 mg PO TID 10. econazole *NF* 1 % Topical [**Hospital1 **] 11. Guaifenesin-CODEINE Phosphate [**6-15**] mL PO Q6H:PRN cough 12. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Hypercalcemia Chronic kidney disease AV graft placement Left arm hematoma due to AV graft leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], Thank you for choosing [**Hospital1 69**] for your health care. You were admitted to our hospital for a high level of calcium in your blood, which caused you to feel weak. This was most likely due to dietary supplements of calcium and vitamin D. You were treated with medications (called diuretics) which helped your kidneys excrete the calcium, as well as excrete fluids. You were followed by the nephrology team and the endocrinology team. While you were in the hospital, you also had surgery to place an AV graft. This graft will be used for hemodialysis in the future. Initially you had some bleeding which required monitoring in the medical intensive care unit but you stabilized. You are being discharged home in good condition. You should make sure to follow up with your nephrologist, transplant team, and primary care provider after being discharged from the hospital. Also, because of your irregular heart rhythm and risk factors for heart disease you should see Cardiology. Please see appointments below. Note that while you were here, you had elevated blood sugars so you are being discharged on your usual twice-a-day insulin but also Humalog insulin correction scale. This was reviewed with your daughter, who will help administer the insulin. If you note values <80 or >300 please seek emergent help from your PCP or [**Name9 (PRE) **] providers. While you were here, some changes were made to your medications: Please START: -Furosemide, 40 mg per day. -Nephrocaps, one capsule per day. -Sevelamer Carbonate, 800 mg three times a day with meals. -Aspirin 325mg daily. Please STOP: -Calcitriol until your outpatient providers restart it. -Hydrochlorothiazide until your outpatient providers restart it. -calcium carbonate (Tums) until your outpatient providers restart it. -Lisinopril, until your outpatient providers restart it. Please take your other medications as previously prescribed. Followup Instructions: [**Last Name (un) **] DIABETES Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Appt: Monday, [**9-4**] at 12:30pm PRIMARY CARE Department: [**State **]When: THURSDAY [**2158-9-7**] at 10:45 AM With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking TRANSPLANT SURGERY Department: TRANSPLANT CENTER When: MONDAY [**2158-9-11**] at 10:45 AM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage NEPHROLOGY Name: [**First Name8 (NamePattern2) **] [**Doctor First Name 83789**], NP (works with Dr [**First Name (STitle) 10083**] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3637**] Appt: [**9-14**] at 10:30am CARDIOLOGY Department: CARDIAC SERVICES When: TUESDAY [**2158-10-3**] at 10:30 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2171-6-26**] Discharge Date: [**2171-6-29**] Date of Birth: [**2100-4-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: 1. placement of a internal jugular central line, now removed. 2. hemodialysis x 2 History of Present Illness: Patient is a 71 yo male with ESRD on HD, COPD on 2L at home, and untreated [**Hospital 58642**] transfered from the MICU after a hypotensive episode at HD on [**2171-6-26**]. He had diarrhea before going to HD, and developed hypotension during HD, which limited his diuresis. He remained SOB and went to the ED, where he was noted to have hyperkalemia to 7.2 with peaked T waves on the ECG and had a lactate of 5.8. He was admitted to the MICU after he was given a central line, bolused, given kayexalate, and given antibiotics. CT ABD was negative for infection and ischemia. He stabilized in the MICU, was dialized and given kayexalate. His shortness of breath resolved and his potassium decreased. He was deemed appropriate for transfer to the floor. Past Medical History: 1. ESRD on HD, began dialysis [**2166**]. AV graft placed in LUE on [**2171-1-10**]. Congenital absence of one kidney. Gets HD MWF in [**Location (un) **]/[**Location (un) 4265**]--followed by Dr. [**First Name (STitle) 805**]. On [**2171-2-13**], underwent attempted thrombectomy, left upper arm AV graft. Ligation of left upper arm AV graft and placement of right femoral Quinton catheter. 2. HTN 3. Hypercholesterolemia 4. DM, type 2 5. Diastolic CHF, EF >55% 6. COPD 7. h/o GI bleeding 8. unilateral kidney 9. s/p cataract surgery [**73**] H/o gastric lipoma, 11. PVD, s/p angioplasty. 12. h/o VRE UTI 13. Restless legs syndrome 14. CMML - diagnosed 6 months ago, pt of Dr. [**Last Name (STitle) 6944**]. Diagnosed by bone marrow biopsy, did not have any symptoms. Not being treated. Social History: Pt is a retired medical record coder at the VA. He is widowed with 4 children and 5 grandchildren. Lives with 1 daughter. 120 pack year hx, quit 20 years ago. Quit smoking 14 years ago, but smoked [**2-17**] ppd for 40+ years. No EtOh. No drug use. Pt was in the army from [**2118**]-[**2142**]. Family History: M: Died at 64 of MI; DM F: Died at 41 of MI Aunts maternal and paternal with DM. Physical Exam: Vitals: T 97.1 BP 102/53 HR 70 RR 18-22 SpO2 94-99 (2L) I/O 600/0 FSGlu 133 General: comfortable, NAD Skin: pink, warm, no rashes HEENT: NCAT, MMM, clear oropharynx, no LAD Heart: HRRR, nl S1 and S2, no m/r/g Pulm: Bibasilar inspiratory crackles L>R. No w/r Abd: BS wnl, S/NT/ND/no HSM Ext: no c/c/e Neuro: cn2-12 intact grossly. A+O x 3 Pertinent Results: [**2171-6-26**] 11:57PM LACTATE-1.2 K+-5.6* [**2171-6-26**] 08:37PM LD(LDH)-211 CK(CPK)-55 TOT BILI-0.3 Troponin negative x 3 Lactate was 5.4 upon admission on [**6-26**] and 1.3 upon discharge. INR was 1.6 on admission on [**6-26**] to the MICU and 1.2 upon discharge Hct was 49.6 upon admission on [**6-26**] and 32.2 upon discharge Platelets were 45 upon admission on [**6-26**] and 61 upon discharge WBC were 8.7 on admission and 5.1 Glucose was 245 on admission and 76 on discharge with a maximum of 279 on [**6-26**] at 5pm. [**2171-6-26**] 12:03PM ALT(SGPT)-39 AST(SGOT)-57* CK(CPK)-54 ALK PHOS-100 AMYLASE-46 TOT BILI-0.5 Stool C-diff was negative x 2 Blood cultures pending CXR [**6-26**]: IMPRESSION: Interval resolution of findings of pulmonary edema, with no new cardiopulmonary process. CT ABD/PELVIS [**6-26**]: IMPRESSION: 1. Choledocholithiasis. Small stone in the common bile duct within the pancreatic head. Minimal intrahepatic biliary dilatation and moderate dilatation of the common bile duct, which is not significantly changed compared to the prior study. 2. Mildly prominent lymph nodes within the hepatoduodenal ligament and along the left external iliac change which are nonspecific. Attention can be paid on followup examinations. 3. 8-mm right retroperitoneal soft tissue nodule abutting the lateral wall musculature is also a nonspecific finding. 4. Vague ground glass opacity in the lingula. Attention can be paid to this area on follow-up examinations. Hip XR [**6-27**]: IMPRESSION: No acute fracture or dislocation. If clinical concern for fracture persists, recommend further evaluation with MR. Left UE graft US [**6-28**]: IMPRESSION: Heterogeneous fluid collection just deep to fistula, most likely hematoma. CT Hip [**6-28**]: no abscess. Hip osteoarthritis with geod formation. ECG [**6-26**] 12:04pm: Probable sinus tachycardia with premature atrial beats and a three beat run of supraventricular tachycardia. Inferior myocardial infarction, age indeterminate. Peaked T waves in the precordial leads. Compared to tracing on [**2171-5-27**] the tachycardia, premature atrial beats and inferior wall myocardial infarction are all new. ECG [**6-26**] 1:50pm: Probable sinus tachycardia with premature atrial beats and a three beat run of supraventricular tachycardia. Compared to tracing #1 on [**2171-6-26**] the inferior Q waves are now absent. ECG [**6-27**] 7:52am: Sinus rhythm. First degree A-V block. Non-specific inferolateral ST-T wave changes. Compared to tracing #2 on [**2171-6-26**] the sinus tachycardia and premature atrial beats are absent. Brief Hospital Course: Mr. [**Known lastname **] was transferred to the floor on the evening on [**6-27**]. Sepsis: He remained afebrile with stable vital signs on the floor. No definitive source of infection was found. His lactate normalized on [**6-26**]. He was c-diff negative x 2. Thrombocytopenia: His platelet count rose steadily throughout his stay and was 61 upon discharge. ESRD: He was dialysed on [**6-26**] and [**6-28**]. Hyperkalemia: His hyperkalemia resolved with dialysis. SOB: He remained without SOB for the remainder of his stay. He was managed with tiotropium, advair, nebulizers prn. CMML: No active issues. Not on treatment. Medications on Admission: 1. Aspirin 81 mg qd 2. Fosinopril 10 mg qd 3. Requip 0.25 mg [**Hospital1 **] 4. Diltiazem 30 mg tid Tu/Th/Sa/[**Doctor First Name **] 5. Toprol XL 25 mg qhs 6. Calcium Acetate 1334 mg tid 7. Tiotropium qd 8. Sevelamer 1600 tid 9. Colace 100 mg [**Hospital1 **] 10. Nephrocaps qd 11. Advair 250/50 [**Hospital1 **] 12. Omeprazole 20 mg qd 13. Vitmain E 400 units qd 14. Lovastatin 10 mg qhs 15. Insulin NPH 15 units qhs, RISS Discharge Medications: 1. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Capsule(s)* Refills:*2* 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*1 Cap(s)* Refills:*2* 4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*60 Cap(s)* Refills:*2* 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol): Last dose Monday [**2171-7-1**] following hemodialysis. Disp:*1 * Refills:*2* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 10. Fosinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation twice a day. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous at bedtime. 15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per sliding scale Subcutaneous qachs. 16. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 17. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO three times a day: on Tuesday, Thursday, Saturday, Sunday. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. Hypotension, resolved. 2. Sepsis of undetermined etiology. 3. Hyperkalemia, resolved. 4. SOB, resolved. Discharge Condition: Good Discharge Instructions: You have been treated for low blood pressure, infection, and high potassium. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Changes made to your medication list are as follows If you have increased shortness of breath, chest pain, dizziness, loss of consciousness, or fever/chills, please see the nearest medical provider of hospital emergency department. Followup Instructions: Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Phone:[**Telephone/Fax (1) 3241**]) on [**2171-7-24**] at 3:00pm. Please follow up with your primary care doctor Dr. [**First Name (STitle) **] M [**First Name (STitle) **], in [**6-25**] days. You should discuss restarting your blood pressure medications.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.21", "39.95" ]

icd9pcs

[ [ [] ] ]

8395, 8452

5455, 6093

326, 410

8603, 8610

2803, 5432

9072, 9459

2342, 2424

6570, 8372

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6119, 6547

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2439, 2784

275, 288

438, 1198

1220, 2010

2026, 2326

69,388

117,267

9391

Discharge summary

report

Admission Date: [**2161-9-1**] Discharge Date: [**2161-9-10**] Date of Birth: [**2103-6-26**] Sex: M Service: SURGERY Allergies: Flagyl / Augmentin / Naprosyn Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2161-9-1**]: Exploratory laparotomy, extended right colectomy, end-ileostomy and Hartmann procedure. History of Present Illness: 58M w multiple medical comorbidities xferred from OSH w abdominal pain and diarrhea x 4 days. Patient is chronically ill with a question of poor compliance s/p recent AMA discharge from [**Hospital1 18**] [**8-17**] after 3 day admission for gait instability. Patient now reports 4 days of nausea, poor po intake, non-bloody diarrhea, subjective fever, chills and malaise. Also describes black stools but unable to quantify duration. This was accompanied by progressive diffuse abdominal pain that eventually prompted visit to OSH ED. At OSH patient was hemodynamically stable though CT A/P showed contained ascending colon perforation with severe associated inflammation. Also demonstrated WBC to 14 and blood glucose in 400s. Patient transferred to [**Hospital1 18**] ED for further management. On arrival patient reiterates complaints above and describes severe diffuse abdominal pain worse w movement and made better only w narcotic pain medication. Also w mild L sided chest pain. Denies headache, blurry vision, double vision, dysuria. Past Medical History: PMH: CAD c/b MI s/p CABG ([**2148**]; TTE LVEF 25% 9/11), Hx CVA ([**7-/2159**]; Mild residual L ataxic hemiparesis); L ICA occlusion w supraclinoid reconstitution at PCA, R ICA 50% stenosis; Hyperlipidemia, PVD, IDDM, Hx nonmelanoma skin cancer (dermatofibrosarcoma protuberans), Cataracts, B/L diabetic retinopathy PSH: R undescended testicle (childhood), tonsillectomy (childhood), 4 vessel CABG ([**Hospital1 3278**]-[**2148**]), R CFA to AK [**Doctor Last Name **] bypass graft w reversed R LSV ([**Doctor Last Name **]-[**2149**]), R 5th met head rsxn ([**Doctor Last Name **]-[**2149**]), R eye vitrectomy for retinal detachment ([**2154**]), Radical rsxn dermatofibrosarcoma protuberans ant chest wall ([**Doctor Last Name 1924**]-[**2155**]), Coverage sternal wire/partial closure large tumor defect w local tissue flap, STSG ([**Doctor Last Name **]-[**2155**]), R hallux arthroplasty ([**Doctor Last Name **]-[**2158**]), R BK-[**Doctor Last Name **] stent ([**Doctor Last Name **]-[**2158**]), R hallux amputation ([**Doctor Last Name **]-[**2158**]), R eye cataract excision ([**Doctor Last Name **]-[**2159**]) Social History: Lives alone. Retired on disability. Tobacco: Current 0.5 ppd, long time smoker; EtOH: denies; Recreational drugs: denies Family History: Mother - EtOH abuse, CAD, Lung Ca; Father - EtOH abuse; Brother - Type 2 diabetes Physical Exam: On presentation to [**Hospital1 18**]: VS: 99.6 90 128/47 16 98%RA GEN: WD, WN middle aged M in NAD HEENT: NCAT, EOMI, anicteric; +NGT CV: RRR PULM: CTA B/L w no W/R/R, no respiratory distress ABD: +involuntary guarding, severe diffuse tenderness to light palpation (R>L), minimally distended, no mass, no hernia PELVIS: normal rectal tone, prostate WNL, black stool - guaiac POSITIVE EXT: WWP, no CCE, 2+ B/L radial/DP/PT NEURO: A&Ox3, no focal neurologic deficits DERM: no rashes/lesions/ulcers PSYCH: normal judgment/insight, normal memory, normal mood/affect Pertinent Results: LABORATORIES: Admit: [**2161-9-1**] 06:20AM BLOOD WBC-10.3 RBC-4.14* Hgb-9.4* Hct-30.3* MCV-73* MCH-22.6* MCHC-30.9* RDW-22.4* Plt Ct-294 [**2161-9-1**] 06:20AM BLOOD PT-14.7* PTT-34.5 INR(PT)-1.3* [**2161-9-1**] 06:20AM BLOOD Glucose-400* UreaN-20 Creat-1.3* Na-128* K-3.7 Cl-91* HCO3-23 AnGap-18 [**2161-9-1**] 06:20AM BLOOD ALT-15 AST-12 CK(CPK)-59 AlkPhos-133* TotBili-1.2 [**2161-9-1**] 06:20AM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.4 Mg-1.9 Discharge: IMAGING: CT A/P [**9-1**]: 1. Marked and diffuse bowel wall thickening and edema along the ascending colon, with small pockets of extraluminal gas. 2. Large portacaval lymph node, interspersed with microcalcifications. Numerous small retroperitoneal lymph nodes. 3. Significant age-advanced vasculopathy. 4. Appearance of intrahepatic vascular congestion. 5. Small-to-moderate ascites. MICROBIOLOGY: BCx [**9-1**]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. FIRST/SECOND MORPHOLOGY; Isolated from only one set in the previous five days PATHOLOGY: Specimen Type: Right hemicolectomy with portion of transverse colon. Specimen Size: Greatest dimension: 54 cm. Additional dimensions: 7.5 cm x 7.5 cm. Tumor Site: Right (ascending) colon; Tumor configuration: Ulcerating. Tumor Size:Greatest dimension: 9 cm. Additional dimensions: 5.5cmx3cm. Macroscopic Tumor Perforation: Present. MICROSCOPIC Histologic Type: Mucinous adenocarcinoma (greater than 50% differentiation) with focal signet ring cells. Histologic Grade: High grade Extent of Invasion Primary Tumor: pT4a: Tumor penetrates the visceral peritoneum. Regional Lymph Nodes: pN2b: Metastasis in 7 or more regional lymph nodes. Lymph Nodes: Number examined: 20.; Number involved: 17. Distant metastasis: pMX: Cannot be assessed. Margins: Prox/Distal: NEGATIVE; Circumferential (radial) margin: Involved by invasive carcinoma (tumor present 0-1 mm from CRM). Lymphatic Small Vessel Invasion: Present. Intramural, extramural. Extensive. Venous (large vessel) invasion: Absent. Perineural invasion: Absent. Tumor Deposits (discontinuous extramural extension): Present. Additional Pathologic Findings: Other polyps (type(s)): Adenoma. Brief Hospital Course: The patient was transferred from an outside hospital on [**2161-9-1**] for management of a contained perforation of the ascending colon. Surgery consultation was obtained in the [**Hospital1 18**] ED and patient was admitted to the acute care surgery service for further management in the TSICU. Given patient's extensive medical comorbidities and anti-coagulation (on plavix) he was initially admitted to the TSICU with a plan for observation and serial abdominal exams. He was made NPO, resuscitated with IVF and started on broad spectrum IV antibiotics (zosyn). Over the course of [**9-1**] patient's abdominal exam continued to worsen and decision was made to bring patient to the OR [**9-1**] PM for exploratory laparotomy. Findings intra-operatively included a large perforating tumor of the ascending colon. An extended right hemicolectomy was performed with long Hartmann's stump and end ileostomy. Postoperatively, patient was returned to [**Location 10115**] extubated having tolerated procedure well. Systems based hospital course per below. Patient was transferred to CC6 [**9-3**]. Neuro: Post-operatively, the patient received intermittent Morphine IV as well as a TAP block. Pain control was changed to intermittent dilaudid IV with improved effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. On [**2161-9-4**] the patient began to show signs of agitation and delirium. He was evaluated by psychiatry who determined the delirium to be most likely due to narcotic pain medication. He was started on standing and prn antipsychotics (haldol) per psychiatry recommendations. Haldol was discontinued on [**9-7**] given a QTc interval of 464, and his delirium continued to improve. By the day of discharge he was longer exhibiting symptoms of acute delirium. He remained alert, calm and cooperative at the time of discharge. CV: All cardiovascular medications were held at time of admission given possibility of evolving sepsis. Medications were resumed on [**9-6**]. On [**9-7**] his QTc interval was noted to be 464 ms (from 448 preoperatively on [**9-1**]) and his standing haldol was discontinued. On [**9-8**] a follow up ECG showed a QTc of 443 ms. [**First Name (Titles) **] [**Last Name (Titles) 19206**] were routinely checked and repleted as needed. The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored and he remained on telemetry monitoring. Pulmonary: Patient with baseline COPD. Home inhaler regimen was continued as in patient. Pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. An NGT was in place postoperatively and was discontinued [**9-3**]. His diet was advanced to clear liquids on [**9-5**] and regular (diabetic diet) on [**9-6**], which was tolerated well. Patient passed flatus and had liquid stool output from his ileostomy. He had [**Name Initial (MD) **] ostomy RN consult who began ostomy teaching while he was in the hospital. The patient demonstrated some independence with his ostomy care, but was still requiring assistance at the time of discharge. He was set up with visiting nursing services upon discharge for this. A foley placed [**9-1**] and was removed on [**9-3**]. On [**9-4**], the patient was found to be retaining urine and the foley was replaced. On [**9-8**] he was started on flomax. After two doses of flomax his foley was removed on [**9-10**]. However, he was unable to void and the foley was replaced. He was given instructions to follow up with urology as an outpatient. Also of note, his creatinine was elevated to 1.6 at highest on [**9-5**]. See below for dates of vancomycin. After discontinuation of vancomycin, his creatinine trended downward appropriately to 1.2 on [**9-9**]. Pathology returned from colonic resection demonstrated T4N2 colonic mucinous adenoCA w signet ring features. See above for further details. Hematology/oncology was consulted, an appointment was schedule for Mr. [**Known lastname 32068**] as an outpatient to discuss treatment options on [**2161-9-16**]. ID: Pre-operatively, the patient was started on IV zosyn and was continued postoperatively given visceral perforation. IV vancomycin was also started empirically. Antibiotics were discontinued on [**9-6**] (vanco) and [**9-7**] (zosyn). The patient's temperature was closely watched for signs of infection, and he remained afebrile with a normal white count after discontinuation of antibiotics. HEME: Patient was admitted having last taken plavix on [**8-29**]. Plavix was held given likelihood of surgery at time of admission. Clopidogrel and ASA were resumed [**9-3**]. Endo: Given his history of IDDM, his blood sugars were monitored closely throughout his hospitalization. The patient was triggered on [**2161-9-6**] for persistent blood glucose levels > 400. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained who recommended [**Hospital1 **] standing NPH and a sliding scale. By the day of discharge, his blood glucose levels were controlled on the insulin regimen recommended by [**Last Name (un) **]. The patient was continued on this regimen at discharge and was given a copy of the sliding scale. He was instructed to follow up with his PCP [**Last Name (NamePattern4) **] [**12-7**] weeks regarding his blood glucose levels and insulin regimen. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. Physical therapy was also consulted given his decreased mobility and deconditioning, who cleared him as safe to go home with no further PT needs. At the time of discharge on POD 9, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, and ambulating with a walker. His pain was well controlled and his blood glucose levels were stable. Medications on Admission: [**Last Name (un) 1724**] (compliance questionable): ASA 81', plavix 75', Metoprolol succinate 12.5', lisinopril 2.5', lasix 40 QHS, spironolactone 12.5', ezetimibe 10', simvastatin 20 QHS, combivent 18-103 2 INH QID prn, Novolin-N 20u QAM, 7u QPM, Insulin aspart 20u QAC prn, FeSO4 300(60)''', acetaminophen 325 Q6H prn, fluticasone 50 NAS Discharge Medications: 1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 13. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*60 Tablet(s)* Refills:*0* 14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a day). Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*0* 15. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous four times a day as needed for per sliding scale. Disp:*3 vial* Refills:*2* 16. NPH insulin human recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous twice a day. Disp:*3 vial* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] [**Hospital3 **] Discharge Diagnosis: Primary Diagnosis: Perforated tumor of the transverse colon Secondary Diagnosis: Congestive heart failure Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the acute care surgery service for management of perforated colon. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Your blood glucose levels where elevated while you were in the hospital. You were seen by the specialists at [**Last Name (un) **] Diabetes center for this, who recommended a different insulin regimen than what you were taking prior to coming to the hospital. You are being given a copy of the sliding scale the specialists recommended, which you should continue while you are at home until you follow up with your PCP as instructed below. You should also take the fixed dose of insulin as prescribed 12 units NPH twice/day. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *Your staples will be removed at your follow-up appointment. Followup Instructions: Please call ([**Telephone/Fax (1) 6815**] upon discharge to schedule an appointment in the acute care surgery clinic next Thursday [**2161-9-17**], or with any questions/concerns. Clinic is located in the [**Hospital **] Medical Office Building, [**Location (un) **], [**Hospital1 18**]. You staples will be removed at this visit. Call the [**Hospital 159**] Clinic at [**Telephone/Fax (1) 164**] upon discharge to schedule an appointment within the next 1-2 weeks. At the appointment, the need for the foley catheter will be evaluated. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2161-9-16**] at 2:00 PM With: [**Doctor First Name **] [**Last Name (NamePattern5) 21185**], 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 Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-7**] weeks. Call ([**Telephone/Fax (1) 32070**] upon discharge to schedule an appointment. Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-7**] weeks regarding your insulin regimen, need for a psychiatry referral, and other medical issues. Call Office ([**Telephone/Fax (1) 1300**] upon discharge to schedule an appointment. Completed by:[**2161-11-26**]

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icd9cm

[ [ [] ] ]

[ "45.73", "04.81", "46.23" ]

icd9pcs

[ [ [] ] ]

13772, 13836

5695, 11804

303, 409

14005, 14005

3493, 5672

15944, 17331

2797, 2881

12196, 13749

13857, 13857

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14277, 15549

249, 265

437, 1489

13939, 13984

13876, 13918

14020, 14132

1511, 2640

2656, 2781

71,405

112,265

54459

Discharge summary

report

Admission Date: [**2150-2-27**] Discharge Date: [**2150-3-5**] Date of Birth: [**2084-7-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 922**] Chief Complaint: Exertional/rest angina Major Surgical or Invasive Procedure: [**2150-2-27**] emergent coronary artery bypass grafting x4 (LIMA-LAD,SVG-RI,SVG-OM!,SVG-PDA) left heart catheterization, coronary angiogram [**2150-2-27**] History of Present Illness: This 65 year old gentleman with no prior cardiac history describes a 9 month history of episodic exertional chest discomfort and dyspnea. These episodes have occurred while walking 2 or more blocks while carrying books or groceries. He also reports having less frequent chest discomfort occurring at rest but only lasting seconds and resolving spontaneously or with SL nitroglycerin that he was recently prescribed. The patient was seen by Dr. [**First Name (STitle) **] and had an abnormal stress test, as noted below, so has now been referred for catheterization. Cath revealed 90% Left main 100% RCA occulsion. He was referred for urgent operation. Past Medical History: Unstable angina Bicuspid aortic valve. Pectus excavatum. anal cancer [**2125**] (s/p chemo and radiation therapy) iron deficieny anemia hypothyroidism anxiety/depression basal cell cancer of the face gastroesophageal reflux prostate cancer Social History: Lives with: Alone in [**Location (un) **]. Retired. Tobacco: has smoked 45+ years/1ppd since age 17; now trying to quit - down [**12-29**] ciagarettes / day ETOH: socially ~ 5 wines/ week Contact upon discharge: [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **]- [**Telephone/Fax (1) 111461**] Family History: non-contributory Physical Exam: Pulse: 75 Resp: 12 O2 sat:94% RA B/P Right: Left: 113/79 Height: 5'8" Weight: 153# General: AAO x 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Pectis excavatum Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x, well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:cath site Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [**2150-3-4**] 05:00AM BLOOD WBC-8.9 RBC-4.37* Hgb-12.2* Hct-35.6* MCV-82 MCH-28.0 MCHC-34.4 RDW-15.5 Plt Ct-221 [**2150-3-4**] 05:00AM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-135 K-4.3 Cl-101 HCO3-24 AnGap-14 [**2150-2-27**] 10:30AM BLOOD Glucose-123* UreaN-21* Creat-1.0 Na-136 K-4.1 Cl-105 HCO3-22 AnGap-13 [**2150-2-27**] 10:30AM BLOOD ALT-14 AST-18 CK(CPK)-168 AlkPhos-62 Amylase-63 TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2150-2-27**] 10:30AM BLOOD %HbA1c-6.0* eAG-126* Findings LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Aneurysmal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Normal descending aorta diameter. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Bicuspid aortic valve. Mild AS (area 1.2-1.9cm2). Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate ([**12-29**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: Written informed consent was obtained from the patient. 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. Results were Conclusions PRE-CPB: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve is bicuspid. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild to moderate ([**12-29**]+) central mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of study. POST-CPB: The patient is on a phenylephrine infusion. The left ventricular systolic function remains normal. Estimated EF>55%. The right ventricular systolic function remains normal. Valvular function remains unchanged. There is no evidence of aortic dissection. Brief Hospital Course: Upon finding the severe left main disease, emergent revascularization was undertaken. He went to the Operating Room where quadruple bypass grafting was performed. He weaned from bypass on Vasopressin, NeoSynephrine and Propofol. He did well, extubating and weaning from Vasopressin the day of surgery. NeoSynephrine weaned over the next 24 hours. A Lasix infusion was begun and he responded with a brisk diuresis. Beta blockade was also started. CTs were removed per protocol as were temporary pacing wires. On POD 4 he transferred to the step down unit, where diuresis was continued and beta blockade titrated as he remained tachycardic. Physical Therapy worked with him for mobility and strength. He did well and on POD 6 was ready for transfer to rehabilitation for further recovery. Arrangements were made for follwo up and medications and restrictions are as noted elsewhere. He was discharged [**Hospital6 1643**] Center. Medications on Admission: CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 (One) Tablet(s) by mouth once a day First dose 300 mg then 75 mg daily ISOSORBIDE MONONITRATE - 30 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day LEVOTHYROXINE - (Prescribed by Other Provider) - 100 mcg Tablet - 1 (One) Tablet(s) by mouth once a day LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg Tablet - 1 (One) Tablet(s) by mouth as needed METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once a day NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1 (One) Tablet(s) sublingually As needed as needed for chest pain Take one SL NTG for chest pain. [**Month (only) 116**] repeat iafter 5 minutes x2, call 911 if pain persists after 3rd pill TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 5 mg Tablet - [**12-29**] Tablet(s) by mouth at bedtime Discharge Medications: 1. flu vaccine [**2148**] (36 mos+)(PF) 45 mcg (15 mcg x 3)/0.5 mL Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One Dose). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. 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* 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. 13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. 14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: unstable angina Bicuspid aortic valve. s/p emergency coronary artery bypass grafts anxiety/depression prostate cancer gastroesophageal reflux Pectus excavatum. anal cancer [**2125**] (s/p chemo and radiation therapy) iron deficieny anemia hypothyroidism basal cell cancer of the face Discharge Condition: Alert and oriented x3, nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainageleg(left) clean and dry. healing well Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) 914**]([**Telephone/Fax (1) 170**]) on [**2150-3-30**] at 1:30pm Cardiologist :have Dr [**Last Name (STitle) 6420**] recommend one Please call to schedule the following: Primary Care:Dr.[**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 6420**] ([**Telephone/Fax (1) 5723**]in [**4-2**] 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:[**2150-3-5**]

[ "530.81", "305.1", "788.20", "V15.3", "300.00", "V10.83", "244.9", "414.01", "414.2", "754.81", "411.1", "746.4", "311", "185", "V87.41", "280.9", "V10.06" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8765, 8848

5397, 6336

330, 490

9176, 9372

2520, 5374

10160, 10811

1788, 1806

7386, 8742

8869, 9155

6362, 7363

9396, 10137

1821, 2501

268, 292

1669, 1772

518, 1176

1198, 1440

1456, 1652

20,711

150,175

3245

Discharge summary

report

Admission Date: [**2185-2-7**] Discharge Date: [**2185-2-21**] Date of Birth: [**2104-5-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Diarrhea/AMS Major Surgical or Invasive Procedure: PICC line placement Blood transfusions History of Present Illness: Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with a h/o colon cancer s/p hemicolectomy, bladder cancer s/p ureterostomy, HTN, & CKD who presents to the [**Hospital1 18**] after 2 days of diarrhea. The patient lives alone and today, he was found in bed covered in feces & complaining of rectal pain. Per report, he was discharged from [**Hospital6 **] in [**Month (only) 404**] after a GIB requiring multiple units of blood. As part of his work-up, he was found to have metastatic disease in the liver of unknown primary on CT and ERCP confirmed an ulcerated necrotic mass. A biliary stent was placed as part of his treatment and he was discharged on Cefpodoxime to complete treatment on [**12-22**]. His interval history is unclear, but he presents today with two days of diarrhea, described as watery, "constant," and without melena/hematochezia. In the ED, initial VS were: T98.8 P115 BP111/63 R20 O2 Sat 100%RA. There, the patient denied F/C/N/V, CP, SOB, abdominal pain, and was without diarrhea. Labs revealed a WBC of 15.9 and a serum lactate of 6.0. He received IV Vancomycin & Zosyn as well as 2u pRBC's and 3L NS, but he remained persistently tachycardic with hr's in the 100's. A CT abdomen/pelvis demonstrated constipation so he was disimpacted 700-800cc of guaiac positive brown stool. He was noted to have some minor skin irritation around the anal verge. At the end of the disimpaction, blood clots were noticed among the stool. A repeat lactate was 3.9. At the time of transfer, patient's VS were: T98.6 P120 BP126/74 R24 O2Sat 99% on RA. On the floor, patient is alert, but mildly uncooperative, denying any pain. Past Medical History: #. Saddle pulmanary emboli [**2181-12-3**] s/p IVC filter. - warfarin therapy eventually discontinued secondary to SDH [**7-/2182**] #. Left acoustic neuroma s/p XRT, left cerebello-pontine angle mass still present on subsequent imaging, stable since [**2173**] #. colon cancer (per chart, initially dx in [**2172**] with resection), per daughter was dx in [**12-9**] (GIB while on coumadin), underwent hemicolectomy [**1-9**] with primary reanastomosis. no adjuvant chemo/xrt. note, path 13.X6cm mass, adenoca. Margins clear BUT 2 of 18 LN examined were +cancer (T3N1). #. Bladder cancer s/p bladder resection [**2166**] s/p ureterostomy #. recurrent UTIs #. lower back pain: L3-4 disc bulging, had admission in [**2178**] for inability to walk #. Severe DJD #. HTN #. OSA #. Iron deficiency Anemia #. Hyperlipidemia # CKD, creat has been around 2.0 since [**11-8**], previously was 1.1, unclear etiology and was never worked up. Social History: Patient lives independently in apartment with 24 hour personal care attendants. Per his family, he is alert & oriented x 1 at baseline. He has 2 daughters that live nearby. Patient quit smoking more than 35 yrs ago after smoking about 15 pack-yrs. Rare alcohol use. No illicit drug use. Family History: No family history of premature coronary artery disease, sudden cardiac death, thyroid disease, colon cancer, diabetes, or hypertension. Physical Exam: Vitals: T: 99.8 BP: 93/48 P: 58 R: 20 O2: 98%RA General: Alert & oriented to self only, lying in bed, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding, but large ventral hernia with urostomy located just inferior to the umbilicus with yellow urine draining into the ostomy bag. Ostomy site is pink without exudate. Rectal: mild erythema around the anal verge, no ulceration Ext: cool, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2185-2-6**] 07:40PM CBC: WBC-15.9*# RBC-3.14*# Hgb-6.6*# Hct-23.4*# MCV-75*# MCH-20.9*# MCHC-28.1*# RDW-16.2* Plt Ct-441* Diff: Neuts-84.9* Lymphs-11.4* Monos-3.5 Eos-0 Baso-0.1 Coags: PT-14.1* PTT-23.5 INR(PT)-1.2* Chesmistries: Glucose-195* UreaN-62* Creat-1.6* Na-134 K-5.3* Cl-102 HCO3-17* AnGap-20 ALT-74* AST-71* AlkPhos-442* TotBili-0.4 Lipase-75* LD(LDH)-1163* Albumin-2.6* Calcium-7.7* Phos-2.5* Mg-2.1 freeCa-1.14 Iron Studies: Iron-18* calTIBC-346 Ferritn-72 TRF-266 Lactate Trend: [**2185-2-6**] 07:56PM BLOOD Lactate-6.0* [**2185-2-6**] 08:38PM BLOOD Lactate-6.3* [**2185-2-7**] 02:00AM BLOOD Lactate-3.9* [**2185-2-7**] 05:55AM BLOOD Lactate-2.5* Micro: **FINAL REPORT [**2185-2-8**]** MRSA SCREEN (Final [**2185-2-8**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS Blood Culture, Routine (Final [**2185-2-12**]): ENTEROCOCCUS SP.. UNABLE TO FURTHER SPECIATE. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVE TO Daptomycin AT 0.50 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML ________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ <=0.5 S Imaging: CXR [**2185-2-7**]: SINGLE AP VIEW OF THE CHEST: Lung volumes are low, with linear opacities at the lung bases consistent with atelectasis. The cardiomediastinal silhouette is unchanged, with a tortuous aorta and mild cardiomegaly. There is no hilar or mediastinal enlargement. Pulmonary vascularity is normal. IMPRESSIONS: Bibasilar atelectasis, without other acute cardiopulmonary abnormality. CT A/P [**2185-2-6**]: 1. Moderate pneumobilia with CBD stent in place, extending from mid CBD into the duodenum. Wall thickening and inflammatory changes in the second portion of the mediastinum, likely related to ERCP. No abnormalities of the pancreas noted on non-contrast CT. 2. Rectum distended with fecal matter, likely impacted, with wall thickening and inflammatory change of the distal rectum. 3. Large hypodense masses within the liver, incompletely characterized but concerning for metastases. 4. 3.4 cm soft tissue densities in the mesentery adjacent to the duodenum and pancreatic head, mass or enlarged lymph nodes. 5. Extensive atherosclerotic disease. 6. Bilateral hydroureter, with dilation of the ileal conduit to the level of the the abdominal wall hernia; unchanged from prior exams. 7. Severe degenerative disease. [**2185-2-17**] Lower Extremity Doppler: No evidence of left lower extremity deep vein thrombosis. [**2185-2-18**] TTE: No obvious vegetations seen, but very limited image quality [**2185-2-20**]: Abd Ultrasound: Diffusely heterogeneously echogenic liver with multiple areas of hypoechogenicity, concerning for diffuse metastatic disease Brief Hospital Course: Mr. [**Known lastname 15138**] is an 80 year old Russian-speaking man with h/o multiple malignancies (bladder, colon, acoustic neuroma), chronic kidney disease, hypertension, new ampullary adenocarcinoma, and recent dx of metastatic disease of unknown primary who presented to the [**Hospital1 18**] with diarrhea and enterococcal bacteremia. # Septic shock: Patient initally admitted to the ICU and required IVFs along with peripheral vasopressors. [**12-6**] blood cultures grew enterococcus sensitive to ampicillin and vancomycin. He was initially treated with broad spectrum antibiotics but eventually narrowed to ampicillin. Because the patient refused to take PO antibiotics, he was given IV ampicillin. At time of discharge, he was on IV ampicillin (10 days) without any other positive blood cultures. It was thought that his bloodstream infection may have originated in his biliary tree vs a GI source. As such, the plan at time of discharge was for a total 3 week course (10 days after discharge). The family declined a EGD/[**Last Name (un) **] to evaluate for a definitive source of his bacteremia. He did undergo a TTE [**2-18**] which was unremarkable but a poor study. It was felt that the patient would be unable to tolerate TEE with a low clinical risk of endocarditis. # GI bleed/Iron deficiency Anemia: Patient has a baseline Hct in low-30's & MCV in mid-70's since [**2181**] by OMR records. On admission patient with Hct below baseline to 23.4 and manual disimpaction revealed blood clots concerning for GI bleed. Patient was tranfused 1U PRBC and his Hct increased appropriately. EGD was planned, but later it was decided that an EGD was not needed given his goals of care, and overall prognosis. On the floor, he had guiaic positive stools but no frank blood per rectum. He was given 2 more units of PRBC and his hematocrit was stable at 30 at his time of discharge. # Malignancies: Patient with history of multiple malignancies including bladder, colon, and acoustic neuroma, now with report of an ulcerating necrotic mass seen on ERCP at OSH and a CT torso demonstrating multiple liver lesions, a large pericardial effusion, and stranding around the 2nd portion of the duodenum. New lesion is an ampullary adenocarcinoma per [**Hospital3 **] hospital records. Given prognosis of metastatic cancer, a family meeting was held in which the family decided to make the patient DNR/DNI with limited intervention, with the exception of antibiotic treatment for his presumed infection and pain control. Oncology was consulted but given his poor performance status and multiple other co-morbities, they did not feel that systemic chemotherapy would not be recommended. Patient is at risk for additional biliary obstructions as well as possible bowel obstructions and additional metastasis. He is also at risk of infection from cholangitis. They express that they would like the best quality of life for him, minimizing in invasive procedures. The goal would be to get his to rehab with antibiotics and see how he does clinically. Patient's family is interested in hospice for symptoms control and will readdress depending how he does. # AVNRT: Several episodes of AVNRT to HR 170s with BP 80-90s/50s-60s was noted when patient was sleeping. These arryhthmias were not responsive to vagal maneuvers but broke with 6mg IV adenosine each time. Patient was put on metoprolol but continued to experience episodes of AVNRT. A CCB was added with good effect. # Decreased Hearing: Patient has history of L acoustic neuroma and bilateral cerumen plugs likely contributing. Carbamide peroxide otic drops bilaterally was given twice a day. # Chronic Kidney Disease: Unknown etiology of CKD, but may be secondary to history of bilateral hydronephrosis. Baseline Cr 1.2-1.4. Medications were renally dosed. A Cr on admission was 1.6 and is 1.2 upon discharge. # Dementia: At baseline, patient A&O x 1 and requires 24 hour assistance for all of his ADL's at home. His family reported that his mental status during this hospitalization is consistent with his baseline. # Recurrent UTI: Patient is status post ureterostomy for bladder cancer in [**2166**] leading to frequent UTI's due to various pathogens resistant to Cipro/Bactrim/Gent/Unasyn. On admissions, UA was negative and patient had no urinary symptoms. # Hyperlipidemia: Diagnosis on online medical records, but patient not on medications at home. # OSA: Diagnosis on online medical records, but patient does not use CPAP at home. Medications on Admission: Lopressor 25mg PO BID Discharge Medications: 1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. 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. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itchiness. 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for sbp < 100, HR < 55. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for SBP < 100, HR < 55. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 10. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for rectal pain. 11. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: Enteroccoccal Bacteremia Cholangitis Dementia Hearing Loss Hemorroids AVNRT Secondary: Ampullary Adenocarcinoma Metastatic Disease of the liver Discharge Condition: Mental Status: Confused - always Level of Consciousness: Alert and interactive Activity Status: Bedbound Discharge Instructions: You were admitted to the hospital for diarrhea and changes in your thinking. You were in the intensive care unit (ICU) when you were first admitted to the hospital. You were given antibiotics and found to have a bacteria called enterococcus in your blood. This went away with antibiotics. Since you did not want to take oral antibiotics, a PICC line was placed. You have 9 more days of ampicillin antibiotics left to complete your course (last dose [**2185-3-2**]). Because bacteria were found in your blood, you had a TTE (an ultrasound of your heart) to look for infection on the heart valves. There was no infection seen on the heart valves. You also developed painful hemorrhoids which improved with steroid cream. You were given blood transfusions for a falling blood count. Given the slow decline of your blood count, this may be partially a result of frequent blood draws. There was some microscopic blood in your stool as well and you may be losing some blood in your stool. Given that you had no active signs or symptoms of rapid blood loss you were given transfusions as needed. It was felt that further testing would be harmful to your health. Your heart rate was very fast several times while you were in the hosiptal. You were given meds to control your heart rate. Followup Instructions: Please follow up with Dr [**Last Name (STitle) 3357**] by calling his office at [**Telephone/Fax (1) 4606**]. Completed by:[**2185-2-25**]

[ "564.09", "389.9", "V15.3", "038.0", "427.89", "197.7", "785.52", "995.92", "V10.51", "V10.05", "V12.04", "156.2", "V45.72", "294.8", "576.1", "280.0", "423.9", "403.90", "578.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13332, 13404

7541, 12045

325, 366

13602, 13602

4202, 4202

15040, 15181

3330, 3468

12117, 13309

13425, 13581

12071, 12094

13733, 15017

3483, 4183

273, 287

394, 2053

4218, 7518

13617, 13709

2075, 3009

3025, 3314

6,179

125,401

4715

Discharge summary

report

Admission Date: [**2149-6-17**] Discharge Date: [**2149-6-18**] Date of Birth: [**2099-6-20**] Sex: F Service: MEDICINE Allergies: Latex / Nsaids Attending:[**First Name3 (LF) 2763**] Chief Complaint: Hyperglycemia, Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 46 year old lady wi with PMH of Type I DM and malignant melanoma who presented to the ED with hyperglycemia and abdominal pain. She reports that when she awoke this morning she was not feeling her usual self and found her blood sugar to be in the mid 400s. She took her insulin per her regular pump indications for sliding scale but on serial rechecks her BS were persistently in the 300s. Over the course of the day she slowly developed epigastric abdominal pain associated w/ nausea and ultimately emesis. She denied fevers, chills, cough, or diarrhea. In the ED, initial VS were: 98.0 112 95/47 18 98%. Initial labs were significant for WBC 22.4, Hct 46, Cr 1.1, K+ 5.2, Hc03 11, glucose of 547 and lactate of 4.4. In the setting of abdominal pain on exam and leukocytosis, a CT abdomen and pelvis was performed with contrast which ruled out on preliminary read an acute process. For her anion gap acidosis she was started on an insulin gtt for treatment of DKA and given IVF 4L NS and started on vancomycin and zosyn for her elevated lactate. A repeat lactate decreased to 3.0. An VBG 7.19/32/49. A chest xray was clear. Blood cultures were drawn. Vitals on transfer were. On arrival to the MICU, pt was stable with VS: 98.6 113 108/49 100% RA 18. Past Medical History: 1) T1DM: Seen at [**Last Name (un) **] in [**Location (un) 577**] by Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **]. Diagnosed [**2125**] at age 26. Has insulin pump and checks BS tid. Had dilated eye exam [**8-17**]. +h/o progressive retinopathy. Last seen by podiatry [**1-17**]. Last known A1c: 9.1 in [**4-19**] 2) Focal nodular hyperplasia, followed with serial U/S by [**Hospital **] clinic 3) h/o malignant melanoma, [**Doctor Last Name 10834**] level IV, dx [**2135**], left upper arm, s/p wide excision and negative sentinel node biopsy, no further tx. Had second primary [**Doctor Last Name **] level IV in [**2138**], s/p wide excision with no sentinel node procedure. 4) Anticardiolipin Ab 5) HTN 6) h/o vitreal hemmorhage 7) h/o chronic sinusitis, seen by ENT over last year 8) migraine headaches 9) LBP with disc herniation L5-S1, with compression of L S1 root 10) Infertility, s/p intrauterine fertilization 11) Fibroid uterus Social History: - Tobacco: none - Alcohol: occasional - Illicits: none - housing: married lives w/ 1 child Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.6 BP:108/49 P:113 R:18 O2: 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE PHYSICAL EXAM: Vitals: T: 98.6 BP:112/51 P:101 R:18 O2: 100% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Admission: [**2149-6-17**] 12:03AM GLUCOSE-547* UREA N-22* CREAT-1.1 SODIUM-134 POTASSIUM-5.2* CHLORIDE-92* TOTAL CO2-11* ANION GAP-36* [**2149-6-17**] 12:03AM WBC-22.4*# RBC-4.95 HGB-15.0 HCT-46.8 MCV-95 MCH-30.3 MCHC-32.0 RDW-12.8 [**2149-6-17**] 12:03AM NEUTS-85.9* LYMPHS-12.1* MONOS-1.3* EOS-0.2 BASOS-0.5 [**2149-6-17**] 12:20AM LACTATE-4.4* [**2149-6-17**] 01:45AM LACTATE-3.0* [**2149-6-17**] 03:17AM TYPE-[**Last Name (un) **] PO2-49* PCO2-32* PH-7.19* TOTAL CO2-13* BASE XS--14 COMMENTS-GREEN TOP Discharge: [**2149-6-17**] 07:01AM BLOOD WBC-15.5* RBC-4.07* Hgb-12.3 Hct-36.6# MCV-90 MCH-30.1 MCHC-33.5 RDW-12.5 Plt Ct-294 [**2149-6-17**] 07:01AM BLOOD Neuts-72.5* Lymphs-22.9 Monos-3.9 Eos-0.3 Baso-0.5 [**2149-6-18**] 03:01AM BLOOD Glucose-99 UreaN-14 Creat-0.6 Na-139 K-4.1 Cl-111* HCO3-20* AnGap-12 [**2149-6-18**] 03:01AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.8 Brief Hospital Course: This is a 46 yo lady with PMH of Type I DM and malignant melanoma who presents with an anion gap acidemia in the setting of elevated lactate and glucose in addition to a leukocytosis of unclear source. # Metabolic Acidemia: Pt had AG metabolic acidosis upon arrival to MICU, most likely [**2-13**] to DKA considering history of uncontrolled blood glucose. AG metabolic acidosis could also be [**2-13**] lactic acidosis given her elevated lactate of 4.4 (now downtrending to 3.0). Her elevated lactate may be associated with pt's DKA or associated with potential toxic ingestion of salicylates (pt currently taking Aspirin). Given that bicarb may worsen the hypokalemia and hyperosmolarity observed in DKA, bicarbonate was avoided in empiric treatment of lactic acidosis. Patient's lactate stabilized during hospitalization. Repeat ABG showed resolution of acidemia. Patient received aggressive fluid resuscitation with D5 NS + K. Patient was restarted on insulin drip and converted to insulin sliding scale per recommendation from [**Last Name (un) **] Endocrinology. # Hyperglycemia/Insulin Dependant Diabetes: Pt had a blood glucose of 547 upon transfer to the MICU as well as an AG of 36. [**Last Name (un) **] Endocrinology found that the patient's insulin pump was malfunctioning and the likely cause of this episode of DKA. #Leukocytosis: The patient was admitted with an elevated WBC of 22.4. The patient had no clear source of infection (clinically afebrile with negative blood cultures and negative abdominal CT and CXR). Leukocytosis was most likely in association with DKA. During the patient's hospitalization, her WBC downtrended. #HYPERLIPIDEMIA: Patient was continued on home dose of simvastatin. #HTN: Patient was continued on home moexipril. . =================== TRANSITION OF CARE: - Pt had leukocytosis during hospitalization, no suspected infectious focus: please recheck CBC at PCP appointment, and follow up blood cultures - Pt needs more diabetes education (possibly reusing lancets for fingersticks) Medications on Admission: INSULIN PUMP (HUMALOG INSULIN) MOEXIPRIL [UNIVASC] - 15 mg Tablet - 1 Tablet(s) by mouth once a day SIMVASTATIN ASPIRIN [BABY ASPIRIN] MULTIVITAMIN WITH MINERALS PYRIDOXINE [VITAMIN B-6] Discharge Medications: 1. moexipril 15 mg Tablet Sig: One (1) Tablet PO once a day. 2. Insulin Pump IR1250 Misc Sig: humalog insulin Miscellaneous as directed: humalog insulin pump per previous home regimen. 3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. simvastatin Oral 6. pyridoxine Oral Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 19849**], It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with high blood sugars (diabetic ketoacidosis). You were started on an insulin drip to treat your high blood sugars. You also received IV fluids because you were dehydrated and to fix your electrolyte imbalance. Your white blood cell count was also higher than normal, but we found no sign of infection and your white blood cell count has decreased over the past two days. You were seen by [**Last Name (un) **] who examined your insulin pump and found that your pump was malfunctioning, and because you were not receiving insulin, your blood sugars were high. . Please attend the follow up appointments listed below with your primary care doctor and your [**Last Name (un) **] Diabetes physician. . We did not make any changes to your home medications. Please continue taking them as you were prior to hospitalization. Per your endocrinologist, your Pump Basal/I:[**Doctor Last Name **] insulin plan is: Home pump settings (units/hr): Midnight 1 5am 1.8 7am 1.4 10a 0.8 12p 0.6 6p 0.6 Insulin drip @ 1.5 units/hr. I:[**Doctor Last Name **]-- 1:11g breakfast, 1:10g lunch, 1:8g dinner Followup Instructions: Please attend the follow up appointments listed below with Department: Primary Care/ [**State **]When: FRIDAY [**2149-6-27**] at 10:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: Endocrine/ [**Last Name (un) **] Diabetes Center When: Friday [**2149-6-20**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], Nurse Practitioner Phone: ([**Telephone/Fax (1) 19850**] Address: One [**Last Name (un) **] Place, [**Location (un) 86**], [**Numeric Identifier 718**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2149-6-18**]

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icd9cm

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icd9pcs

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24143

Discharge summary

report

Admission Date: [**2169-10-27**] Discharge Date: [**2169-11-1**] Date of Birth: [**2119-7-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1185**] Chief Complaint: COFFEE-GROUND VOMIT Major Surgical or Invasive Procedure: ENDOSCOPIC GASTRODUODENOSCOPY with biopsy History of Present Illness: 50M with history of heavy ETOH use, Meniere's disease, psychiatric history including panic disorder, depression & anxiety, presented 2d ago with hematemesis, RUQ & R-sided chest pain, and intoxication after binge drinking. Binge drinks on vodka 1/5 L at a time, recurrent admissions for withdrawal management and detox. 3 days ago he started having severe RUQ pain, non-radiating, exacerbated by movement and eating, no known alleviating factors. Started vomiting 2 days PTA; vomiting progressively increasing frequency until admission. Vomiting intermittently streaked w/black blood. ROS positive for mild, productive cough x1 week & gradual weight loss x 2 years, negative for F/C. . Substance abuse history includes 30 yrs heavy drinking, several admissions for ETOH withdrawal, hx attending dual diagnosis detox programs, 2 withdrawal seizures (one at home, one while hospitalized). Past ICU admissions for DTs. Longest sober period was 5 years ([**2155**]-[**2160**]). Cocaine and marijuana use in the past, not currently using. . In the ED, initial VS were: 140 132/90 16 95%. Coffee ground emesis witness in the ED but unknown volume. RUQ US negative for cholecystitis. CXR showed RLL opacity, slightly more dense than prior. Labs notable for leukocytosis WBC 13 (w/ 87.4% PMN no bands), ETOH 202, plt 105, HCT 38 -> 33. Total 3L IVF received, no blood products given. Received diazepam 10mg x2, Ativan 2mg x2, morphine 4mg x1, PPI bolus/gtt, and zofran. Despite benzodiazepines, he remained tachycardic and tremulous. 2 large bore PIVs placed. . In the MICU over the past 2d he was retching frequently. No further hematemesis, but he did receive benzos on CIWA for tremor, anxiety & tachycardia. Reported similar vomiting episodes have occured with Meniere's disease flares previously. C/o persistent RUQ pain. He received IVF for low uop. . He has been followed in the MICU by GI who initially recommend EGD but delaying until patient no longer retching and withdrawing from ETOH. Suggested NGT placement (not done), antiemetics (on compazine), PPi drip, and transfusion for Hct <25. Hct stable >25 x3 today. When rectal exam showed guaiac positive brown stool, GI concluded no indication for EGD. CT chest showed R rib fracture (minimally displaced ninth and nondisplaced eighth). Also increased RLL opacity on CXR read as worsening atelectasis. Prior to MICU callout his benzos were decreased to q4H and diet advanced to clears. On the floor pt reports no appetite. Focused on R-sided chest pain where he says he has multiple rib fractures he suspects he sustained during his recent bender but cannot remember specifically. We note that although he reported suicidality w/plan (heroin o/d) during another recent admission, he denies suicidality at present. Past Medical History: Past Medical History: - COPD - Meniere's disease - diagnosed in [**2165**], has not followed up with outpatient care - Hypothyroidism - Hx of Borderline HTN - History of frostbite to bilateral toes ("my toes turned black") Past psychiatric history: -Diagnoses: Depression, anxiety, panic disorder -Hospitalizations: [**Hospital1 **], [**Location (un) **] , [**Hospital3 **]. Numerous detoxes ([**Location (un) 22870**], [**Location (un) 3244**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). Thinks last inpatient psych was [**Hospital1 **] 4 11/[**2168**]. -SA/SIB: Denies -Violence: Denies -Therapist: [**Doctor First Name **] at [**Location 8391**] Behavioral Health until 2-3 months ago, when she fired him for coming to an appointment intoxicated. She now no longer works there. -Psychiatrist: Has been seeing someone at [**Location 8391**] BH Social History: He lives alone in an apartment in [**Location 8391**]. Divorced after he crashed 2 cars while intoxicated. He has been homeless in the past. Has been in jail for burglary and steeling whisky. He used to smoke 1-1.5 ppd (started smoking at age 10), but now smokes a few cig/day. He drinks daily ([**1-25**] vodka). He states the past 2 years have been very hard, mostly because of death of his sister. Family History: Father - alcoholism Mother - depression, anxiety, hospitalizations Two sisters - depression, anxiety, psych hospitalizations, EtOH. One sister died of cirrhosis, other is sober. Physical Exam: MICU ADMISSION EXAM VS: HR 108, BP 140/80s, 94% on 2L NC General: Alert, oriented, intermittently falls asleep during interview, slightly movement triggers wretching, came up from ED with emesis bin with approx 100 cc gastric contents with some red blood HEENT: Sclera anicteric, MMdry, no visible lice Neck: supple, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased breath sounds right base, otherwise no wheezes/rhonchi/rales Abdomen: soft, tender in RUQ to moderate palpation with voluntary guarding, no rebound, Skin: 1 cm blanching macules on abdomen Ext: warm, well perfused, 2+ pulses, no edema Neuro: CN2-12 intact, 5/5 strength, no sensory deficits . MICU->FLOOR TRANSFER EXAM VS 97.5 120/77 85 18 97/RA General: Alert, oriented, fatigued-appearing, not retching HEENT: NCAT EOMI sclera anicteric, MM dry, no visible lice Neck: supple, no LAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breath sounds R base & halfway up, R-sided chest wall tenderness to palpation, lidocaine patch in place, prominent wheeze throughout all lung fields Abdomen: soft, distended RUQ ttp +voluntary guarding, no rebound, Skin: 1 cm blanching macules on abdomen (c/w tinea versicolor) Ext: WWP, 2+ pulses, no edema Neuro: CN2-12 intact, 5/5 strength, no sensory deficits, +mild UE tremor R>L . DISCHARGE PHYSICAL EXAM VS 98.9 98.4 127/92 73 18 98/RA General: Alert, oriented, lying comfortably in bed HEENT: NCAT EOMI sclera anicteric MM dry no visible lice Neck: supple no LAD CV: RRR, normal S1/S2, no murmurs, rubs, gallops Lungs: decreased breath sounds R base, R-sided chest wall mildly tender to palpation, lidocaine patch in place, no wheeze Abdomen: soft, distended RUQ mildly ttp no guarding, no rebound, Skin: no rash Ext: WWP, 2+ pulses, no edema Neuro: CN2-12 intact, 5/5 strength, no sensory deficits, +mild UE tremor R>L Pertinent Results: ADMISSION LABS [**2169-10-27**] 05:52AM BLOOD WBC-13.5*# RBC-3.97* Hgb-13.0* Hct-38.8* MCV-98 MCH-32.6* MCHC-33.4 RDW-16.1* Plt Ct-140* [**2169-10-27**] 05:52AM BLOOD Neuts-87.4* Lymphs-7.4* Monos-4.0 Eos-0.9 Baso-0.3 [**2169-10-27**] 08:20AM BLOOD PT-12.3 PTT-22.4 INR(PT)-1.0 [**2169-10-27**] 05:52AM BLOOD Glucose-201* UreaN-25* Creat-0.8 Na-131* K-5.5* Cl-84* HCO3-23 AnGap-30* [**2169-10-27**] 05:52AM BLOOD ALT-40 AST-81* AlkPhos-50 TotBili-0.5 [**2169-10-27**] 05:52AM BLOOD Albumin-4.6 Calcium-8.4 Phos-4.2 Mg-2.0 [**2169-10-27**] 08:20AM BLOOD TSH-3.2 [**2169-10-27**] 08:20AM BLOOD Free T4-0.52* [**2169-10-27**] 05:52AM BLOOD ASA-NEG Ethanol-202* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-10-27**] 01:07PM BLOOD Lactate-1.6 . MICRO . [**10-27**] BLOOD CULTURES - PENDING [**10-31**] R ANTECUBITAL FOSSA WOUND CULTURE (FROM SITE OF PIV) - PENDING . PATHOLOGY . [**10-31**] GI BIOPSY - PENDING . IMAGING . RUQ US: No imaging signs of acute cholecystitis. No gallstones. Normal CBD. . CXR: The RLL opacity with chronic pleuroparenchymal scaring and calcifications has slightly increased over time. Chest CT might be considered for further work-up. Otherwise, the lungs are clear, the hila and cardiac shilhouette are normal and there is no pneumothorax. . CT chest/abdomen [**10-28**]: Increased right lower lobe opacity on chest radiograph likely reflects superimposition of bibasilar atelectasis upon the preexisting chronic changes in the basal right pleura. 2. Minimally displaced right ninth rib fracture and nondisplaced eighth right rib fracture. . CT HEAD [**10-29**] FINDINGS: No acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarction is seen. [**Doctor Last Name **]-white matter differentiation is preserved, with mild periventricular white matter hypodensity compatible with chronic small vessel ischemic disease. There is no shift of normally midline structures. The ventricles and sulci are mildly prominent, compatible with alcoholism, if diagnosed clinically. Mineralization is seen in the bilateral basal ganglia. There is no fracture. Imaged paranasal sinuses and mastoid air cells demonstrate minimal left maxillary mucosal thickening. IMPRESSION: No acute intracranial pathological process. . RUE DOPPLER ULTRASOUND [**10-31**] FINDINGS: The right and left subclavian vein are patent with normal color flow and symmetric waveforms with normal phasicity. The right internal jugular vein, subclavian vein, axillary vein, brachial and basilic veins demonstrate normal grayscale appearance, compressibility, color flow, and waveforms. At the antecubital fossa and just proximal to the antecubital fossa, there is echogenic clot distending the right cephalic vein which is noncompressible and has no color flow consistent with acute thrombus. Downstream, the right cephalic vein is patent (more proximally in the arm). IMPRESSION: 1. Partial thrombosis of the right cephalic vein at and just proximal to the antecubital fossa consistent with superficial thrombophlebitis. 2. No right upper extremity DVT. . EGD [**10-31**]: Ulcer in the gastroesophageal junction Erythema and congestion in the antrum and stomach body compatible with gastritis (biopsy) Otherwise normal EGD to third part of the duodenum Recommendations: Follow-up biopsy results Continue PPI daily. Gastritis likely [**2-22**] EtOH. Bleeding likely [**2-22**] clean-based esophageal erosion. Brief Hospital Course: 50 y/o w/ heavy ETOH use and depression/anxiety and panic disorder presented with coffee ground hematemesis and tachycardia, RUQ pain, found to have now-resolved UGIB and and R rib fractures. . #Alcohol Abuse/Withdrawal ETOH 202 on admission. Noted pt's hx of multiple presentations for detox. Current psychiatric/social issues likely barrier to ETOH cessation. Initially scored on CIWA for tremor, anxiety, nausea/vomiting, received valium initially q1H then spaced out. No DTs, no seizure, no hallucinations. No benzodiazepines received in last 4d prior to discharge. Patient reports that his post-dc plan is to return home and try to stay sober again, has an AA sponsor. Very high risk of recurrence esp given that this plan as it has failed him repeatedly in the past. Followed by social work. . #Upper GI Bleed Presented w/coffee-ground emesis. Initial ddx included gastritis/esophagitis, MW tear and/or PUD. Unknown amount of blood loss; Hct trending down from 38.8 on admission to a nadir of 25.8 one day later. Coffee-ground emesis also witnessed directly in the ICU. EGD initially deferred until patient was no longer actively withdrawing from alcohol; once he was stable, an EGD was performed which showed only a clean ulcer near the G-E junction, no active bleeding. Hct self-resolved and trended upward, Hct 34.7 upon discharge. No blood transfusion. We note here that we also suspected esophageal varices from presumed underlying alcoholic cirrhosis given years of heavy ETOH, but imaging showed no signs of cirrhosis and EGD revealed no varices. . #Recurrent vomiting Patient was actively retching in ED and MICU. This was thought to be [**2-22**] known Meniere's disease and alcohol withdrawal. Patient reported symptoms as similar to prior flares of his Meniere's. Resolved after 2d, concurrent with cessation of withdrawal symptoms but also received meclizine and PRN compazine. We also investigated possible head injury given rib fractures, but head CT showed no intracranial bleed nor signs of head trauma. . #Traumatic R rib fractures Patient reported R-chest pain and RUQ abdominal pain. No memory of trauma while intoxicated, but imaging showed new 8th and 9th R rib fractures. RUQ US and CT torso negative for other pathology. Pain initially treated with oxycodone which was weaned. Continued to receive tylenol PRN and daily lidocaine patch. CT chest/head negative for other injuries. . #RLL opacity Patient has chronic inflammation and scarring of his RLL [**2-22**] an old stab wound. CT torso showed increasingly dense effusion overlying this site, which could have represented pneumonia, effusion, or atelectasis. He has history of smoking and COPD. No leukocytosis or fever. Chest CT read as increasing bibasilar atelectasis superimposed on the chronic RLL plaque. No oxygen requirement. No sputum cultures sent. No antibiotics given. Initial leukocytosis (likely inflammation [**2-22**] rib fractures) self-resolved. . #Mild transaminitis RUQ US shows only fatty liver, no cirrhosis, not suggestive of cholecystitis or free RUQ fluid. Lipase wnl. CT abdomen showed normal liver, GB, and pancreas. LFTs only very mildly elevated in non-obstructive pattern. Chronic alcoholism and recent "bender" likely inflammed chronically-challenged liver. LFTs trended down towards wnl prior to discharge, and patient had no further abdominal pain, only reproducible R chest wall pain at rib fracture sites, as above. . #Thrombocytopenia He presented w/thrombocytopenia new since 1 month ago, although review of older labs shows prior episodes of thrombocytopenia too. Considered whether it might be due to underlying liver dysfunction, but INR was normal. No evidence of DIC/TTP or other consumptive process. Hemolysis labs negative. No clear history of HIT. Heparin was avoided. Platelets improved to wnl after UGIB resolved. . #COPD Chronic. We noted wheezing on exam despite Spiriva QD and albuterol nebs Q6H. Temporarily given q8H iprotoprium and q4H albuterol nebs until wheezing resolved, then restarted on home tiotoprium QD. RR and O2 sat remained >95%/RA throughout admission. . #Lice Treated with lindane shampoo in ED and permethrin in the MICU. Contact precautions maintained. No evidence of lice seen on the floor. . #Chronic hypothyroidism Patient takes synthroid at home, reportedly not fully complaint with medication when he is intoxicated. Labs showed TSH wnl, fT4 low. He was restarted on synthroid home dose 75 mcg QD. Will require outpatient follow-up for dose adjustment prn. . #Hx Depression/anxiety and panic disorder Longstanding. Likely contributing to ETOH dependence. Patient had been suicidal during recent admission but answered no to questions of current suicidal ideation during this admission. Denied depression and anxiety throughout this admission, and indeed he was very calm and well-appearing. He was continued on home citalopram. Did not re-start clonazepam at time of discharge given tendency toward addiction. . # TRANSITIONAL ISSUES I. Needs repeat chest CT in 3 months to monitor chronic changes in basal R pleura. II. Needs follow-up thyroid function testing in [**1-22**] months. III. Review biopsy results at GI appointment, eval any need for H pylori treatment. Medications on Admission: Of note, patient states he does not reliably take his medications while drinking ETOH 1. citalopram 40 mg daily 2. clonazepam 1 mg [**Hospital1 **] 3. omeprazole 40 mg daily 4. ferrous sulfate 325 mg daily 5. Spiriva daily 6. ProAir HFA 90 mcg/Actuation q4-6H PRN 7. folic acid 1 mg daily 8. thiamine HCl 100 mg daily 9. multivitamin daily 10. levothyroxine 75 mcg daily Discharge Medications: 1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: maximum 3 grams per day. Disp:*100 Tablet(s)* Refills:*0* 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain for 2 weeks: apply to right chest near rib fractures. Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0* 9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 10. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 11. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS UPPER GASTROINTESTINAL BLEED . SECONDARY DIAGNOSES GASTRIC ULCER GASTRITIS ALCOHOL DEPENDENCE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after vomiting blood. You were in the intensive care unit. We watched your blood counts, which normalized. We also did an endoscopy which showed a healed ulcer in your stomach and generalized stomach inflammation called gastritis. This, in combination with nausea and vomiting from drinking alcohol, caused you to bleed. Bleeding like this can be life-threatening. This is another important reason to stop drinking alcohol. . We treated you for alcohol withdrawal symptoms. You saw a social worker here to discuss your efforts to stop drinking. We support your effort to quit drinking, and encourage you to get help from your AA sponsor and physicians when you are struggling. . You had bad nausea and vomiting related to alcohol withdrawal and Meniere's disease. This stopped several days before you went home. . You were also treated for lice. . We also found that you had rib fractures, which were very painful. We treated you with tylenol, oxycodone, and lidocaine patch. Your pain was resolving before you left the hospital. . You developed a blood clot in a vein near your right elbow. This was not a large clot and not very deep, so it should resolve by itself. . We made the following changes to your medications: 1. STOPPED CLONAZEPAM 2. STARTED LIDOCAINE PATCH, APPLY 1 PATCH TO RIGHT CHEST ONCE PER DAY FOR TWO WEEKS. 3. STARTED MECLIZINE, TAKE TWO 12.5 MG TABLETS (25 MG TOTAL DOSE) THREE TIMES PER DAY FOR NAUSEA OR VOMITING ASSOCIATED WITH YOUR MENIERE'S DISEASE. 4. STARTED TYLENOL, TAKE TWO 325 MG TABS EVERY 6 HOURS AS NEEDED FOR RIB FRACTURE PAIN. MAXIMUM TYLENOL DOSE 3 MG PER DAY. . Please review the attached medication list with your primary care doctor at your next appointment. Followup Instructions: Follow-up appointments: . Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE Location: [**Hospital **] COMMUNITY HEALTH CENTER Address: 409 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**] Phone: [**Telephone/Fax (1) 6511**] Appointment: MONDAY [**11-6**] AT 12:10PM . Department: GASTROENTEROLOGY When: WEDNESDAY [**2169-11-15**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

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icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2198-11-20**] Discharge Date: [**2198-11-25**] Service: NEUR MED CHIEF COMPLAINT: Falling down with left-sided weakness. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old right-handed woman with history of atrial fibrillation, hypertension, high cholesterol, who was found unresponsive on the morning of admission by her son. She had been in her usual state of health the night before. He went to check on her in the morning around 8:00, and he found her in bed, not talking, with her eyes closed and moaning. He called the emergency medical service, who brought her to the emergency department. When first seen in the E.D., she continued to have her eyes closed with moaning, no response to verbal stimuli, would move all four extremities to noxious stimuli, but was thought to have a right eye deviation as well a left facial droop and a left hemiparesis. She was sent to the Neuro Intensive Care Unit overnight for blood pressure monitoring and was sent out to the neurology floor the next morning. She had a head CT on the day of admission because of her pacemaker, which showed evidence of atrophy and large ventricles with no evidence of an acute stroke. PAST MEDICAL HISTORY: Significant for coronary artery disease, abdominal aortic aneurysm repair, atrial fibrillation, hypertension, aortic valve replacement with porcine valve in [**2188**], CABG x3 in [**2188**], multiple stents to her coronary arteries, rheumatic fever, high cholesterol, dementia, status post pacemaker for sick sinus syndrome. There is no history of diabetes. MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg p.o. b.i.d. 2. Captopril 25 mg p.o. t.i.d. 3. Zantac 150 mg p.o. b.i.d. 4. Aspirin 325 mg p.o. q.d. 5. Lipitor 20 mg p.o. q.d. 6. Stool softener. 7. Digoxin 0.125 mg p.o. q.d. The patient in the past had been on Coumadin, however it was discontinued 1-1/2 years ago after multiple falls and a subdural hemorrhage. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives on her own in an apartment above her son, who visits her several times a day. He reports that she still drives, she cooks for herself, and he just checks on her multiple times a day. FAMILY HISTORY: Unknown. OBJECTIVE: At the time of admission, her blood pressure was 220/90. Later it went up to almost 250/118, heart rate was 78. She was satting 91% on room air with a respiratory rate of 18. She was afebrile. Generally, she was awake, alert, talkative, in no acute distress by the time she was transferred to the floor, however on initial admission she was lying in bed, would open her eyes spontaneously, would moan. HEENT exam was normocephalic, atraumatic with mucous membranes that are moist. Cardiovascular: Rate was irregularly irregular. Respiratory: Clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, with positive bowel sounds. Extremities: No edema. Warm feet bilaterally. Neurologically, the patient was uncooperative with motor exam, however she moved all four extremities. It was felt that the right upper extremity was weak. On her cranial nerve exam, pupils were reactive bilaterally with a right deviation of her eyes. Also she was noted to have a left facial droop. On motor exam she would withdraw her legs to noxious stimuli bilaterally. Her reflexes were 2+ and symmetric throughout with upgoing toes bilaterally. LABS ON ADMISSION: Her white count was 12, hematocrit 40, chem-7 was unremarkable. CK was 165 with an MB of 4, troponin of less than 0.3. Calcium 9.6, digoxin 1.0. UA was negative. EKG showed some T-wave inversions on anterolateral leads. HOSPITAL COURSE: 80-year-old woman found unresponsive with a possible right frontoparietal stroke with left face and arm weakness, as well as decreased alertness which had resolved by the morning after admission. She continued to be in atrial fibrillation throughout her hospital course. She had a repeat head CT which showed no evidence of subacute infarct. She was ruled out for myocardial infarction with consecutive cardiac enzymes. She continued to be very frontal after she woke up a bit. Her exam was notable for very colorful language, very emotional, she would be tearful at times and then laughing and joking, swearing. Quite often she was inattentive. Her speech would wander off the subject. She was not oriented to the hospital or the year at any time. She continually said it was [**2182**] or [**2189**]. She often thought she was at home, later she thought she was at a hotel. Her naming and repetition were intact. She could do days of the week backward with prompting. Her recall was 1 out of 3 immediately. She was very perseverative and unable to do 2-step commands. Also her left arm and face weakness had totally resolved by the time she arrived to the medical floor. Instead, there was noted to be a slight right facial droop. Her strength in her arms was full, as well as the strength in her legs, with no evidence of a drift. She had some agitation after receiving a dose of Ativan which made her sleepy and a little bit more confused for several days, however she was changed to Seroquel every night at 6:00 pm with significant improvement, decreased agitation during sleep as well as increased alertness during the day. She had an EEG which showed background rhythm which was slightly slow, as well as evidence of sleep, but no evidence of epileptiform activity. She did have some moderately high blood sugars, in the 160s and 170s, during admission, however the son denies that she has any history of diabetes. She will need to be followed up as an outpatient for evaluation of her glucose issues. Otherwise, the patient was observed in the hospital for several days with continued improvement in her mental status. The plan is to discharge her today. DISCHARGE DIAGNOSES: 1. Dementia. 2. TIA. 3. Atrial fibrillation. 4. Status post CABG. 5. Status post aortic valve replacement, porcine valve. 6. High cholesterol. 7. Hypertension. DISCHARGE MEDICATIONS: 1. Captopril 75 mg p.o. t.i.d. 2. Atenolol 100 mg p.o. b.i.d. 3. Lipitor 20 mg p.o. q.d. 4. Seroquel 25 mg p.o. q. 6:00 pm. 5. Digoxin 0.125 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. and 325 mg to 650 mg q.4-6h. p.r.n. 7. Colace 100 mg p.o. b.i.d. [**Last Name (LF) **],[**First Name3 (LF) **] 13.140 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2198-11-25**] 11:49 T: [**2198-11-25**] 11:20 JOB#: [**Job Number 106276**]

[ "427.31", "414.01", "V45.81", "V45.01", "V42.2", "272.0", "435.9", "401.9", "290.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2221, 3409

5873, 6041

6064, 6535

1615, 1994

3667, 5852

112, 152

180, 1207

3424, 3649

1229, 1589

2010, 2205

21,358

144,899

45414

Discharge summary

report

Admission Date: [**2185-7-4**] Discharge Date: [**2185-7-21**] Date of Birth: [**2133-4-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Cowden's disease Major Surgical or Invasive Procedure: Total colectomy End ileostomy Sigmoidoscopy History of Present Illness: 52 M with h/o COwdens disease, with stabbing pain in his belly. This patient was status post right colectomy with ileal transverse anastomosis and presented with multiple polyps in his colon, some of which had dysplastic features and he was diagnosed with Cowden's syndrome. Preoperatively his options were explained and he was recommended to undergo a panproctocolectomy with ileostomy. Past Medical History: DM Osteoarthritis GERD Cowden's Manic/depression Appy Multiple polyps. Social History: quit tobacco in [**2178**] quit recreational druc use in [**2178**] no h/o of EtOH Pt lives with his 76 yo Mother. Family History: noncontributory Physical Exam: 97 84 20 121/666 97%ra NAD, healthy appearing. RRR, CTA B/L. Healed upper transverse abdominal incision. Rectal exam revealed normal anus, anal verge, sphincter tone, and mucosa without palpable mass. Pertinent Results: [**2185-7-17**] 05:24AM BLOOD WBC-17.5* RBC-3.78* Hgb-10.6* Hct-30.3* MCV-80* MCH-27.9 MCHC-34.8 RDW-15.0 Plt Ct-296 [**2185-7-12**] 06:08AM BLOOD WBC-39.2*# RBC-4.89 Hgb-13.5* Hct-39.0* MCV-80* MCH-27.6 MCHC-34.6 RDW-15.0 Plt Ct-369# [**2185-7-17**] 05:24AM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-135 K-4.2 Cl-99 HCO3-23 AnGap-17 [**2185-7-12**] 06:08AM BLOOD Glucose-172* UreaN-52* Creat-2.3* Na-132* K-3.7 Cl-98 HCO3-16* AnGap-22* [**2185-7-5**] 05:50AM BLOOD Glucose-134* UreaN-13 Creat-1.0 Na-142 K-4.9 Cl-107 HCO3-24 AnGap-16 [**2185-7-15**] 05:16PM BLOOD ALT-16 AST-16 LD(LDH)-181 AlkPhos-89 Amylase-157* TotBili-0.6 [**2185-7-18**] 07:38AM BLOOD Lipase-376* [**2185-7-15**] 05:16PM BLOOD Lipase-483* [**2185-7-19**] 08:57AM BLOOD Phos-2.9 Mg-2.1 Brief Hospital Course: The patient was taken to the OR on [**2185-7-4**] for a Panproctocolectomy with ileostomy with extensive lysis of adhesions. He tolerated the procedure well, there were no complications, and he was transfered to the floor from the PACU. Late on the post-operative night, the patient has an episode of aggitation, confusion, and paranoia which responded to Ativan. He was also started on thiamine and B12. POD 1 his PCA was stopped secondary to patient lacking the understanding to use it despite repeated teaching. IV morphine PRN provided good pain control. POD 3 bowel fuction was beginning and the patient started on sips/clears. Patient continued to have episodes of confusion, aggitation, and paranoia. POD4 he was advanced to full liquids, po main meds, and foley removed. He was doing well and screened for rehab. However on [**7-11**], the patient had changes in mental status, high stoma outpoint, tachycardia, SBP in the 90's, K 3.0, and nl ABG. Electrolytes several hours later showed Cr 2.2 (from 1.2), K 3.6, and Na 132 (from 136). The patient continued to be aggitated now with poor urine output. He was transfered to the ICU with ARF for CVl and CVP monitoring. He was treated with aggressive fluid hydration and replacement of the stoma output. He soon developed an elevated WBC and ileus, was pan cultured and placed on triple antibiotics. An inpatient psychiatric consult was obtained reccomending continuing to hold home meds and the use of haldol with ativan. POD 11 the vanc/levo was stopped. All cultures negative. POD 12 flagyl stopped following 3 negative C Diff cultures and he was transfered to the floor with complete resolution of his ARF. POD 12 the NGT was d/c'd. POD 13, clears were started. By POD 15 the patient was tolerating a regular diet. Of note, the patient also had and asymptommatic elevation of pancreatic emzymes while in the ICU. A RUQ US showed a sl distended GB with sludge, no stones/duct dilatation/GB wall edema, small pericholecystic fluid, echogenic liver c/w fatty infilatration. No further work-up was performed. Inpatient psychiatry followed the patient after his ICU stay. Their final reccomendations is to hold his numerous home psychiatric medications. He will be discharged on Topiramate 50mg po qhs (which was started POD 14) to be increased 50mg qday until [**Location (un) 1131**] 200mg po qhs. The haldol was stopped and ativan made prn. Medications on Admission: protonix 40', klonopin 1q6 prn, luvox 100"', glyburide 2.5', welbutrin SR 200", seroquel 200"", topamax 200', trazodone 50hs Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)): increase by 50mg daily until reaching goal of 200mg po qhs. Disp:*60 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital - [**Location (un) 701**] Discharge Diagnosis: Cowden's disease Non-insulin dependent diabets gastroesophageal reflux disease mania Discharge Condition: Good Discharge Instructions: You may resume your normal diet. You may resume your normal activities, but should not lift heavy objects (>15 lbs). Care for ostomy as per nurse teaching. You may shower, but do not take a bath or swim. Pat the wound dry after showering. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Inability to pass gas or stool from the ostomy * Other symptoms concerning to you Take medications as prescribed; some of your home psychiatric medications have been held. Topiramate starting at 50mg po qhs and to be increased by 50 mg/daily until reaching goal 200mg po ghs. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. Call his office, [**Telephone/Fax (1) 9**], to make an appointment. Please follow up with Dr. [**Last Name (STitle) 64786**] (outpatient psychiatry) [**Telephone/Fax (1) 64787**]. Please follow up with Dr. [**Last Name (STitle) 27273**] [**Telephone/Fax (1) 65924**]

[ "759.6", "997.4", "250.00", "E878.6", "296.20", "560.1", "584.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "46.23", "45.8", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

5525, 5603

2073, 4495

327, 373

5731, 5738

1294, 2050

6385, 6711

1033, 1050

4671, 5502

5624, 5710

4522, 4648

5762, 6362

1065, 1275

271, 289

401, 791

813, 885

901, 1017

27,682

107,046

26713

Discharge summary

report

Admission Date: [**2118-6-20**] Discharge Date: [**2118-7-2**] Date of Birth: [**2071-7-1**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2118-6-20**] Emergent Five Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending, vein grafts to diagonal, first obtuse marginal, second obtuse marginal and posterior descending artery) History of Present Illness: Mr. [**Known lastname **] is a 46 year old male with ESRD and known CAD. In [**2116-12-16**] he underwent placement of drug eluding stent to the circumfex. RCA was totally occluded at that time. Since [**2117-8-15**], he had self discontinued taking Aspirin, Plavix, Lipitor and Lopressor secondary to AV fisutla bleeding complications. On the day of admission, he presented to OSH with progressive worsening chest pain for several weeks duration. He was started on intravenous therapy and transferred to the [**Hospital1 18**] for further evaluation and treatment. He did rule in for a myocardial infarction with positive cardiac enzymes. Past Medical History: -Coronary Artery Disease, s/p PCI/Stenting(see above) -End Stage Renal Disease, s/p Renal Transplantation 27 years ago(failure since [**2109**]), on Hemodialysis, Left AV Fistula -Hypertension -Congestive Heart Failure -Obstructive Sleep Apnea -Hyperphosphotemia Social History: Married, lives with wife. Family History: Denies premature coronary artery disease Physical Exam: vitals: bp 96/60, hr83, rr 30, sat 96% on 3l general: no acute distress, nontoxic heent: oropharynx benign, moist mucous membranes neck: supple, no jvd lungs: tachypneic, crackles noted anteriorly heart: regular rate and rhythm, normal s1s2 abdomen: benign extremeties: warm, no edema, left AV fistula with good thrill pulses: 1+ distally neuro: alert and oriented x 3, no focal deficits noted Pertinent Results: [**2118-6-20**] 04:45PM BLOOD WBC-11.5* RBC-3.85* Hgb-12.7* Hct-37.7* MCV-98 MCH-33.1* MCHC-33.8 RDW-13.9 Plt Ct-326 [**2118-6-20**] 04:45PM BLOOD Neuts-73.2* Lymphs-20.3 Monos-2.4 Eos-3.2 Baso-0.9 [**2118-6-20**] 04:45PM BLOOD PT-12.1 PTT-30.6 INR(PT)-1.0 [**2118-6-20**] 04:45PM BLOOD Glucose-122* UreaN-50* Creat-13.8* Na-135 K-7.1* Cl-91* HCO3-26 AnGap-25* [**2118-6-20**] 04:45PM BLOOD ALT-16 AST-23 AlkPhos-101 TotBili-0.7 [**2118-6-20**] 04:45PM BLOOD Albumin-3.9 [**2118-6-20**] 04:45PM BLOOD %HbA1c-5.7 [**2118-6-20**] Cardiac Cath: 1. Coronary angiography of this right dominant system revealed severe 3 vessel disease. The LMCA was angiographically normal. The proximal LAD had a 90% stenosis after D1, followed by 80% mid stenosis. D1 had 99% proximal stenosis. The LCx was 100% occluded proximally at the site of prior stent placement in [**2116**]. The RCA was 100% occluded proximally with distal filling via left to right collaterals. 2. Resting hemodynamics revealed severely elevated right sided filling pressures with RVEDP of 30 mmHg. There was severe pulmonary arterial systolic hypertension with PASP of 72 mmHg. Pulmonary capillary wedge pressure was severely elevated (a/v/m=44/50/40 mmHg). There was systemic arterial systolic hypotension with aortic systolic pressure of 96 mmHg. Cardiac output was compromised at 2.10 l/min/m2. 3. Left ventriculograpy was not performed. Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent cardiac catheterization which showed critically severe three vessel coronary artery disease(see result section). He was therefore taken urgently to the operating room where coronary artery bypass grafting was performed by Dr. [**First Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Given his end stage renal disease, CVVHD was initiated for fluid management with gradual transition to hemodialysis. He has an isolated episode of SVT which was successfully treated with Adenosine with conversion back to a normal sinus rhythm. He initially remained critically ill and was kept intubated and sedated for several days. Tube feedings were eventually initiated for nutritional support. He required placement of a left chest tube for hemothorax on postoperative day four. On postoperative day five, fevers were noted along with a leukocytosis. Pan cultures were obtained, and empiric antibiotics were initiated. Chest x-ray was suscipious for pneumonia. Given persistent agitation, the psychiatry service was consulted which attributed it to postoperative delirium. He intermittenly required Haldol and Ativan for behavioral control. He was eventually extubated without incident and gradually weaned from inotropic support. His chest tubes and pacing wires were DC'd without incidence, After his CSRU stay. Pt did quite well. He was transfered to the floor. On the floor he made steady progress. He worked with PT. He progressed to a point were he no longer needed rehab. He also recieved hemodialysis while on the floor in his regualr scheduled cirriculum. M / W / F. Pt [**Name (NI) 1788**] in stable condition Medications on Admission: Transfer Meds: Intravenous Heparin, Plavix 300mg(single dose), Protonix, Aspirin 325 qd, Lopressor Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Sensipar 60 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease - s/p Emergent CABG Postop Delirium Postop Hemothorax End Stage Renal Disease - prior Renal Transplantation(failure [**2109**]) Hypertension Congestive Heart Failure Obstructive Sleep Apnea Discharge Condition: Good Discharge Instructions: 1)Please shower daily, no baths. 2)Avoid creams, lotions, ointments to surgical incisions. 3)Please call cardiac surgeon if start to experience sternal drainage, or signs of wound infection. 4)No driving for at least one month. 5)No lifting more than 10 lbs for at least 10 weeks. Followup Instructions: Dr. [**First Name (STitle) **] in [**2-17**] weeks, call for appt Dr. [**Last Name (STitle) 1295**] or Dr. [**Last Name (STitle) 656**] in [**12-18**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**12-18**] weeks, call for appt Dr. [**Last Name (STitle) 11427**] in [**12-18**] weeks, call for appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2118-7-2**]

[ "425.4", "293.9", "585.6", "998.11", "428.0", "403.91", "447.1", "414.01", "410.71", "428.40", "327.23", "511.8", "276.7" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "34.04", "39.95", "38.93", "36.14", "38.95", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

6034, 6093

3442, 5224

286, 519

6351, 6358

2006, 3419

6687, 7117

1535, 1577

5373, 6011

6114, 6330

5250, 5350

6382, 6664

1592, 1987

236, 248

547, 1189

1211, 1476

1492, 1519

28,552

183,345

34013

Discharge summary

report

Admission Date: [**2122-7-14**] Discharge Date: [**2122-7-29**] Date of Birth: [**2044-10-22**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Type A Aortic Dissection Major Surgical or Invasive Procedure: [**2122-7-14**] - Emergent repair of aortic dissection History of Present Illness: 77 year old female found to have a type A aortic dissection at [**Hospital3 **], Her pain started the night prior to admission and was localized to her chest with radiation to her back. A CT scan at [**Hospital1 **] revealed a type A dissection and she was transported to the [**Hospital1 18**] for emergent surgical management. Past Medical History: HTN Aortic aneurysm DM CRI Social History: Lives with Husband Family History: N/C Physical Exam: 110 186/110 157cm 120lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: CTA bilaterally HEART: ST, no M/R/G ABD: Soft, ND/NT/NABS EXT:warm, 1+ DP/PT pulses, no bruits, no varicosities. NEURO: No focal deficits. Pertinent Results: [**2122-7-29**] 02:19AM BLOOD WBC-12.6* RBC-3.20* Hgb-9.5* Hct-29.9* MCV-94 MCH-29.7 MCHC-31.8 RDW-16.2* Plt Ct-518* [**2122-7-28**] 03:28AM BLOOD WBC-14.6* RBC-3.31* Hgb-10.0* Hct-31.0* MCV-94 MCH-30.3 MCHC-32.4 RDW-16.1* Plt Ct-531* [**2122-7-27**] 03:06AM BLOOD WBC-13.3* RBC-3.16* Hgb-9.4* Hct-29.3* MCV-93 MCH-29.7 MCHC-32.0 RDW-16.1* Plt Ct-472* [**2122-7-26**] 12:51AM BLOOD WBC-14.0* RBC-3.31* Hgb-9.9* Hct-30.8* MCV-93 MCH-30.0 MCHC-32.2 RDW-15.7* Plt Ct-461* [**2122-7-26**] 12:51AM BLOOD PT-12.9 PTT-39.9* INR(PT)-1.1 [**2122-7-29**] 02:19AM BLOOD Glucose-145* UreaN-36* Creat-1.1 Na-147* Cl-116* HCO3-25 [**2122-7-28**] 04:00PM BLOOD K-3.8 [**2122-7-28**] 03:28AM BLOOD Glucose-107* UreaN-36* Creat-1.2* Na-148* K-3.6 Cl-113* HCO3-24 AnGap-15 [**2122-7-27**] 03:06AM BLOOD Glucose-193* UreaN-38* Creat-1.1 Na-145 K-3.6 Cl-113* HCO3-27 AnGap-9 [**2122-7-26**] 12:51AM BLOOD Glucose-147* UreaN-43* Creat-1.3* Na-144 K-4.0 Cl-113* HCO3-24 AnGap-11 [**2122-7-25**] 01:42AM BLOOD Glucose-111* UreaN-46* Creat-1.3* Na-146* K-4.4 Cl-113* HCO3-27 AnGap-10 [**2122-7-24**] 02:06AM BLOOD Glucose-147* UreaN-50* Creat-1.5* Na-145 K-3.8 Cl-109* HCO3-27 AnGap-13 [**2122-7-17**] 01:51AM BLOOD ALT-5 AST-34 LD(LDH)-230 AlkPhos-115 Amylase-132* TotBili-0.6 [**2122-7-29**] 02:19AM BLOOD Phenyto-9.3* [**2122-7-28**] 03:28AM BLOOD Phenyto-7.9* [**2122-7-27**] 03:06AM BLOOD Phenyto-8.9* [**2122-7-26**] 12:51AM BLOOD Phenyto-11.7 [**2122-7-25**] 01:42AM BLOOD Phenyto-15.1 [**2122-7-24**] 04:38PM BLOOD Phenyto-16.6 [**2122-7-15**] ECHO PRE-CPB:1. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. There are simple atheroma in the aortic root. The ascending aorta is markedly dilated There are simple atheroma in the ascending aorta. There is a dissection flap that originates around the right coronary and extends into the arch. The aortic arch is moderately dilated. There are complex (>4mm) atheroma in the aortic arch. There is intramural thrombus present in the descending aorta. There is spontaneous echo contrast in the descending thoracic aorta. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are not well seen. Mitral regurgitation is present but cannot be quantified. 7. There is a moderate sized pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusions of nitroglycerine. Well-seated synthetic graft in the aortic position from the sinotubular junction. No apparent leak. There is residual intramural thromus at the level of right coronary cusp. Coronary flow is visible in both the RCA and LMCA. The descending aorta is unchanged post decannulation. There is a small right pleural effusion. The pericardial effusion is small.. [**Known lastname **],[**Known firstname **] [**Medical Record Number 78526**] F 77 [**2044-10-22**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2122-7-20**] 10:07 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2122-7-20**] SCHED CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 78527**] Reason: ischemic event/bleed [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p emergent AAA REASON FOR THIS EXAMINATION: ischemic event/bleed CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: RSRc MON [**2122-7-20**] 2:08 PM Evolution of multiple subacute infarctions throughout right frontal, parietal, temporal, bilateral occipital, and cerebellar lobes. No hemorrhage, mass effect, or midline shift. Final Report HISTORY: 77-year-old female with emergent AAA repair several days prior. Please evaluate for ischemic event or hemorrhage. COMPARISON: CTA head four days prior. TECHNIQUE: Contiguous axial imaging was performed from the cranial vertex to the foramen magnum without IV contrast. HEAD CT WITHOUT IV CONTRAST: Multifocal cortical and subcortical hypodensities involving the frontal, parietal, and occipital lobes as well as the cerebellum bilaterally are more well defined, indicative of evolving ischemic infarction. There is no hemorrhage, edema, mass effect, or shift of normally midline structures. The visualized paranasal sinuses are unremarkable. The mastoid air cells are clear. Mild periventricular hypodensity is indicative of chronic small vessel ischemic disease. IMPRESSION: Multiple bilateral hypodensities consistent with evolving subacute infarction. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name 3900**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: MON [**2122-7-20**] 4:31 PM Imaging Lab Radiology Report CHEST (PORTABLE AP) Study Date of [**2122-7-27**] 1:47 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2122-7-27**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 78528**] Reason: ptx [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p trach/bronch REASON FOR THIS EXAMINATION: ptx Final Report INDICATION: 77-year-old female status post trach and bronchoscopy. COMPARISON: [**2122-7-24**].. FRONTAL CHEST RADIOGRAPH: Over the interval, the patient has undergone tracheostomy which is appropriately positioned. A right internal jugular central venous line has been removed and there is no pneumothorax. The left- sided PICC line tip resides within the proximal SVC. The Dobbhoff tube has been removed. There is a persistent left retrocardiac opacity and small left- sided pleural effusion. There is a small right-sided pleural effusion as well. Radiology Report PORTABLE ABDOMEN Study Date of [**2122-7-27**] 1:47 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2122-7-27**] SCHED PORTABLE ABDOMEN Clip # [**Clip Number (Radiology) 78529**] Reason: free air [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p PEG REASON FOR THIS EXAMINATION: free air Provisional Findings Impression: CXWc TUE [**2122-7-28**] 1:15 PM New PEG tube overlies the left mid abdomen. No evidence of free intraperitoneal air. Stool and gas to the rectum. Final Report INDICATION: 77-year-old woman status post PEG, evaluate for free air. COMPARISON: [**2122-7-20**]. SINGLE SUPINE VIEW OF THE ABDOMEN AT 2:00 P.M.: There has been interval placement of a PEG tube, overlying the left mid abdomen. There is no gross evidence of free intraperitoneal air. Stool and gas present in the colon, extending from the cecum to the rectum. Other findings are unchanged. Skin staples overlie the mid upper abdomen. Phleboliths are present in the pelvis. Degenerative changes are present at the hips bilaterally and the lower lumbar spine, where there is mild convex leftward scoliosis. IMPRESSION: No gross evidence of intraperitoneal air. Brief Hospital Course: Mrs. [**Known lastname 56811**] was admitted to the [**Hospital1 18**] on [**2122-7-14**] for emergent surgical management of her type A dissection. She was taken to the operating room where she underwent replacement of her ascending aorta and hemiarch using a 38mm gelweave graft. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. She received multiple blood products. Her sedation was weaned to off but she remained unresponsive to pain without pupillary reflex, head CT showed Subacute infarction involving the cerebellum, frontal, parietal, and occipital lobes bilaterally as well as chronic infarction in the right temporal lobe. She began having seizures and was loaded with and started on dilantin. She was followed closely by neurology. Dobhoff tube was placed and she was started on tube feeds. She remained unresponsive. Repeat head ct showed Multiple bilateral hypodensities consistent with evolving subacute infarction. She was started on cipro and zosyn for gram negative bacteria in sputum and UTI. General surgery consulted to plan for trach/PEG placement. Her neuro exam improved very slightly and she opened her eyes to noxious stim. Repeat EEG showed mild to moderate encephalopathy but no evidence of seizures. Neurological prognosis remained poor. Tracheostomy and PEG tube were placed on [**7-27**]. Dilantin level should be maintained at 15-20. Tube feeds were restarted, and she tolerated 8 hours of trach collar. PICC line became totally occluded seconadry to IV dilantin and her dilantin was changed to PO. BUE U/S for edema showed right axillary DVT but none on left. PICC line was changed to a single lumen. She was raedy for discharge to rehab on [**7-29**]. Medications on Admission: Prednisone 2mg QD Vytorin 10/10 QD HCTZ 25mg QD Metformin 500mg QD Detrol 4mg QD Timolol eye drops Labetolol 100mg QD Nifedipine 90mg QD Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-28**] PO BID (2 times a day). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-28**] Drops Ophthalmic PRN (as needed). 8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 9. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. HydrALAzine 10 mg IV Q6H:PRN sbp > 160 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 15. Phenytoin 125 mg/5 mL Suspension Sig: Two [**Age over 90 1230**]y (250) mg PO BID (2 times a day). 16. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 17. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection [**Hospital1 **] (2 times a day). 18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day): while on lasix . Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Aortic dissection s/p repair intra-op CVA right axillary DVT HTN CVA CRI DM Aortic Aneurysm Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 11763**] Follow-up with Dr. [**First Name (STitle) **] after discharge from rehab. [**Telephone/Fax (1) 4475**] Completed by:[**2122-7-29**]

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icd9cm

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21905+57269

Discharge summary

report+addendum

Unit No: [**Numeric Identifier 57430**] Admission Date: [**2134-3-7**] Discharge Date: [**2134-3-23**] Sex: M Service: TRA SERVICE: Trauma surgery service. HISTORY OF PRESENT ILLNESS: This 85 year-old male was a restrained driver, who hit a telephone pole. The patient is Italian speaking only. There was question of loss of consciousness. The patient was driving approximately 30 miles per hour. No air bag was deployed. There was damage to the steering wheel but no damage to the windshield. PAST MEDICAL HISTORY: Hypertension, diabetes. PAST SURGICAL HISTORY: Abdominal surgery. PHYSICAL EXAMINATION: Temperature on arrival was 99.2; heart rate was 88; blood pressure 122/92; heart rate was 20, saturating 100%. Patient, on exam, had a small laceration on the back of the head. The patient's pupils were equal and reactive to light. Chest was clear to auscultation bilaterally. He was very tender on palpation on the right chest. Heart was regular rate and rhythm with no murmurs. Abdomen was soft, nontender, nondistended. Positive bowel sounds. The patient was guaiac negative. Normal tone. Pelvis was stable. The patient had bilateral knee abrasions. The patient had a fast exam that was negative. CT of the head was negative. C spine CT was negative for any fractures. CT of the abdomen showed a contusion of the right hepatic lobe. CT of the chest showed acute rib fracture including the right third, fourth and fifth with hematoma. There was left lower lobe collapse or contusion. There was a retrosternal hematoma and sternal fracture and a small aortic hematoma on the aortic arch and small fluid superior pericardial process. Patient also had bilateral knee films which did not show any signs of fracture. The patient was admitted to the ICU on the trauma surgery service. LABORATORY DATA: The patient's hematocrit on admission was 27; white count was 8.7. BUN was 46; creatinine was 2.4. CK was 581. MB was 10. Troponin was 0.13. PROCEDURES PERFORMED: Tracheostomy and percutaneous endoscopic gastrostomy. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the trauma surgery service. Cardiac surgery was consulted for the presence of the peri-aortic hematoma. Upon evaluation, they felt that this lesion could be watched without further intervention. Otherwise, the patient was in the ICU for pulmonary toilette. Patient was advanced to regular diet by hospital day number #[**Serial Number 57431**]. However, after transfer to the VICU, the patient had an acute desat event where his sats went down to 76%. The patient was transferred back to the trauma ICU where the patient underwent intubation for presumed respiratory failure. The patient was started on antibiotics. Sputum was sent that grew out hemophilus influenza beta lactamase negative and gram negative rods. The patient was treated for the pneumonia and was slowly weaned from the vent settings; however, the patient did not tolerate being off of the ventilator support. Thus, the patient underwent a tracheostomy and percutaneous endoscopic gastrostomy. After the patient was intubated, the patient also was noted to have a significant amount of effusion on the left chest and the chest tube on the left side was placed to remove the effusion. The chest tube was subsequently discontinued when there was a minimal amount of fluid coming from the chest tube. The patient, of note, also was in atrial fibrillation during this time which was controlled with both Lopressor and Amiodarone. The patient was converted to sinus rhythm. After the patient was trached and PEG'd, the patient was doing well with Neurontin and Roxicet and Tylenol for pain management. The patient was on Amiodarone and Lopressor. The patient tolerated periods of trache mask but continues to require some ventilatory support. Gastrointestinal: The patient was on tube feeds. Genitourinary: The patient's Foley was discontinued on hospital day number 12. The patient was off of antibiotics and finished his course of antibiotics for treatment of pneumonia. The patient was recommended to transfer to the ventilator rehab for further care. CONDITION ON DISC: Good. DISCHARGE STATUS: Rehab. DISCHARGE DIAGNOSES: 1. Diabetes. 2. Hypothyroid. 3. Asthma. 4. Thyroid nodule. 5. Congestive heart failure. 6. Hypercholesterolemia. 7. Hypertension. 8. History of dehydration and renal insufficiency. DISCHARGE MEDICATIONS: Heparin 5000 units subcutaneous t.i.d. Beclomethasone spray nasal b.i.d. Lipitor 20 mg p.o. q. 8 hours. Mucomyst nebs q. 4 to 6 hours prn. Tylenol prn. Sliding scale insulin. Metoprolol 25 mg p.o. b.i.d. Amiodarone 200 mg p.o. t.i.d. Please wean the Amiodarone over a period of time. Lansoprazole 30 mg p.o. daily. Levoxyl 75 mg p.o. daily. Hydrochlorothiazide 25 mg p.o. daily. Glipizide 5 mg p.o. b.i.d. Roxicet 5 to 10 mg p.o. every 4 to 6 hours. Maalox prn. Albuterol q. 6 hours. Atrovent q. 6 hours. Flonase prn. Aspirin and Colace. FOLLOW UP: Please follow-up with trauma surgery service. Please call for follow-up in 2 to 3 weeks. Please follow-up with PCP. [**Name10 (NameIs) 357**] also follow-up with ENT and obtain an audiogram. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Doctor Last Name 6052**] MEDQUIST36 D: [**2134-3-22**] 15:33:39 T: [**2134-3-22**] 16:51:12 Job#: [**Job Number 57432**] Name: [**Known lastname 10675**],[**Known firstname 10676**] Unit No: [**Numeric Identifier 10677**] Admission Date: [**2134-3-7**] Discharge Date: [**2134-4-6**] Date of Birth: [**2049-9-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5964**] Addendum: Patient developed a LGIB and underwent colonoscopy, which revealed ischemic colon; he was taken to the OR and underwent a right hemicolectomy (see separate operative note for details). Biopsy revealed evidence of ischemic injury; a liver bx revealed bile duct hematoma. He did well post-operatively. He was transfered from the ICU to the hospital floor on HD 25. His tube feedings were continued; he was not started on any laxatives or softeners because of his surgical anastomosis. He now is having regular bowel movements on his own. He did have episodes of hypoglycemia; his glipizide has been held, and he is on RISS. he will need continued monitoring of his blood glucose now that his tube feedings are running. His blood sugars have been running higher the last 2 days and he may need further adjustment of his medications. He had a fever spike on HD 26; his abdominal wound was erythematous; the abdominal staples were removed and the wound left open; now performing loosely packed with kerlix, wet to dry dressing changes tid. He was started on Levofloxacin 250 mg IV QD for positive wound cultures. He will continue on Levofloxacin for a total 14 day course. The patient continues to need respiratory care for his trach. He has a productive cough and also requires suctioning PRN. He is on a humidified trach mask with O2 sats 95%. However, he does not maintain his O2 sats off of supplemental oxygen. He is able to wear and tolerate the Passy Muir valve. He will need continued pulmonary toilet, including chest PT and a speech re-evaluation at rehab. A Geriatric consult was obtained early in his hospital stay and several recommendations were made regarding his medications and medical care. The patient has been seen and evaluated by PT and OT; and they have recommend acute care rehab stay. Major Surgical or Invasive Procedure: s/p chest tube [**2134-3-17**] s/p tracheostomy and PEG placement [**2134-3-19**] s/p colonoscopy [**2134-3-24**] s/p right hemicolectomy [**2134-3-27**] Abdominal wound opened [**2134-4-2**] Pertinent Results: CHEST (PORTABLE AP) [**2134-4-3**] 9:37 PM CHEST (PORTABLE AP) Reason: ? PTX, PNA [**Hospital 5**] MEDICAL CONDITION: 84M s/p mvc and r hemicolectomy, s/p trach, now with CP REASON FOR THIS EXAMINATION: ? PTX, PNA PORTABLE CHEST X-RAY, [**2134-4-3**] COMPARISON: [**2134-3-26**]. INDICATION: Chest pain following tracheostomy placement. A tracheostomy tube remains in place with the tip just above the level of the clavicles. There is no pneumomediastinum or pneumothorax. Left subclavian catheter has been removed. There is stable cardiomegaly. Lung volumes are increased in the interval. There is improving aeration in the left lower lobe and decrease in a left pleural effusion. Scattered patchy and linear opacities in the left lung are likely due to residual atelectasis, and there is also minimal atelectasis in the right base. Bilateral areas of pleural thickening and/or pleural fluid are present laterally, and note is made of prior fractures involving several right-sided ribs. IMPRESSION: Marked improvement in left lower lobe atelectasis. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 8**] [**Known lastname 10678**],[**Known firstname 10676**] [**2049-9-1**] 84 Male [**Numeric Identifier 10679**] [**Numeric Identifier 10677**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 11**], [**Doctor Last Name **],[**Doctor First Name **]/dif SPECIMEN SUBMITTED: RIGHT COLON, LIVER BIOPSY Procedure date Tissue received Report Date Diagnosed by [**2134-3-27**] [**2134-3-29**] [**2134-3-31**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 11**]/kg DIAGNOSIS: I. Ileo-colectomy (A-I): 1. Chronic ulceration with hemorrhage of the cecum and colon, most consistent with ischemic injury. a. Ulcer in cecum extending deep into muscularis propria. b. Ulcers in ascending colon extending into the submucosa. 2. Ileal segment, appendix and distal colonic margin, within normal limits. II. Liver wedge biopsy (K): Bile duct hamartoma. Clinical: Cecal ulceration and liver contusion, post-motor accident. Gross: The specimen is received fresh in two parts, both labeled with "[**Known lastname **], [**Known firstname **]" and the medical record number. Part 1 is additionally labeled "right colon" and consists of a 25 x 22 cm ileocolectomy specimen. The ileum is 2.2 cm in length. The stapled proximal ileal margin measures 5 cm and the distal stapled resection margin measures 8 cm. An appendix is identified measuring 13 x 0.6 cm. The serosal surface is erythematous. There is a focal area thickened fat on the cecal serosal surface. The specimen is opened along the anti-mesocolic border to reveal dusky mucosa with multiple areas of ulceration measuring up to 4.3 x 2.4 cm in the right colon and cecum. The ulceration extends to 7.9 cm from the distal margin and 5.1 cm from the proximal margin. There are no polyps or masses seen grossly. The specimen is submitted as follows: A-B = distal margin, ileal margin in C, representative sections of normal colon and normal ileum is in D, representative sections of appendix is submitted in E, a section of cecum ulceration through serosal thickening is submitted in F, additional sections of cecal ulceration are submitted in G, representative sections of ulceration of the right colon is submitted in H-I. Part 2 is additionally labeled "liver biopsy" and consists of a tan brown tissue fragment measuring 1.1 x 0.8 x 0.2 cm. The specimen is entirely submitted in J. PORTABLE ABDOMEN [**2134-4-1**] 7:19 AM PORTABLE ABDOMEN Reason: ? ileus, obstruction [**Hospital 5**] MEDICAL CONDITION: 84M s/p mvc, s/p R hemicolectomy, with abd distention REASON FOR THIS EXAMINATION: ? ileus, obstruction HISTORY: 84-year-old male status post right hemicolectomy, now with distended abdomen. PORTABLE SUPINE ABDOMEN: There are multiple loops of mildly dilated air- filled small bowel in the mid abdomen. The large bowel is of normal caliber and air is seen in the transverse colon and splenic flexure. There is a paucity of gas in the descending colon and rectum. There are no air-fluid levels and no free intra-abdominal air is identified. A gastrostomy tube projects over the left upper abdomen. Laparotomy staples are present over the lower midline. IMPRESSION: Partial or incomplete small bowel obstruction. Followup radiographs or abdominal CT are suggested. Cardiology Report ECG Study Date of [**2134-3-15**] 1:55:36 AM Ireegular tachycardia - mechanism uncertain - may be atrial flutter or atrial tachycardia with variable block Right bundle branch block Left anterior fascicular block The ST-T changes are diffuse - clinical correlation is suggested Since previous tracing of [**2134-3-9**], sinus tachycardia absent Read by: [**Last Name (LF) 3106**],[**First Name3 (LF) 33**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 108 0 168 366/429.57 0 -71 92 CT ABDOMEN W/O CONTRAST [**2134-3-13**] 4:11 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: please eval abd Field of view: 42 [**Hospital 5**] MEDICAL CONDITION: 84 year old man with retrosternal hematoma s/p MVA, recent resp failure req intub, with abd distention, tenderness, guarding RLQ REASON FOR THIS EXAMINATION: please eval abd CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 84-year-old man with retrosternal hematoma status post MVA, recent respiratory failure and guarding, please assess right lower quadrant. TECHNIQUE: Non-contrast axial CT imaging through the abdomen and pelvis was reviewed. CT ABDOMEN WITHOUT CONTRAST: There are new small bilateral pleural effusions, right greater than left with concomitant bibasilar atelectasis. There is a new consolidation in the left base. Again demonstrated are right rib fractures, retrosternal hematoma is not imaged. NGT tip is in the stomach. 1.6 cm hypodense lesion in the liver tip and puncate calcifications are unchanged. The pancreas, spleen, adrenal glands, and kidneys are unremarkable. CT PELVIS WITHOUT CONTRAST: The rectum, and sigmoid appear unremarkable. Ascending colonic wall is slightly thickened with pericolonic fluid. The ascending colon is mildly dilated, the cecum measures 8 cm, and the ascending colon measures 7.5 cm. There are some air- fluid levels within the large bowel, but contrast is seen in the rectum. A Foley catheter is seen within the bladder that contains iatrogenic gas. Foley ballon may be within the prostate. There is a left inguinal hernia containing fat. BONE WINDOWS: The osseous structures are only remarkable for degenerative disease, and the right-sided rib fractures. IMPRESSION: 1. Mildly dilated ascending colon with mild bowel wall thickening and inflammation suggestive of nonspecific colitis. Ddx includes infection, inflammation or ischemia. 2. Stable incompletely characterized 1.6 cm hypodense liver lesion. 3. Worsening bilateral pleural effusions with bibasilar consolidations. 4. Right rib fractures. 5. Foley balloon may be within prostate. CT CHEST W/O CONTRAST [**2134-3-17**] 9:00 PM CT CHEST W/O CONTRAST Reason: eval for loculated pleural effusion [**Hospital 5**] MEDICAL CONDITION: 84M with persistent L sided effusion, despite CT placement REASON FOR THIS EXAMINATION: eval for loculated pleural effusion CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: An 84-year-old man with persistent left-sided effusion despise chest tube placement. COMPARISON: [**2134-3-7**]. TECHNIQUE: MDCT of chest without IV contrast. FINDINGS: There is complete collapse of the left lung without evidence of an effusion. The left main bronchus is open proximally. A chest tube is seen terminating in the left lung apex. There is ipsilateral shift of normally midline structures. A moderate- sized right-sided pleural effusion with associated atelectasis is noted. Small pericardial effusion is unchanged. The right upper lobe lung contusion is resolving. Right thyroid mass is stable in appearance. There is resolution of the fluid in the substernal region. Multiple small subcentimeter right paratracheal, prevascular and precarinal lymph nodes are again noted. Atherosclerotic calcification of the ascending aorta, aortic arch, and descending aorta is noted. Very small calcific focus is visualized in the right lobe of the liver. There are two areas of low attenuation in segment VI, which appear to be unchanged, not clearly visualized or characterized in this study. Multiple right-sided rib fractures and sternal fracture is again noted. IMPRESSION: 1) Complete collapse of the left lung without evidence of pleural effusion on the left side. There is a moderate right-sided pleural effusion. 2) Stable appearance of posttraumatic findings including multiple right rib fractures and sternal fracture. 3) Interval clearing of small retrosternal fluid and small pericardial effusion. 4) Heterogeneous thyroid mass, stable in appearance. Cardiology Report ECHO Study Date of [**2134-3-10**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. BP (mm Hg): 153/58 HR (bpm): 88 Status: Inpatient Date/Time: [**2134-3-10**] at 15:04 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1080**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 0.75 Mitral Valve - E Wave Deceleration Time: 2 msec INTERPRETATION: Findings: Patient declined to lie down during study so study performed while patient sitting in a chair. LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Cannot assess regional RV systolic function. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. Aortic valve not well seen. No AS. MITRAL VALVE: Mitral valve not well seen. LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Tricuspid valve not well visualized. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality as the patient was difficult to position. Conclusions: The left atrium is normal in size. 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 are mildly thickened. The aortic valve is not well seen. There is no aortic valve stenosis. The mitral valve is not well seen. The left ventricular inflow pattern suggests impaired relaxation. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. PORTABLE ABDOMEN [**2134-3-16**] 2:34 PM PORTABLE ABDOMEN Reason: please eval for colonic loops [**Hospital 5**] MEDICAL CONDITION: 84M s/p mvc,with abd distention s/p placement of rectal tube. REASON FOR THIS EXAMINATION: please eval for colonic loops INDICATION: Status post placement of rectal tube, eval for colonic loops. SUPINE PORTABLE RADIOGRAPHS OF THE ABDOMEN: Comparison is made to [**2134-3-15**]. Again seen is an air-filled transverse colon. The caliber and appearance of the transverse colon appears not significantly changed in the interval. IMPRESSION: Unchanged dilated loop of transverse colon. OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) **] J. Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on MON [**2134-4-5**] 8:45 AM Name: [**Known lastname 10675**], [**Known firstname 10676**] Unit No: [**Numeric Identifier 10677**] Service: Date: [**2134-4-1**] Date of Birth: [**2049-9-1**] Sex: M Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2211 PREOPERATIVE DIAGNOSIS: Bleeding ulcer right colon. POSTOPERATIVE DIAGNOSIS: Bleeding ulcer right colon; ischemic right colon. PROCEDURE: Right colectomy; lysis of adhesions and liver biopsy. FIRST ASSISTANT: [**First Name8 (NamePattern2) **] [**Doctor Last Name **], INT INDICATIONS: This man who has had multiple trauma was on the service when he suddenly developed a GI evaluation, including a colonoscopy which revealed the presence of 2 ulcers in the right colon; 1 in the cecum and 1 more proximally in the liver. He had a bleeding episode that stopped and then began to bleed again. DESCRIPTION OF PROCEDURE: He was taken to the operating room, placed in the supine position. The abdomen was prepped and draped using Betadine solution. The incision was made along the patient's old previous midline incision, deepening it down to the level of the fascia. The fascia was then opened. We removed suture material on the way in entered finally the abdominal cavity. There were dense adhesions between several loops of bowel and omental tissue and these were divided. We then turned our attention to the right colon. The right colon was visible and this was mobilized by dividing the lateral peritoneal attachments and also inferiorly the peritoneum that was holding the cecum down to the posterior abdominal wall. Once this was done, we were able to lift the cecum and the colon medially except that there were very firm attachments where the ulcers were in the cecum and also into the hepatic flexure. We had to separate these from the abdominal wall lateral and while doing so, we made a hole in the colon and some fecal material drained out of it. This was aspirated and removed by suction. Once this was done, we chose an area on the transverse colon that allowed us to leave behind at least 1 branch of the middle colic artery and an area on the terminal ileum that allowed us to remove the intervening segment. We came across the mesentery between clamps and ligated the mesentery using 2-0 silk ties. The transected terminal ileum and also the transverse colon using the linear cutter stapler. These 2 pieces of intestine were placed side-by-side and sutured in place using 3-0 silk suture. Making new openings in the field, the ends of the intestine, we placed a linear cutter stapler down between the middle and then fired it again creating an anastomosis between the 2. Lifting the edges of the openings into the air, we placed a TA stapler across this and fired it, sealing the intestines closed. This staple line, but not the others, was turned in using interrupted 4-0 silk sutures. Once this was done, we approximated the mesocolon using interrupted 4-0 silk sutures. The liver itself looked as if it had miliary white spots on it. This is in a patient who previously, several months ago, had a colon carcinoma removed. We decided to carry out a biopsy of the lateral margin of the liver that included at least 1 of the white spots. This was done with a blade. We used the electrocautery to stop the bleeding from the liver surface. Once this was done, we decided to close the patient after irrigation with normal saline. The #1 looped PDS was started at either end of the incision and we closed the abdominal wall. Skin clips were placed in the skin after irrigation with normal saline. The patient tolerated the procedure well. ESTIMATED BLOOD LOSS: 300 cc. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 6630**] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) one Injection TID (3 times a day). 2. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed for secretions. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. ML(s) 12. Maalox 225-200 mg/5 mL Suspension Sig: One (1) ML PO TID (3 times a day) as needed for pain. 13. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 15. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 18. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 12 days. 19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 21. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - Acute Rehab Discharge Diagnosis: s/p motor vehicle crash Peri-aortic hematoma Rib fracture and sternal fracture Discharge Condition: Stable Discharge Instructions: Follow-up with ENT Follow-up for Audiogram Follow-up with trauma surgery - Dr. [**Last Name (STitle) **] [**Name (STitle) **] with fevers, chills, nausea, vomiting, diarrhea and abdominal pain Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] ([**First Name9 (NamePattern2) **] [**Location (un) **]) [**Location (un) **] INTERNAL MEDICINE Date/Time:[**2134-5-20**] 9:00 Please followup with Trauma Surgery in 2 weeks with Dr. [**Last Name (STitle) **]. Please call for a follow-up appointment: [**Telephone/Fax (1) **]. Please followup with ENT; call [**Telephone/Fax (1) 1848**]; Dr. [**Last Name (STitle) 2556**] Audiogram scheduled Wed [**2134-4-7**] at 2:15 PM, [**Street Address(2) 10680**], [**Hospital **] Medical Building [**Location (un) **] Suite 6E. Provider: [**Name10 (NameIs) 10681**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) 10682**], AU.D. Phone:[**Telephone/Fax (1) 10683**] Date/Time:[**2134-4-7**] 2:30 [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**] Completed by:[**2134-4-6**]

[ "518.5", "557.9", "427.31", "428.0", "244.9", "998.2", "998.59", "861.21", "401.9", "569.82", "807.03", "682.2", "E823.0", "482.2", "511.9", "250.00", "759.6", "807.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.73", "96.6", "99.15", "96.04", "45.23", "31.1", "33.24", "45.93", "50.12", "43.11", "34.04", "96.72" ]

icd9pcs

[ [ [] ] ]

26049, 26122

7691, 7885

26245, 26253

7904, 7990

26494, 26779

4224, 4414

24034, 26026

26143, 26224

26277, 26471

17016, 19531

575, 595

4999, 7653

2091, 4203

618, 2062

19658, 24011

19567, 19629

26802, 27411

192, 503

526, 551

42,251

179,370

38341

Discharge summary

report

Admission Date: [**2182-6-12**] Discharge Date: [**2182-6-22**] Date of Birth: [**2128-11-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: CT guided needle biopsy Intubation Arterial cannulation, a-line placement Central line placement History of Present Illness: Pt is a 53 Y M with Hx of DM2, HTN who is transferred from [**Hospital3 **] after being hospitalized from [**6-5**] - [**6-12**] with bilateral pneumonia and concern for new malignancy. 2 weeks prior to admission to the OSH, he was experiencing cold-like symptoms and received Azithromycin without relief. This was switched to Levaquin, again without improvement. He claimed that for these 2 weeks, he was basically bed-bound and extremely tired. At the end of that time, he was coughing to where "my face turned [**Doctor Last Name 352**]" and had some sputum production and low-grade fevers. He received a CXR which showed bilateral PNA; he was admitted to the [**Hospital1 2436**] ICU for hypoxic respiratory failure and Pneumosepsis. On [**6-5**] he started Ceftriaxone, Azithromycin, and IV steroids for supposed concurrent COPD exacerbation. He also received 1 dose of Vancomycin. He could not tolerate BiPAP and was given nasal O2. His respiratory status stabalized and was transferred to the floor requiring 4L of NC. He claims that during his hospital stay, he did not feel that his breathing had improved. Urinary Legionella Ag and strep Ag were negative as were MRSA screen and blood cultures drawn on [**6-5**]. CTPA was negative for PE but did reveal mediastinal and retroperitoneal adenopathy. CT of the abdomen and pelvis a 6.3x4.8cm mass, "concern for a renal cell carcinoma vs. lymphoma." The patient was agreeable for transfer to [**Hospital1 18**] for work-up of this potential malignancy. . On arrival, he mentions orthopnea and LE edema which began around the time he started his cold and has worsened. He also mentions that the afternoon of transfer, he experienced 1 minute of blurry vision where his daughter noted his left pupil was bigger than the right but resolved spontaneously without any associated headaches, nausea, confusion, or vomiting. . Review of Systems: (+) Per HPI; 11 lb weight loss in 3 weeks (-) Denies chills, night sweats. Denies loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. . Past Medical History: PMH: Bilateral PNA DM2 on Metformin HTN Hyponatremia Atypical chest pain with a normal stress test in [**2179**] Hyperlipidemia Asthma as a child OSA Seasonal allergies Social History: Works in IT. Lives at home with daughter and wife. Denies tobacco, etoh, illicits. Family History: There is no family history of premature coronary artery disease or sudden death. Father with CABG x4 in his 60s. Physical Exam: ADMISSION EXAM VS: T 97.4 bp 144/90 HR 98 RR 18 SaO2 93% on 3L NC RR 18 GEN: NAD, awake, alert HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and without lesion, PERRLA at 3mm NECK: Supple, cannot appreciate JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp slightly labored, Crackles at bases with expiratory wheezes from bases to apices. ABD: Soft, Obese, NT, ND, no HSM, cannot palpate kidney; bowel sounds present MSK: normal muscle tone and bulk EXT: No c/c, 1+ edema bilaterally, normal perfusion SKIN: No rash, warm skin NEURO: oriented x 3, normal attention,no focal deficits, intact sensation to light touch PSYCH: appropriate . Pertinent Results: [**2182-6-12**] 10:14PM GLUCOSE-130* UREA N-16 CREAT-0.5 SODIUM-132* POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-28 ANION GAP-12 [**2182-6-12**] 10:14PM ALT(SGPT)-18 AST(SGOT)-14 LD(LDH)-188 ALK PHOS-66 TOT BILI-0.3 [**2182-6-12**] 10:14PM TOT PROT-5.3* ALBUMIN-3.3* GLOBULIN-2.0 CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-1.6 URIC ACID-3.5 [**2182-6-12**] 10:14PM WBC-13.2*# RBC-4.84 HGB-13.9* HCT-39.6* MCV-82 MCH-28.7 MCHC-35.2* RDW-13.4 [**2182-6-12**] 10:14PM NEUTS-81.8* LYMPHS-8.6* MONOS-8.4 EOS-1.1 BASOS-0.1 [**2182-6-12**] 10:14PM PLT COUNT-294 [**2182-6-12**] 10:14PM PT-13.3* PTT-25.8 INR(PT)-1.2* [**2182-6-12**] 10:14PM FIBRINOGE-413* [**2182-6-12**] 10:14PM RET AUT-1.4 [**2182-6-12**] 09:45PM URINE HOURS-RANDOM CREAT-42 SODIUM-33 POTASSIUM-13 CHLORIDE-21 TOT PROT-6 PROT/CREA-0.1 [**2182-6-12**] 10:14PM RET AUT-1.4 [**2182-6-12**] 09:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2182-6-12**] 09:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG . CXR from [**Hospital1 2436**]: bilateral PNA with pleural effusions. Images not available for viewing . CT Chest [**5-15**] FINDINGS: The thyroid gland is unremarkable. There is no supraclavicular or axillary lymphadenopathy. There is extensive mediastinal and hilar lymphadenopathy, similar in extent to the prior study from only a few days earlier. For example, right anterior mediastinal node measuring 1.5 x 1.5 cm, previously measured 1.6 x 1.4 cm (4:11); 2.2 x 1.2 cm right precarinal node (4:20), previously measured 1.2 x 2.3 cm; more inferiorly, 2.5 x 1.9 cm node (4:23), previously was 2.5 x 2.0 cm. Multiple nodes are seen in the prevascular station which also are similar in appearance to the prior exam. Right paraesophageal nodal conglomerate is unchanged and measures 4.9 x 3.7 cm (4:33). Large right hilar nodal conglomerate, measures 4.9 cm in maximal dimension (4:28) compared to 4.8 cm. Left hilar adenopathy measures 4.1 cm (4:29) compared to 4.3 cm. There is resultant compression of the right main stem bronchus (4:27) and bronchus intermedius as well as the right lower lobe bronchus. The heart has a rounded appearance with a small pericardial effusion. This concerning for pericardial constriction from underlying process involving the lungs and mediastinum. LUNGS: In the right upper lobe there are multiple foci of consolidation, multiple nodules, ground-glass opacities and interlobular septal thickening. This pattern is also seen in the right lower lobe but is less extensive. More frank consolidation with air bronchograms are present in the right middle lobe and left lower lobe. Within the left upper lobe there are innumerable predominantly sub-centimeter discrete rounded nodules. There are bilateral pleural effusions greater on the right, similar in extent compared to the prior study. These findings are suggestive of primary lung malignancy, lymphoma, possible infection such as tuberculosis and less likely vasculitis. There is no pneumothorax. This study is limited for evaluation of subdiaphragmatic structures but demonstrates extensive retroperitoneal lymphadenopathy, better assessed on the recent outside hospital scan with IV contrast, however, the overall extent appears unchanged. For example, right retroperitoneal node measuring 1.7 x 2.8 cm (4:63), previously measured 1.4 x 2.7 cm on the prior study; epigastric node measuring 1.8 cm, is similar to the prior study (4:57); left paraaortic nodal conglomerate measures 3.2 x 2.3 cm compared to 3.2 x 2.1 cm on the prior study. OSSEOUS STRUCTURES: There are no suspicious bony lesions. IMPRESSION: 1. Multifocal process within the lungs with frank consolidation in the right middle and left lower lobes, severe multifocal opacities with nodules, centrilobular septal thickening in the right upper lobe and less extensive in the right lower lobe with multiple nodules in the left upper lobe. Extensive mediastinal and hilar lymphadenopathy, unchanged from the prior exam. Possible etiologies include primary lung cancer, lymphoma, infection such as TB and less likely vasculitis. 2. Associated compression of the right main stem bronchus, bronchus intermedius and right lower lobe bronchus from lymphadenopathy. 3. Rounded appearance to the heart, with small pericardial effusion suggesting pericardial constriction from this underlying process. Recommend clinical monitoring. 4. Bilateral pleural effusions, worse on the right, unchanged from the prior exam. 5. Extensive retroperitoneal and paraaortic lymphadenopathy, similar in appearance to the prior study. . MR [**Name13 (STitle) 430**] [**6-13**] FINDINGS: The study is limited by motion artifact. There is no evidence of hemorrhage. There are areas of increased FLAIR signal corresponding to punctate foci of slow diffusion within the bilateral parietal lobes, the left frontal lobe, and the left temporal and occipital lobes. There is also a focus of slow diffusion within the left cerebellar hemisphere. There is no evidence of mass lesion or hemorrhage. There are no definite areas of abnormal enhancement. The visualized paranasal sinuses, mastoids, and orbits are unremarkable. IMPRESSION: Study is limited by motion artifact. Multiple foci of slow diffusion in both cerebral hemispheres, as well as in the left cerebellar hemisphere, without enhancement. These are compatible with acute/subacute ischemia, likely from a central embolic source. Consideration might be given to NBTE ("marantic endocarditis"), in this setting. . [**6-19**] TISSUE BIOPSY PATHOLOGY Pleural fluid, cell block: Consistent with metastatic poorly-differentiated carcinoma (see note). Note: Immunohistochemical stains reveal that the tumor cells show patchy positivity for CK20, CK7 (focal), and P504S and are negative for TTF-1, P63, and B72.3. [**Last Name (un) **]-31 shows focal dim staining in rare tumor cells. Calretinin appears to stain tumor cells (patchy) and mesothelial cells. WT-1 highlights background mesothelial cells. The patient's prior pathology specimen S12-33153P was also reviewed for comparison. The morphologic and immunophenotypic findings are consistent with poorly-differentiated carcinoma similar to that described in the patient's para-aortic node specimen (S12-33153P). The immunoprofile is not specific but may be compatible with renal cell carcinoma; however, other sites cannot be entirely excluded. Clinical correlation is required. Please also see the corresponding cytology C12-[**Numeric Identifier 85415**]. Brief Hospital Course: Mr. [**Known lastname **] was transferred to [**Hospital1 18**] from [**Hospital3 **] after being hospitalized from [**6-5**] - [**6-12**] with bilateral pneumonia and concern for new malignancy. On [**6-5**] he started Ceftriaxone, Azithromycin, and IV steroids for supposed concurrent COPD exacerbation. Urinary Legionella Ag and strep Ag were negative as were MRSA screen and blood cultures drawn on [**6-5**]. CTPA was negative for PE but did reveal mediastinal and retroperitoneal adenopathy. CT of the abdomen and pelvis a 6.3x4.8cm mass, "concern for a renal cell carcinoma vs. lymphoma." He reported that orthopnea and LE edema began around the time he started his respiratory symptoms. He was transferred to [**Hospital1 18**] for further care. While in house, he had left para-aortic lymph node biopsy [**2182-6-13**] which showed poorly differentiated carcinoma with clear cell features. His oxygen demand was initially 3L on nasal cannula with saturation in the 90's. This gradually worsened to 6L on NC to 6L NC plus shovel mask with saturation maintaining 90-95%. LENI's negative bilaterally in the lower extremities. MRI brain was concerning for acute/subacute ischemia from central embolic source with no vegetations on TTE. TEE was recommended by neurology consult team however given his poor current status this has been deferred. He is on IV heparin for this with goal PTT of 50-70 to avoid bleeding. on [**2182-6-19**] CXR was suggestive of superimposed pneumonia (vanc and zosyn were started for nosocomial pneumonia on that day) in addition to underlying pulmonary metastases and new mild pulmonary edema. VS on the floor prior to MICU transfer were: Afebrile, Saturating mid-high 80's to low 90's on nasal cannula and shovel mask sitting in chair and looking exhausted with the head bowed down. Per hospitalist, this was definitely different from what he was on admission. BP was 103/65, HR 105, RR 30's. On arrival to the MICU, patient's VS. T 97.7, HR 105, BP 90's/50's, RR 28, Sat 88% on NRB. He was put on face mask ventilation but continued to have increased work of breathing and worsening respiratory status. Repeat ABGs showed respiratory acidosis and failure with pH 7.09-7.14 pCO2 55-60 PO2 56-82 and HCO3 19-21. Patient was intubated. Femoral line and a-line were placed. Patient suspected to be in pneumosepsis, and became hypotensive and required pressor support with levophed and vasopressin. Continuing hypotension required additional support with phenylephrine. Given decompensation, family meeting was held at midnight on [**6-22**]. Mr. [**Known lastname 85416**] wife decided DNR with no escalation of care. He expired peacefully overnight. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]:PRN dyspnea 2. fenofibrate *NF* 200 Oral daily can substitute forumlary med 3. Atorvastatin 80 mg PO HS 4. Lisinopril 30 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Chlorthalidone 12.5 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Aspirin 81 mg PO DAILY Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2182-6-24**]

[ "518.81", "196.1", "327.23", "486", "272.4", "530.81", "584.9", "496", "276.2", "V49.86", "511.9", "189.0", "434.01", "276.1", "250.02", "401.9", "427.5", "424.90", "197.0", "368.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91", "40.11", "38.93", "34.91", "96.04" ]

icd9pcs

[ [ [] ] ]

13779, 13788

10587, 13278

314, 412

13854, 13863

3965, 10564

13915, 13949

3154, 3269

13751, 13756

13809, 13833

13304, 13728

13887, 13892

3284, 3946

2348, 2845

266, 276

440, 2329

2867, 3037

3053, 3138

47,884

124,207

39508

Discharge summary

report

Admission Date: [**2113-11-16**] Discharge Date: [**2113-11-28**] Date of Birth: [**2065-10-20**] Sex: F Service: NEUROLOGY Allergies: Doxycycline / Lotrel Attending:[**First Name3 (LF) 5018**] Chief Complaint: headache Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 48 y/o woman who comes in from OSH with CT concerning for mass. The hx is very limited given the patient being uncooperative and limited info provided by her boyfriend. The only thing the patient states is that the light hurts her and she has a bad headache. Does not give more info despite pleading. Talked with her boyfriend who lives with her who states that she started to complain of headache yesterday. He also states that she was complaining of left hand numbness for months/ ? weakness? Otherwise unable to provide other details at this time. He states that her walking seemed ok. Past Medical History: HTN? Social History: Per the boyfriend smokes 1ppd and drinks a 12 pack per week. Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: T:98 P:64 R: 16 BP:147/85 SaO2:98% General: Awake, not cooperative. HEENT: NC/AT, Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: Has sunglasses on, keeps her eyes closed. Oriented to self, and [**2113**] but does not answer when asked month or recent holidays. Pupils are 2mm. hard to tell if they are reactive. Eyes conjugant, lateral gaze intact. Don't know if vertical. Moving all 4 ext, refuses to give effort. I think the left arm is weaker then right. The tone is decreased in the Left side and the reflexes are brisker on the left. There is an upgoing toe on the left. DISCHARGE PHYSICAL EXAM: Physical Exam: General: Awake, pleasant and cooperative, NAD. HEENT: NC/AT, Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2 Abdomen: soft. Extremities: No C/C/E bilaterally. Skin: no rashes or lesions noted. Neurologic: MS: speech fluent, AAOx3 CN: PERRL 3-->2mm, EOMI, L facial droop MOTOR: No pronator drift, mild weakness in L triceps, FE, IP, otherwise full strength throughout SENSORY: intact to light touch throughout COORDINATION: reaches for an object accurately bilaterally REFLEXES: toe is mute on the L and down on the R GAIT: deferred Pertinent Results: ADMISSION LABS: [**2113-11-16**] 08:40PM BLOOD WBC-10.6 RBC-4.73 Hgb-14.6 Hct-43.1 MCV-91 MCH-30.9 MCHC-33.9 RDW-13.3 Plt Ct-286 [**2113-11-16**] 08:40PM BLOOD Neuts-64.9 Lymphs-26.9 Monos-5.4 Eos-2.2 Baso-0.7 [**2113-11-16**] 08:40PM BLOOD PT-12.6* PTT-39.0* INR(PT)-1.2* [**2113-11-16**] 08:40PM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-141 K-4.5 Cl-108 HCO3-22 AnGap-16 [**2113-11-17**] 10:57AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 Cholest-269* [**2113-11-17**] 10:57AM BLOOD %HbA1c-5.8 eAG-120 [**2113-11-17**] 10:57AM BLOOD Triglyc-151* HDL-28 CHOL/HD-9.6 LDLcalc-211* [**2113-11-17**] 10:57AM BLOOD TSH-1.1 [**2113-11-17**] 10:57AM BLOOD HCG-<5 [**2113-11-17**] 10:57AM BLOOD CRP-26.6* [**2113-11-19**] 09:15AM BLOOD b2micro-1.1 [**2113-11-16**] 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS: [**2113-11-27**] 07:10AM BLOOD WBC-8.5 RBC-4.91 Hgb-14.9 Hct-42.7 MCV-87 MCH-30.3 MCHC-34.8 RDW-13.2 Plt Ct-229 [**2113-11-27**] 07:10AM BLOOD PT-20.9* INR(PT)-2.0* [**2113-11-27**] 07:10AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-142 K-3.5 Cl-102 HCO3-33* AnGap-11 [**2113-11-27**] 07:10AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2 IMAGING: ECHO [**2113-11-17**]: Conclusions The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast (rest injection only). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. MRI [**2113-11-17**]: IMPRESSION: 1. The large right frontal infarction as well as multiple scattered smaller right frontal and parietal ischemic infarcts appear to be embolic in nature. Given associated T2 hyperintensity and significant mass effect with midline shift, the infarcts are likely subacute (days old). There is no hydrocephalus, no evidence of herniation and no hemorrhagic transformation of the infarct. 2. Extra-axial mass originating from the right petroclival dura which is extending into the right cavernous sinus. While this lesion most likely represents a meningioma, differential diagnosis includes a dural-based metastasis, tuberculosis, or sarcoid. 3. The mass appears to encase the cavernous segment of the right ICA and causes severe stenosis. These findings should be further assessed by MRA of head and neck. MRA [**2113-11-17**]: IMPRESSION: Occlusion of the right internal carotid in the neck with reconstitution in the intracranial region. Diminished flow signal in branches of the right middle cerebral artery are seen in the region of infarct. The remaining arteries of the anterior and posterior circulation are normal. CT HEAD [**2113-11-18**]: IMPRESSION: 1. No significant change in large right frontal lobe infarction. Additional smaller right frontal and parietal infarcts are better seen on prior MR. 2. No evidence of hemorrhagic transformation. 3. Persistent leftward shift of normally midline structures, not significantly changed. No definite central herniation. CTA [**2113-11-19**]: IMPRESSION: Subacute right anterior and middle cerebral artery territory infarcts. High grade (>95%) stenosis of the origin of the right internal carotid artery, with "string sign" more distally. Other findings, noted above. CT HEAD [**2113-11-21**]: IMPRESSION: 1. Interval stability of subacute right anterior and middle cerebral artery territory infarcts. 2. No evidence of hemorrhagic conversion or new infarct in other regions. 3. Similar degree of mass effect causing subfalcine herniation, effacement of the frontal [**Doctor Last Name 534**], and 13-mm leftward shift of midline structures, possibly 1 mm less than two days ago without significant change. CAROTID U/S [**2113-11-23**]: Impression: Right ICA critical, 95%stenosis. Left ICA <40% stenosis. CT HEAD [**2113-11-26**]: IMPRESSION: Interval evolution of infarction with mildly decreased but persistent edema and decreased leftward shift of midline structures. No evidence of hemorrhagic conversion. Brief Hospital Course: 48yo F with HTN who presented with headache and was found to have multiple strokes in the ACA/MCA territory, on admission thought likely embolic, also had cerebral edema and 11mm midline subfalcine shift likely secondary to ischemic stroke. # Neuro: She was admitted with significant HA and somnolence which persisted throughout ICU stay. On [**2113-11-21**] she was noted to be more engaged with more manageable headache intensity on fioricet/tylenol. Although she was intermittently oriented x3, she became somewhat paranoid and very disinhibited likely as a result of her strokes. In terms of motor strength, she had left sided face/arm/leg weakness that were stable. Repeat CT scans of her head revealed slightly increase midline shift without hemorrhage. She was started on mannitol. Stroke workup revealed 95% stenosis of her right ICA as well as and incidental meningioma around intracranial ACA that Nsurg decline to operate on and will follow up on in brain tumor clinic. She was started on heparin Gtt for the stenosis and then bridged to coumadin. Her exam improved on mannitol, and eventually the mannitol was able to be stopped. Her repeat head CT on [**11-26**] showed improved edema and size of the infarct. She will be seen for a likely CEA by vascular surgery at the end of [**Month (only) 404**], but will be seen by neurology prior to that appointment for the final determination if she should go for the CEA. She will receive a repeat CTA before her neruology appointment. She received a hypercoagulability workup while here prior to being started on coumadin which was negative. Therefore we felt that the most likely cause of her stroke was from her 95% R ICA stenosis. She was treated with fioricet for her HA while here. # CVS: No afib noted on tele, BP allowed to autoregulate from 120-160 with hydral prn. We started pt on simvasatin 40mg QD for an LDL of 211. # Nutrition: She passed swallow eval and was started on a limited oral diet but intermittently refused food given paranoia about poisoning. Eventually her paranoia improved and she continued to eat a soft diet. # Code: Full; Contact [**Name (NI) **] [**Name (NI) **] (boyfriend) [**Telephone/Fax (1) 87257**] (c) /[**Telephone/Fax (1) 87258**] (h) or sister: [**Telephone/Fax (1) 87259**] PENDING RESULTS: None TRANSITONAL CARE ISSUES: Patient will need her INR monitored to acheive a goal of [**1-19**], and will need her warfarin dose adjusted accordingly. Medications on Admission: Does not take meds (listed though are lisinopril and metoprolol) Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for headache for 7 days: Do not exceed 4 grams of tylenol in 24 hours. 3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 9. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Please adjust dose to acheive goal INR of [**1-19**]. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Right ICA 95% stenosis ACA/MCA territory infarcts clival meningioma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. NEURO EXAM: slow to respond; mild L-sided weakness, L facial droop Discharge Instructions: Dear Ms. [**Known lastname 87260**], You were seen in the hospital because of a headache and confusion and it was found that you had a stroke. We made the following changes to your medications: 1) We STARTED you on SIMVASTATIN 40mg once a day. 2) We STARTED you on FIORICET 1 to 2 tabs every 4 hours as needed for headache. Do not exceed 4 grams of tylenol in 24 hours. 3) We STARTED you on HYDROCHLOROTHIAZIDE 25mg once a day. 4) We STARTED you on FOLIC ACID 1mg once a day. 5) We STARTED you on THIAMINE 100mg once a day. 6) We STARTED you on a MULTIVITAMIN once a day. 7) We STARTED you on DOCUSATE 100mg twice a day. 8) We STARTED you on SENNA 8.6mg twice a day as needed for constipation. 9) We STARTED you on COUMADIN 4mg once a day, but this dose will be adjusted to maintain an INR of [**1-19**]. 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: Department: RADIOLOGY When: TUESDAY [**2113-12-26**] at 9:30 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: RADIOLOGY When: TUESDAY [**2113-12-26**] at 9:45 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: NEUROLOGY When: WEDNESDAY [**2114-1-3**] at 1:30 PM With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Brain [**Hospital 341**] Clinic When: [**2114-1-8**] at 10:30am With: Dr. [**Last Name (STitle) 6570**] ([**Telephone/Fax (1) 6574**] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] DEPARTMENT: Vascular Surgery WHEN: [**2114-1-15**] 09:00a WITH: [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 2625**] WHERE: LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **] VASCULAR SURGERY [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "225.2", "348.5", "305.00", "293.0", "433.11", "401.9", "310.0", "305.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10186, 10229

6835, 9298

294, 301

10341, 10341

2420, 2420

11605, 13090

1058, 1068

9414, 10163

10250, 10320

9324, 9391

10589, 10755

3268, 6812

1858, 2401

10784, 11582

246, 256

329, 933

2437, 3251

10356, 10565

955, 962

978, 1041

1843, 1843

6,856

194,572

6549

Discharge summary

report

Admission Date: [**2122-8-18**] Discharge Date: [**2122-9-5**] Date of Birth: [**2067-3-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 17683**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: PROCEDURE: 1. Exploratory laparotomy, diverting end colostomy, left- sided. 2. Irrigation of pelvic abscess, placement of drains in pelvic abscess. 3. Intubation History of Present Illness: Mr. [**Known lastname 25087**] is a gentleman with rectal cancer originally treated in the beginning of [**2116-11-11**] with combined modality 5-FU, leucovorin, and radiation therapy with good response. He was well until [**2121-7-11**] when his CEA began to rise. Workup revealed a left lower lobe nodule and a right upper lobe mass. He underwent a VATS resection of the right upper lobe on [**2121-12-10**] and the pathology revealed a metastatic tumor from a colonic origin. Mediastinal lymph node sampling was negative. He then underwent a left lower lobe wedge resection on [**2122-1-22**] of the left lower lobe nodule and this was also consistent with a colonic metastasis. He began tx with FOLFOX + Avastin. He required a 20% dose reduction of 5FU bolus and CI due to n/v and abdominal cramping. He completed 3 cycles of this, last dose on [**2122-6-4**]. During his course he developed neck pains and headaches and was found to have a rising CEA. A restaging CT was performed on [**2122-6-15**] and uncovered a PE in a small branch of the LLL pulmonary artery. To evaluate his headache prior to anticoagulation, and MRI was performed on [**2122-6-16**] found a brain metastasis on the right occiptal lobe, and dural enhancement in the L brain. His PE was managed with an IVC filter given the brain metastasis. He underwent resection of his brain metastasis on [**2122-6-19**] with Dr. [**Last Name (STitle) **]. Additionally, an upper extremity ultrasound on [**2122-6-22**] documented the presence of a LIJ thrombus with extension to the subclavian. He began whole brain XRT. This was complicated by forgetfullness, low grade fevers, and persistent headache. His steroids were tapered. He was admitted twice to [**Hospital3 417**] hospital for evaluation of dehydration, hypotension, and fever, without any source identified. He contninued to lose weight and be weak with occasional headache. His steroids were increased with improvement of his headaches, and no further fevers. He was noted to be hyponatremic at the end of [**Month (only) 205**], along with elevated liver enzymes. His phenytoin was being tapered off. Liver US was unremarkable, and LFTs trended down after cessation of phenytoin. A repeat MRI on [**2122-8-13**] was negative. He was advised increase PO intake with gatorade for his hyponatremia. He developed difficulty with constipation, and reported having small incompletely evacuating bowel movements since the end of [**Month (only) 205**]. Laxatives were escalated, but he continued to have difficulty. His home health aide reported he was self rectalizing to assist with his bowel movements. Suppositories were advised, but he continued to have difficulty. He developed worsening abdominal pain and constipation and was referred to his local ED, where he went on [**2122-8-17**]. There he was disimpacted. He was evaluated by surgery and underwent CT scan which demonstrated an anastamotic perforation and abcess with fluid collection. He was transferred to [**Hospital1 18**] for further management. He notes that for the last several weeks he has been having constipation with cramping. This weekend (3dPTA) he began to experience significantly worsened diffuse abdominal pain, which has persisted through his OSH hospitalization. He has had nausea since his chemotherapy, not recently worsened. He has not noted any fevers. Past Medical History: rectosigmoid CA s/p resection [**2116**] and chemo/XRT HTN hyperlipidemia VATS- RUL/LLL nodule - cervical meiastinoscopy with LN biopsy revealed no evidence of malignancy, then s/p VATS RUL Social History: Seven to ten pack year history, discontinued in the [**2086**]. He has had exposure to asbestos working in a shipyard from [**2090**] to [**2095**]. He uses alcohol occasionally and socially. He denies any exposure to uranium, nickel, cadmium, or radon. Lives with wife and 2 [**Name2 (NI) 25084**] 17/19. Family History: Father died of cirrhosis at the age of 49. One sibling with paranoid schizophrenia. One grandparent died of TB. One grandparent had a stroke. One grandparent had an MI. Physical Exam: On discharge- T 96.4 P 93 BP 93/66 RR16 98%4L Gen- weak white male, looks older than stated age, NAD HEENT- NCAT, EOMI Pulm- CTAB. no W,R. soft exp rhonchi on L. CV- RRR. no M,R,G Abd- flat, soft, +BS, colostomy with bag, midline incision staples loosely with no erythema or induration GU- foley in place Ext- 2+ LE and UE edema. petechiae on UE's and LE's. Pertinent Results: [**2122-8-31**] 06:55AM BLOOD WBC-17.9* RBC-3.37* Hgb-10.5* Hct-30.7* MCV-91 MCH-31.1 MCHC-34.1 RDW-19.6* Plt Ct-59* [**2122-9-2**] 09:21PM BLOOD Plt Ct-72* [**2122-8-30**] 07:07AM BLOOD PT-13.6* PTT-23.4 INR(PT)-1.2* [**2122-8-28**] 06:34PM BLOOD Fibrino-220 [**2122-8-25**] 05:06PM BLOOD FDP-10-40 [**2122-8-25**] 05:06PM BLOOD Ret Aut-1.4 [**2122-8-31**] 06:55AM BLOOD Glucose-109* UreaN-29* Creat-0.8 Na-133 K-4.2 Cl-100 HCO3-24 AnGap-13 [**2122-8-30**] 07:07AM BLOOD ALT-71* AST-48* LD(LDH)-469* AlkPhos-246* Amylase-79 TotBili-1.1 [**2122-8-30**] 07:07AM BLOOD Lipase-45 [**2122-8-20**] 03:03AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2122-8-31**] 06:55AM BLOOD Calcium-7.1* Phos-3.1 Mg-1.8 [**2122-8-30**] 07:07AM BLOOD Albumin-2.3* Calcium-7.2* Phos-2.8 Mg-1.9 [**2122-8-28**] 06:34PM BLOOD calTIBC-111* VitB12-[**2043**]* Folate-GREATER TH Ferritn-1870* TRF-85* [**2122-8-25**] 05:06PM BLOOD Hapto-248* [**2122-8-19**] 01:45PM BLOOD TSH-0.85 [**2122-8-19**] 08:58AM BLOOD Cortsol-18.8 [**2122-8-25**] 03:38AM BLOOD Lactate-1.8 [**2122-8-26**] 02:51AM BLOOD freeCa-1.13 [**2122-8-29**] 03:23PM BLOOD SEROTONIN RELEASE ANTIBODY-PND Brief Hospital Course: Pt accepted from OSH. He was started on amp/levo/flagyl, dexamethasone and made NPO. CT showed large amount of free intraperitoneal air, large abscess at level of rectosigmoid anastomosis, severe rectal wall thickening, most likely post-radiation, but intramural abscess extension is also possible, additional second collection to the left of bladder dome, and IVC filter in place with thrombus about filter arms. He was taken to surgery emergently for exp lap. They found evidence of some pus in the abdomen. There was no evidence of gross studding or gross soilage high up in the abdomen. Deep in the pelvis, there was a large amount of pus. There was some fecal contamination contained deep in the pelvis. There was obvious air and stool leaking out of a small perforation quite deep in the pelvis. It was unclear whether this was diverticulitis or at the anastomosis. Postop, he was in respiratory distress and was intubated in the ICU. He continued to do poorly in the ICU with lactic acidosis and resp failure. At most acute, base deficit was -20. Pt was extubated on [**8-25**]. Tubefeeding was started on [**8-22**]. TPN was given for 3 days [**Date range (1) 25088**]. Amp was stopped on [**8-22**] and vanco started. On [**8-24**] he was transfused 2 u PRBCs for anemia. Procrit was started. He was transferred to the floor on [**8-30**]. Abx's were dc'd on [**9-1**]. On [**8-20**] it was noted that plt count was falling. At lowest it was 59. Dx of heparin induced thrombocytopenia was made. All heparin was dc'd and at dc plt count was 71. At dc pt is stable and tolerating full diet. He is sating well on O2 via NC. He can get OOB to chair with assist. Anemia has been difficult to follow due to difficulty accessing blood. Thrombocytopenia is improving. Pt continues to have metastatic colon ca. There are no signs of infection. Pt is coherent neurologically. The colostomy is passing gas and stool. Pt is off antibiotics and on a steroid taper. Stable to transfer to rehab for further PT/OT and hopeful eventual transfer home. Medications on Admission: Zofran, Compazine, Percocet, prn ativan, Prozac, HCTZ. Oxycontin, Oxycodone, Colace, Dexamethasone 4/2/4, Priolsec Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*180 Capsule(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*250 ML(s)* Refills:*2* 3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday) for 1 months. Disp:*qs * Refills:*3* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO twice a day: 2 mg [**Hospital1 **] for 2 days, then 2 mg once a day and 1 mg once a day x 3 days, then 1 mg [**Hospital1 **] x 3 days, the 1 mg qday x 3 days, then off. Disp:*27 Tablet(s)* Refills:*0* 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*60 Capsule(s)* Refills:*2* 8. Albuterol Sulfate 0.083 % Solution Sig: [**1-12**] Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 9. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*360 Tablet(s)* Refills:*0* 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for sleep or nausea. Disp:*30 Tablet(s)* Refills:*2* 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*qs * Refills:*2* 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-12**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*qs * Refills:*2* 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: metastatic colon cancer with perferated viscus Discharge Condition: stable Discharge Instructions: Code status: Do not resuscitate (DNR/DNI) Comments: Per Attending discussion with wife: no pressors, no compressions, no shocking. Do not re-intubate. (ammended [**8-25**] per discussion with family after patient extubation) Medications: Artificial Tears 1-2 DROP OU PRN dry eyes [**9-4**] @ 1605 View Reglan 5-10 mg po q 6-8 h prn nausea Miconazole Powder 2% 1 Appl TP TID Dexamethasone 2 mg PO Q PM, 2 mg PO Q NOON for 2 more days, then decrease to 2 mg q NOON and 1 mg q PM for 3 days, then 1 mg [**Hospital1 **] x 3days, then 1 mg qday x 3 days, then dc. Furosemide 40 mg po BID Lorazepam 0.5 mg PO Q8H:PRN sleep or nausea OxycodONE (Immediate Release) 10 mg PO Q4-6H:PRN pain please hold for sedation, RR<10 Fentanyl Patch 25 mcg/hr TP Q72H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Docusate Sodium 100 mg PO BID:PRN traZODONE HCl 50 mg PO HS:PRN Hydrochlorothiazide 25 mg PO DAILY Pantoprazole 40 mg PO Q24H [**8-29**] @ 1643 View Epoetin Alfa 10,000 UNIT SC QMOWEFR Start: HS 10,000 given M, W, F Oxycodone-Acetaminophen Elixir [**5-20**] ml PO Q4-6H:PRN pain please hold for sedation, RR<10 [**8-28**] @ 0939 View Fluoxetine HCl 40 mg PO DAILY IVF- no IV Nutrition- regular diet, allergic to grapes Resp- O2 via NC as needed to keep O2 > 92% chest pt q4hrs strictly Precautions: Aspiration Ostomy care- bag last changed on [**9-4**] Wound care- Incision- Wet to dry dressing changes [**Hospital1 **] Fingersticks- none Activity- as tolerated, out of bed with assist Lines and drains- Closed suction drain 2 bulb suction, empty q4h, keep on suction Foley to gravity, last changed [**8-28**] Vital signs: q4 o2 Sats: with vitals Weight: qd Monitor urine output: q4h Call HO if: T>101.4 ; HR <60 or >110 ; SBP <90 or >160 ; DBP <60 or >90 ; RR <10 or >22 ; O2 <93 DO NOT GIVE PT HEPARIN Followup Instructions: Hem Onc Appt Dr [**First Name (STitle) **] [**Hospital1 18**] [**Hospital Ward Name 23**] Building [**2122-9-8**] at 9 am Call Dr[**Name (NI) 22019**] office to schedule a follow up appt. ([**Telephone/Fax (1) 25089**] [**2122-11-5**] 10:00a [**Last Name (LF) 1533**],[**First Name3 (LF) **] [**Doctor First Name 25090**] MULTI-SPECIALTY THORACIC UNIT-CC9 [**2122-11-5**] 09:30a XCT (TCC) [**Apartment Address(1) **] RADIOLOGY [**2122-9-8**] 09:00a [**Last Name (LF) **],[**First Name3 (LF) **] P. HEMATOLOGY/ONCOLOGY-CC9 [**2122-9-8**] 09:00a [**Doctor First Name **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**] Completed by:[**2122-9-4**]

[ "272.4", "276.1", "568.0", "569.5", "998.59", "518.81", "564.00", "198.3", "458.29", "E878.2", "E934.2", "562.11", "276.52", "197.0", "285.29", "E849.8", "287.4", "567.22", "V10.05", "401.9", "041.09", "V15.84" ]

icd9cm

[ [ [] ] ]

[ "46.11", "99.15", "38.93", "38.91", "96.04", "99.04", "96.72", "96.6", "54.59", "54.19" ]

icd9pcs

[ [ [] ] ]

10362, 10434

6211, 8280

329, 504

10525, 10534

5051, 6188

12441, 13191

4486, 4658

8445, 10339

10455, 10504

8306, 8422

10558, 12418

4673, 5032

275, 291

532, 3932

3954, 4145

4161, 4470

5,686

126,544

17172

Discharge summary

report

Admission Date: [**2188-7-18**] Discharge Date: [**2188-7-30**] Date of Birth: [**2127-9-17**] Sex: M Service: Cardiothoracic service. HISTORY OF PRESENT ILLNESS: This is a 60 year old man with a history of diabetes type I, heavy smoking and two myocardial infarctions over the past five years, who is status post percutaneous transluminal coronary angioplasty three years ago. He presented to an outside hospital with indigestion, chest burning on [**2188-7-3**]. He ruled out for myocardial infarction and was referred to Dr. [**Last Name (STitle) **] who sent the patient to [**Hospital1 69**] for cardiac catheterization on [**2188-7-4**]. Results revealed three vessel disease, for which the patient was referred to Dr. [**Last Name (STitle) 70**] for coronary artery bypass grafting surgery. The patient is to be a postoperative admit. PAST MEDICAL HISTORY: Significant for hypertension, hypercholesterolemia, insulin dependent diabetes mellitus, cataracts bilaterally, myocardial infarction five years ago, obesity, chronic low back pain. PAST SURGICAL HISTORY: Significant for appendectomy, cataract surgery and right [**Hospital Ward Name 4675**] cyst removal. Cardiac catheterization revealed an ejection fraction of 63%, left main with no critical lesions, left anterior descending 40% with distal left anterior descending 80%; first diagonal small with 80% lesion; left circumflex with 70% lesion and right coronary artery totally occluded. His medications preoperatively included Atenolol 125 mg twice a day, Hydrochlorothiazide 25 mg q. day, Colchicine 0.6 mg twice a day, Lipitor 20 mg q. day, Univasc 15 mg q. day, Humulin N 80 units q. a.m. and 80 units q. p.m. Multivitamins q. day. Excedrin q. a.m. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Retired machinist. He smoked two packs per day times 45 years. He quit on [**2188-7-4**]. Former alcoholic who stopped drinking in [**2154**]. He lives in [**Hospital1 1474**] with his wife. PHYSICAL EXAMINATION: Preoperatively, heart rate was 60, sinus rhythm; blood pressure 156/90; weight 321 pounds; height 5'[**96**]". General: Obese, pleasant man, in no acute distress. Skin: Well hydrated, no rashes or lesions. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Normal dentition. Normal buccal mucosa. Neck is supple with no jugular venous distention, no lymphadenopathy, no thyromegaly. Chest is clear to auscultation bilaterally, with no wheezes, rhonchi or rales. Heart: Regular rate and rhythm. S1 and S2 with no murmurs or rubs. Abdomen is obese, nontender, nondistended, normoactive bowel sounds. No guarding, rebound or rigidity. Extremities: Warm with no edema, cyanosis or clubbing, varicosities none. Neurologic: Cranial nerves 2 through 12 grossly intact. Pulses: Femoral 2+ bilaterally. Dorsalis pedis 1+ on the right, 2+ on the left, posterior tibial 2+ bilaterally, radial 2+ bilaterally. No carotid bruits noted. Carotid pulses 2+ bilaterally. LABORATORY DATA: Preoperatively, glucose was 221; BUN 17; creatinine 0.7; sodium 141; potassium 3.7; chloride 99; C02 29. ALT 41; AST 28; alkaline phosphatase 111; total bilirubin of 0.3. White count 9.1; hematocrit of 41.7. Platelets 215. PT 14, PTT 26. INR of 1.3. Negative urinalysis. Electrocardiogram showed a sinus rhythm with Q waves in 2, 3 and F. Normal intervals. HOSPITAL COURSE: As stated previously, the patient was directly admitted to the operating room on [**7-18**]. At that time, he underwent coronary artery bypass grafting times two. Please see the operating room report for full details. In summary, the patient had a coronary artery bypass graft times two with a left internal mammary artery to the diagonal and a saphenous vein graft to obtuse marginal. He tolerated the operation well and was transferred from the operating room to the cardiothoracic Intensive Care Unit. At the time of transfer, mean arterial pressure was 80 with a central venous pressure of 12. He was on nitroglycerin at 0.5 mcg per kg per minute and Propofol at 10 mcgs per kg per minute. The patient did well in the immediate postoperative period. He was weaned off all cardioactive drugs; however, on postoperative day number one, he remained intubated on pressure support ventilation with 12 of pressure support and PEEP and FI02 of 0.5 with an arterial blood gases of 7.42. C02 of 44 and P02 of 78. During the course of the day, the patient was exercised on pressure support ventilation. We were unable to extubate him successfully on postoperative day number one. For the next several days, the patient was exercised with pressure support ventilation, with decreasing amounts of pressure support on a daily basis. He did, however, remain somewhat hypoxic although he did show improvement on a daily basis. On postoperative day number two, it was also noted that the patient had atrial fibrillation and, at that time, he was started on Amiodarone. On postoperative day number three, the patient underwent a transesophageal echocardiogram at that time. No thrombus was seen. His ejection fraction was normal. Following echocardiogram, the patient was successfully cardioverted back to sinus rhythm. On postoperative day number four, the patient underwent a bronchoscopy because of increasing secretions. Bronchoscopy revealed purulent secretions, predominantly in the right upper and right lower lobe, with mild tracheomalacia. At that time, he was started on Zosyn and cultures were sent. On postoperative day number five, the patient was again placed on minimal pressure support ventilation and successfully extubated. He remained in the Intensive Care Unit for the next few days because of required aggressive pulmonary toilette. On postoperative day number seven, the patient was transferred from the cardiothoracic Intensive Care Unit to [**5-30**] for continuing postoperative care and cardiac rehabilitation. Over the next five days, the patient remained on the floor. His activity level was increased with the assistance of the nursing staff and the physical therapist and on postoperative day number 11, it was decided that the patient would be stable and ready for discharge to rehabilitation on the following morning. At the time of this dictation, the patient's physical examination is as follows: Vital signs: Temperature 98.4; heart rate 71 sinus rhythm; blood pressure 130/70; respiratory rate of 20; oxygen saturation 96% on room air. Weight preoperatively was 145 kg. At discharge, his weight was 141.3 kg. LABORATORY DATA: White count of 15; hematocrit of 33.5; platelets 330. Sodium 137; potassium of 4.2; chloride 99; C02 30; BUN 14; creatinine 0.8; glucose 140; PT 14; PTT 51.2. INR of 1.3. PTT of 51.2 was on 1,800 units per hour of heparin. PHYSICAL EXAMINATION: Alert and oriented times three; moves all extremities, follows commands. Breath sounds clear to auscultation bilaterally. Heart sounds: Regular rate and rhythm. S1 and S2. No murmur. Sternum is table. Incision with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no peripheral edema. DISCHARGE MEDICATIONS: Metoprolol 50 mg twice a day. Lasix 40 q. day times ten days. Potassium chloride 20 meq q. day times ten days. Aspirin 81 mg q. day. Atorvistatin 10 mg q. day. Wolfram to reach a goal INR of 2.0. In the past three days, he has received 5 mg, 5 mg and is to receive 7.5 mg on [**7-29**]. Amlodipine 10 mg q. day. Amiodarone 400 mg q. day times one week and then 200 mg q. day. Colchicine 0.6 mg twice a day. Combi-vent two puffs q. six hours. Erythromycin 500 mg twice a day times two weeks. Regular insulin sliding scale on 70/30 insulin, 40 units in the a.m. and 40 units in the p.m. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass grafting times two with left internal mammary artery to the diagonal and saphenous vein graft to obtuse marginal. Hypertension. Hypercholesterolemia. Diabetes mellitus. Obesity. Chronic low back pain. Status post appendectomy. Status post cataract surgery. Status post right [**Hospital Ward Name 4675**] cyst removal. The patient is to have follow-up with his primary care physician in three to four weeks, following his discharge from rehabilitation. He is to have follow-up with Dr. [**Last Name (STitle) 70**] in six weeks following his discharge from [**Hospital1 1444**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 48170**] MEDQUIST36 D: [**2188-7-29**] 05:19 T: [**2188-7-29**] 16:42 JOB#: [**Job Number 48171**]

[ "519.1", "401.9", "997.1", "427.31", "250.01", "414.01", "V45.82", "V15.82", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.11", "96.6", "99.61", "33.23", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

7964, 8910

7324, 7921

3476, 6876

1095, 1785

6899, 7301

7936, 7943

185, 866

888, 1071

1802, 1997

77,661

149,511

25848

Discharge summary

report

Admission Date: [**2127-5-21**] Discharge Date: [**2127-5-31**] Date of Birth: [**2049-12-10**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 6088**] Chief Complaint: LEFT LOWER EXTREMITY ISCHEMIA Major Surgical or Invasive Procedure: S/P LEFT COMMON FEMORAL ARTERY TO PERONEAL BYPASS WITH NRSVG AND 2ND TOE AMPUTATION History of Present Illness: The patient is a 77 yo male with PMH significant for Peripheral vascular disease s/p multiple interventions, coronary artery disease s/p MI [**2098**], atrial fibrillation who was admitted previously on [**5-15**] for LLE bypass for ischemia and non healing ulcer on left toe. The operation was cancelled in the OR for bradycardia in 20's and 30's prior to induction. Cardiology was consulted and they recommended discontinuing digoxin recommends there is no contraindication to proceeding with surgery. Past Medical History: 1. Coronary artery disease status post inferior myocardial infarction [**2099-10-10**], which was treated conservatively. The most recent ejection fraction in our system is 45% to 50%. 2. Hypertension. 3. Hyperlipidemia. 4. Atrial fibrillation with hospitalization in [**2126-6-23**] for a TIA in the setting of a low INR. 5. Peripheral vascular disease status post revascularization of the left lower extremity with dilation and attempt at stenting back in [**2122-10-23**] by Dr. [**First Name (STitle) **]. He also has a history of open repair of infrarenal abdominal aortic aneurysm, with retroperitoneal approach using a bifurcated aortobifemoral graft in [**2126-7-24**], and most recently has been noted to have a left lower extremity toe ulcer. He has undergone serial arteriogram of the left lower extremity and third-order catheterization of left external iliac artery with plans to pursue a bypass next week. 6. Prostate CA 7. Gout 8. Biliary obstruction Social History: Independent at home, drives. Supportive wife. [**Name (NI) **] home in [**State 108**]. Family History: N/C Physical Exam: ADMISSION PE: 97.8, 77, 135/60, 14, 98% 2l GENERAL: A&O X3 IN NAD LUNGS: CTAB, NO RESP DISTRESS HEART: NL S1/S2, NO MURMURS APPRECIATED ABD: SOFT, NT/ND EXTR: WARM, INCISION CDI LLE: DP DOP PT DOP PERONEAL DOP RLE: DP PALP PT DOP Pertinent Results: [**2127-5-24**] 10:42 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2127-5-25**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2127-5-25**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0425 [**2127-5-25**]. 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). [**2127-5-29**] 12:55 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2127-5-30**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2127-5-30**]): Reported to and read back by [**First Name8 (NamePattern2) 64342**] [**Last Name (NamePattern1) 31774**] @ 0522 ON [**2127-5-30**] FA5 [**Numeric Identifier 64343**]. 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). [**2127-5-21**] 08:15PM BLOOD WBC-9.2# RBC-4.13* Hgb-12.1* Hct-36.4* MCV-88 MCH-29.3 MCHC-33.2 RDW-14.5 Plt Ct-215 [**2127-5-29**] 06:50AM BLOOD WBC-9.5 RBC-3.78* Hgb-11.2* Hct-33.9* MCV-90 MCH-29.7 MCHC-33.1 RDW-14.3 Plt Ct-370 [**2127-5-26**] 06:40AM BLOOD PT-13.4 INR(PT)-1.1 [**2127-5-27**] 06:40AM BLOOD PT-14.8* INR(PT)-1.3* [**2127-5-27**] 06:40AM BLOOD Plt Ct-303 [**2127-5-28**] 06:40AM BLOOD PT-16.2* PTT-27.8 INR(PT)-1.4* [**2127-5-28**] 06:40AM BLOOD Plt Ct-320 [**2127-5-29**] 06:50AM BLOOD PT-19.3* PTT-31.0 INR(PT)-1.8* [**2127-5-29**] 06:50AM BLOOD Plt Ct-370 [**2127-5-30**] 05:50AM BLOOD PT-23.9* PTT-32.2 INR(PT)-2.2* [**2127-5-21**] 08:15PM BLOOD Glucose-104* UreaN-22* Creat-0.8 Na-137 K-4.7 Cl-106 HCO3-23 AnGap-13 [**2127-5-28**] 06:40AM BLOOD Glucose-104* UreaN-25* Creat-0.9 Na-139 K-4.0 Cl-106 HCO3-24 AnGap-13 Brief Hospital Course: Mr. [**Known lastname **] was admitted for elective left lower extremity bypass on [**2127-5-21**]. He underwent left CFA to peroneal bypass with NRSVG and 2nd toe amp on [**5-21**]. He tolerated the procedure well and remained hemodynamically stable. He was extubated and transferred to the PACU. Once recovered, he was transferred to the VICU for close monitoring. On POD 1, pulse exam was stable with dopplerable DP/PT/and peroneal on the left. Labs and blood pressure were stable. IV nitroglycerin was weaned off and arterial line removed. Plavix and lovenox/coumadin was restarted for atrial fibrillation. On POD 2, IVF boluses given for low urine output, otherwise stable. POD 3, patient spiked fever to 101.1. CXR and UA was normal. Encouraged IS use and ambulation. On POD 4, patient had 16 beat run of asymptomatic Vtach and electrolytes were repleted, BMP normal. Diuresis held given diarrhea. Patient positive for C.diff and po flagyl initiated on [**5-25**]. Foley was removed and patient voided adequate amounts. On POD 5, physical therapy recommended rehab placement on discharge. Patient should be full weight bearing on the left with a healing sandal when ambulating. The remainder of his hospitalization uneventful, awaiting rehab placement. On the day of discharge, patient was afebrile, voiding, tolerating a regular diet, with a stable pulse exam. He continues to have frequent loose BMs and will be on contact precautions at rehab for [**Name (NI) **]. PO Flagyl and PO vanco should continue for an additional 14 days, ending [**6-13**]. INR was 2.2 the day before discharge, and received 5mg of coumadin at 4pm. He is to receive 5mg of Coumadin tonight at your rehabilitation facility with appropriate titration of the dose with a goal INR of [**12-26**]. Medications on Admission: Clopidogrel 75mg po daily Metoprolol tartrate 12.5mg po daily Pantoprazole 40mg po daily spironolactone 25mg po daily Flomax 0.4mg po daily warfarin 3mg po daily colace 100mg po daily ferrous sulfate 325mg po daily multivitamin 1 tab daily Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for hr<55, sbp<100 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) d/c on [**6-13**]. 10. warfarin 5mg once daily at 4 PM: Dx: Atrial Fibrillation Goal INR:2-3pm. Pt's last dose of coumadin was 4pm [**2127-5-30**]. Due for [**2127-5-31**] dose. Please titrate dosing accordingly with INR goal. 11. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): D/C on [**6-13**] 12. Outpatient [**Name (NI) **] Work PT/INR to be drawn daily until Coumadin dosing stable. Goal INR [**12-26**] for atrial fibrillation Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: LEFT LOWER EXTREMITY ISCHEMIA NON-HEALLING LEFT 2ND TOE ULCER HYPERTENSION HYPERLIPIDEMIA Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes (BASELINE). Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**12-26**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions DISCHARGE INSTRUCTIONS FOLLOWING Toe AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: You may be full weight bearing with healing sandal on the left foot. You should keep this amputation site elevated when ever possible. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your Surgeon. . No heavy lifting greater than 20 pounds for the next 14 days. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. . When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Please keep your left groin area dry with dry gauze, changed twice daily. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET: . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-6-12**] 12:15 Completed by:[**2127-5-31**]

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icd9cm

[ [ [] ] ]

[ "84.11", "39.29" ]

icd9pcs

[ [ [] ] ]

7938, 8116

4516, 6295

334, 420

8250, 8297

2356, 4493

16517, 16691

2072, 2077

6585, 7915

8137, 8229

6321, 6562

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265, 296

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15834, 16494

448, 953

8312, 8422

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1966, 2056

59,505

128,661

51187

Discharge summary

report

Admission Date: [**2120-2-8**] Discharge Date: [**2120-2-13**] Date of Birth: [**2035-9-16**] Sex: M Service: MEDICINE Allergies: Rituxan Attending:[**First Name3 (LF) 3963**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2120-2-8**] Rituximab infusion [**2120-2-9**] Bendamustine, cycle one, 1st dose [**2120-2-10**] Bendamustin, cycle one, 2nd dose History of Present Illness: The patient is an 84 year old male with lymphoplasmacytic lymphoma s/p four weekly doses of Rituxan in [**7-/2119**], with recent admission c/b pericardial effusion and pleural effusion (transudative s/p thoracentesis) who presents from rehabilitation with shortness of breath. The patient reports gradual onset of his symptoms in the days leading up to presentation. He reports no baseline resting shortness of breath immediately after recent discharge and only mild dyspnea on exertion. He denies associated fevers or chills, chest pain, cough, abdominal pain. He endorses stable lower extremity edema that is symmetric in nature. No orthopnea or PND. . Of note, the patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 106227**]. During that admission, the patient presented with new-onset dyspnea, and was noted to have a pericardial effusion with tamponade physiology. He was monitored in the CCU, though no pericardiocentesis was performed given its small size, and follow-up ECHO revealed improvement in the effusion. Ther patient aslo had a new R-sided pleural effusion on CXR. Therapeutic/diagnostic thoracentesis performed, showing transudative fluid, although flow cytometry of the fluid showed a minute population of lymphocytes c/w his known lymphoma. His course was also complicated by new A.Fib with RVR thought [**3-14**] overdiuresis with high right sided pressures and pericardial effusion. He spontaneously converted back to sinus rhythm, and decision was made not to initiate anticoagulation. . In the ED inital vitals were, 97.7 82 174/83 32 99% neb. EKG was stable compared to prior. His exam was significant for JVD, diffuse crackles, 2+ lower extremity pitting edema from calves to dorsum of feet. Bedside ECHO showed small pericardial effusion, circumferential without tamponade physiology. Pulsus was measured as 8mmHg. CXR was felt to demonstrate worsening pulmonary congestion and R-sided pleural effusion. Labs were significant for lactate 1.2, trop <0.01, BNP 4251 (unclear baseline). He was started on a nitro gtt and initiated on BiPaP. No diuresis was attempted given VS on transfer were: 98.5, 76, 133/62, 22, 99 bipap. . On arrival to the ICU, VS: 76 149/68 23 94%RA. He reports improvement in his shortness of breath. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PAST ONCOLOGIC HISTORY: Patient and his nephew report several years of low grade pancytopenia and progressive fatigue. In the last year fatigue has reached the point that the patient has difficulty with some activities of daily living such a shoveling snow and ambulating outside of his house. Patient also reports a recent weight loss but denies fevers, chills or night sweats. Given the progression of symptoms and counts a bone marrow biopsy was performed which demonstrated a monoclonal B cell population consistent with a lymphoplasmacytic lymphoma. Patient started on Rituximab - Rituximab 4 weekly doses [**2119-7-7**] . ADDITIONAL PAST MEDICAL HISTORY: - HTN - HL - dementia, patient reports trouble with memory - BPH - anemia - GERD - Back pain - Peripheral neuropathy - Inguinal hernia - Ventral hernia - Venous stasis . PSgHx: - Cholecystectomy - Excision of scalp skin cancer Social History: Single. Never married. No children. Nephew ([**Known firstname **]) lives with him. this nephew has severe psychiatric illness and patient reports he cares for him. Denies tob, etoh, drugs. Family History: Brother died of pulmonary embolism Physical Exam: Admission Physical Exam: Vitals: 76 149/68 23 94%RA General: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear Neck: JVP elevated to 3 cm above sternal angle, no LAD Lungs: Crackles at left base, Diminished at R base, no wheeze CV: Regular rate and rhythm, normal S1 + S2, no m/r/g Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ edema b/l . Discharge Physical Exam: VS: 96.8 (97.9) 150/82 (135-160/68-76)75 (60-75) 18 95%RA (95-97%RA) Weight 152.1 lbs (155.3 lbs) I/O 30/550 | 664/800+ Gen: comfortable white male, lying in bed HEENT: EOMI, PERRL, clear oropharynx Neck: no cerv LAD, no JVD Lungs: Minimal bibasilar crackles Heart: RRR, Nl S1/S2, No MRG Abd: Soft, ND/NT, normoactive bowel sounds, +palpable nodular spleen Extr: no edema, 2+ distal pulses Neuro: A+O x3, CNs and motor grossly intact Lines: peripherals look good Pertinent Results: ADMISSION LABS: [**2120-2-8**] 09:55PM GLUCOSE-246* UREA N-20 CREAT-1.1 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 [**2120-2-8**] 09:55PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2120-2-8**] 03:00PM CK(CPK)-24* [**2120-2-8**] 03:00PM CK-MB-2 cTropnT-<0.01 [**2120-2-8**] 03:48AM COMMENTS-GREEN TOP [**2120-2-8**] 03:48AM LACTATE-1.2 [**2120-2-8**] 03:35AM GLUCOSE-223* UREA N-21* CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [**2120-2-8**] 03:35AM estGFR-Using this [**2120-2-8**] 03:35AM cTropnT-<0.01 [**2120-2-8**] 03:35AM proBNP-4251* [**2120-2-8**] 03:35AM WBC-5.2 RBC-3.57* HGB-9.9* HCT-30.9* MCV-87 MCH-27.8 MCHC-32.2 RDW-15.4 [**2120-2-8**] 03:35AM PLT COUNT-140*# [**2120-2-8**] 03:35AM NEUTS-80.7* LYMPHS-15.6* MONOS-2.9 EOS-0.3 BASOS-0.5 . RELEVANT LABS: [**2120-2-11**] 06:15AM BLOOD ALT-12 AST-11 LD(LDH)-221 AlkPhos-77 TotBili-0.4 . DISCHARGE LABS: [**2120-2-13**] 05:55AM BLOOD WBC-2.4* RBC-3.52* Hgb-9.8* Hct-30.2* MCV-86 MCH-27.9 MCHC-32.4 RDW-14.6 Plt Ct-112* [**2120-2-13**] 05:55AM BLOOD Neuts-76.0* Lymphs-18.0 Monos-4.7 Eos-0.8 Baso-0.5 [**2120-2-13**] 05:55AM BLOOD PT-11.3 PTT-28.1 INR(PT)-1.0 [**2120-2-13**] 05:55AM BLOOD Glucose-182* UreaN-21* Creat-1.1 Na-144 K-3.2* Cl-106 HCO3-31 AnGap-10 [**2120-2-13**] 05:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9 UricAcd-6.8 . MICROBIOLOGY: [**2120-2-8**] Blood cultures x2: NGTD . IMAGING: [**2120-2-8**] EKG: Sinus rhythm with ventricular premature depolarization. Borderline low QRS voltage in the limb leads. Compared to the previous tracing of [**2120-1-31**] there is no diagnostic change. Rate 83, QTc 442. . [**2120-2-8**] TTE: There is mild regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis. The remaining segments contract normally (LVEF = 45%). The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension. There is a moderate pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. IMPRESSION: Mild regional left ventricular systoilc dysfunction, c/w CAD. Moderate to severe pulmonary hypertension. Moderate circumferential pericardial effusion. Classic echocardiographic signs of tamponade are not seen, although echo evaluation of this physiology has a reduced sensitivity in presence of significant pulmonary hypertension. . [**2120-2-8**] CXR (PORTABLE): Cardiomegaly is again seen, significantly increased since [**2116**], and appearing gradually increased since [**2120-1-23**] possibly reflecting pericardial effusion. Pulmonary vascular congestion and edema have increased since the [**2120-1-30**], examination. There is an enlarged moderate right pleural effusion. A small left pleural effusion is unchanged. There is no pneumothorax. IMPRESSION: Worsening pulmonary vascular congestion and interstitial edema, with enlarged moderate right pleural effusion. Possible pericardial effusion. . [**2120-2-8**] CXR (PORTABLE): Moderately enlarged heart size from known pericardial effusion is similar. Moderate pulmonary edema has improved; however, moderate right and mild left pleural effusion and bibasilar atelectasis are little changed. There is no demonstrable pneumothorax. Mediastinal and hilar contours are stable. . [**2120-2-9**] CXR (PORTABLE): Moderate cardiomegaly from known pericardial effusion and mild bilateral pulmonary edema persists, but improved since [**2120-2-8**]. Moderate right and minimal left pleural effusion and bibasilar atelectasis is unchanged. There is no pneumothorax. Mediastinal and hilar contours are stable. . [**2120-2-10**] CXR (PA/LAT): PA and lateral chest compared to [**1-30**] through [**2-9**]: Since [**2-9**], mild pulmonary edema has cleared. Pulmonary vascular congestion has decreased. Moderate right pleural effusion is substantially smaller. Moderately severe right basal atelectasis and moderate cardiomegaly are stable. No pneumothorax. Brief Hospital Course: 84 yo man h/o HTN, HL, lymphoplasmacytic lymphoma s/p four weekly doses of Rituxan, recent admission for pericardial/pleural effusion who presents with dyspnea; CXR demonstrating volume overload and worsening R-sided effusion, no e/o of tamponade physiology on bedside ECHO. Initially admitted to the ICU for hypoxemia, but improved with diuresis. Patient continued chemotherapy on the floor. . ACTIVE ISSUES: #. Respiratory Distress: Etiology likely multifactorial, including worsening pulmonary congestion (known CHF w EF 45%) and R-sided pleural effusion (see below). On presentation, did have moderate sized pericardial effusion but no evidence of tamponade on ECHO or measured pulsus (8). Patient improved in ICU with diuresis, which was continued on the floor. He was transitioned to room air. . #. Pericardial effusion: Moderate-sized, minimal change on echo since first seen on [**1-24**]. No echocardiographic signs of tamponade. No pericardiocentesis performed as was too small/high risk. Pulsus was 8, within normal limits. Unlikely to be related to his shortness of breath. Patient was monitored and remained hemodynamically stable. . #. Right pleural effusion: On chest x-ray on admission, this was noted to be increased from prior. Transudative on last diagnostic tap ([**1-25**]). Believed to be [**3-14**] CHF, less likely malignant. Cytology of pleural fluid revealed no malignant cells. However, flow cytometry of the fluid showed a minute population of lymphocytes c/w his known lymphoma, unclear if this was simply contamination of the pleural fluid by traumatic tap. IP was consulted to assess possible drainage of effusion, however they felt it was not loculated and deferred the tap with plan to reassess. After aggressive diuresis, repeat chest x-ray showed improvement of pleural effusion. . #. Lymphoplasmacytic lymphoma: Disease appeared to be controlled after 4 cycles of rituxan in [**Month (only) 116**], though concern that pleural and pericardial effusions could be related to underlying disease. Rituxan was started [**2120-1-28**], complicated by a tranfusion reaction with afib w RVR, hypotension. Attempted to give another infusion of rituxan on [**2-8**], and per BMT recs, gave pre-treatment with benadryl, tylenol, and steroids. Unfortunately he had a severe reaction to the infusion, even at an extremely low rate (3cc/hr) this time with wheezing, tachypnea, hypertension and tachycardia. After leaving the ICU, the patient received two doses of bendamustine, without incident. After discharge from the hospital, he will follow up with Dr. [**Last Name (STitle) 3759**]. He will continue bendamustine therapy. Treatment with rituxan will be attempted again at a slower rate. At the time of discharge, the patient had human anti-chimeric and anti-murine antibodies sent out for testing to evaluate for allergy to rituxan. Patient was also started on allopurinol 150 mg PO daily for tumor lysis syndrome. . #. Hypertension: Initially in 170s in ED, started on nitro gtt prior to arrival in the ICU. He was restarted on captopril and metoprolol and weaned of the nitro gtt. He did continue to have some hypertension, so captopril was up-tirated. Blood pressure was well-controlled after increase in captopril and diuresis. . . CHRONIC ISSUES: #. Atrial fibrillation: In sinus during this admission. Continued on his home metoprolol . #. Thrombocytopenia: Above recent baseline. Platelets were monitored. . #. Seizure Ppx: Sustained left temporal lobe caudate head hemorrhage and scattered acute subarachnoid hemorrhages after a fall this year. Continued on his home dose of levetiracetam 500 mg PO BID . TRANSITIONAL ISSUES: # Patient will follow up with Dr. [**Last Name (STitle) 3759**] on Tuesday, [**2-20**], [**2120**]. His office will be in touch about the time for this appointment. At that appointment, he will determine optimal timing for the next dose of rituximab. # Human anti-murine antibody and human anti-chimeric antibody were sent-out at the time of discharge. Dr. [**Last Name (STitle) 3759**] will follow up these labs. # Communication: Patient # Code: Full (discussed with patient) Medications on Admission: Medications: (per recent d/c summary) - fluoxetine 40 mg PO once a day - levetiracetam 500 mg PO BID - omeprazole 20 mg PO once a day. - oxybutynin chloride 5 mg PO BID - docusate sodium 100 mg PO BID - ferrous sulfate 300 mg PO BID - albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Q6H prn - senna 8.6 mg PO BID as needed for constipation. - metoprolol succinate 50 mg PO once a day. - captopril 25 mg PO Q8H - olanzapine 5 mg PO QHS as needed for insomnia. Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO twice a day. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) soln Inhalation every six (6) hours. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 10. captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 11. olanzapine 5 mg Tablet Sig: One (1) Tablet PO qhs prn as needed for insomnia. 12. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 13. ferrous sulfate 324 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary diagnosis: CHF exacerbation . Secondary diagnosis: Lymphoplasmacytic Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 106228**], It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted because you had shortness of breath, caused by an acute worsening of your congestive heart failure. You improved after fluid was taken off with intravenous diuretic medications. While you were in the hospital, you received new chemotherapy with bendamustine. You tolerated this well, and will continue this treatment at your outpatient visits. Also, of note, you had an infusion reaction with rituximab, while you were in the Intensive Care Unit. As this medication is important, treatment with it will be attempted again at a slow rate after you leave the hospital. Please note, the following changes have been made to your medications: 1.) START furosemide 20 mg by mouth daily 2.) START allopurinol 150 mg by mouth daily 3.) INCREASE captopril to 75 mg by mouth three times per day Please continue to take all of your other medications as you had prior to your admission. It is important that you follow up with your doctors [**First Name (Titles) **] [**Name5 (PTitle) 15968**]. Please keep the appointments that have been made for you, as listed below. Wishing you all the best! Followup Instructions: **You will be seen in Dr.[**Name (NI) 8805**] Clinic next Tuesday, [**2-20**]. His office will be in touch with you with the time for this visit.** Department: [**Hospital1 18**] [**Location (un) 2352**] When: FRIDAY [**2120-2-16**] at 8:10 AM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: WEST PROCEDURAL CENTER When: MONDAY [**2120-2-19**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2120-2-19**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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Discharge summary

report

Admission Date: [**2153-4-23**] Discharge Date: [**2153-4-30**] Date of Birth: [**2090-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: chronic cholecystitis, umbilical hernia Major Surgical or Invasive Procedure: [**2153-4-23**] - laparoscopic converted to open cholecystectomy, umbilical hernia repair History of Present Illness: Mr. [**Known lastname 3419**] is a 62 year old gentleman with quite marked coronary disease and chronic atrial fibrillation, who developed severe cholangitis about 8 weeks ago requiring cholecystostomy drainage and ICU stay. He improved with antibiotics and percutaneous drainage, and is now sheduled for cholecystectomy and repair of his umbilical hernia. He was taken off his anticoagulants 5 days prior to surgery. Past Medical History: Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: CABG, in [**2139**] anatomy as follows: . Other Past History: #. CAD s/p CABG [**2139**] at [**Hospital1 2025**], stress test in [**11-25**] negative for ischemia #. CHF, EF 60 % on stress test in [**11-25**] #. HTN #. Hyperlipidemia #. Type 2 diabetes mellitus - on lantus #. CRI - Crea 0.7 in [**Month (only) 1096**], peak at 4 during ICU stay #. b/l leg ulcers w/chronic peripheral edema #. Neuropathy Social History: Retired retail manager. Married, 3 adult children. Former smoker. Denies ETOH. . Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: On admission: VS 98.7, HR 88, 112/67, 18, 94% on 2L NC GEN: NAD HEENT: PERRLA, EOMI, no icterus or injection, oropharynx pink/moist CHEST: CTA B/L HEART: S1S2 RRR, no M/G/R ABD: Soft, appropriately tender postoperatively, mildly distended, no bowel sounds. WOUND: Surgical dsg with bloody staining @ inferior aspect. Pertinent Results: ***** [**4-23**] OPERATIVE REPORT: Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 98484**] Service: [**Last Name (un) **] Date: [**2153-4-23**] Date of Birth: [**2090-6-19**] Sex: M Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**], MD 2178 FIRST ASSISTANT: [**Doctor Last Name **] [**Doctor Last Name **], INT PREOPERATIVE DIAGNOSIS: 1. Chronic cholecystitis with cholecystostomy tube in place. 2. Large incarcerated umbilical hernia. POSTOPERATIVE DIAGNOSIS: Same. OPERATION: 1. Attempted laparoscopy, conversion to open. 2. Open cholecystectomy. 3. Repair of incarcerated umbilical hernia. ANESTHESIA: General. INDICATION: This patient with quite marked coronary disease and chronic atrial fibrillation was taken off his anticoagulants 5 days prior to surgery and brought to the operating room to deal with chronic cholecystitis which was a result of having had a cholecystostomy tube in place when he developed severe cholecystitis and cholangitis and required an intensive care unit stay some 6 or 8 weeks ago. He also had a large incarcerated umbilical hernia. The goal was to try and perform this operation laparoscopically and then repair the umbilical hernia but this turned out to be impossible. TECHNIQUE: We placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24631**] cannula through the upper part of the umbilical hernia after entering the peritoneal cavity, and upon inflating the abdomen it was quite clear that this was not going to be a laparoscopic operation and we therefore made a midline incision. FINDINGS: The patient had extensive adhesions around the gallbladder, between the gallbladder and the liver and between the liver and the abdominal wall. The cystic duct and cystic artery were eventually well-seen. The gallbladder contained multiple small stones and the back of the gallbladder wall had to be left on the liver as there was simply no plane to carry out the dissection. This operation was therefore much more prolonged than normal (at least 75% longer and more complicated). Additionally, the umbilical hernia itself required a substantial dissection to repair it. TECHNIQUE: The gallbladder was first of all visualized after dissecting off for the surrounding adhesions and then it was aspirated of green bile. An attempt was then made to take it down from the fundus towards the cystic-common duct junction but there was simply no plane. We entered the gallbladder, therefore, and left the posterior wall of the gallbladder on the liver bed as we came down towards the neck of the gallbladder. At this point, I identified the cystic duct node and adjacent to it came across the cystic artery. This was therefore doubly clipped. We then proceeded millimeter by millimeter to identify the cystic duct which was done. It was clipped twice and the gallbladder was then removed. As I stated, the back wall of the gallbladder was left on the liver bed as there was simply no plane from all the chronic inflammation. With the gallbladder removed, we carried out a careful check for hemostasis, and we then turned our attention to the umbilical hernia. The midline incision was extended to this area and the incarcerated tissue was reduced and partially excised. The skin of the umbilicus had been so stretched out by the size of this hernia that it too was removed and the patient will have no umbilical skin component. The edges were identified of the fascia and freed up circumferentially. We then closed the entire incision with #1 PDS and staples to the skin. The patient tolerated procedure well and was returned to the recovery room. ***** [**4-25**] ECHO: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2153-2-27**], the findings are similar ***** [**4-27**] CT ABDOMEN/PELVIS: IMPRESSION: 1. Large hematoma extending from the gallbladder fossa inferiorly. High density within the upper portion of the hematoma likely represents more acute bleeding. Active extravasation cannot be assessed without IV contrast. 2. Second pocket of fluid anterior to the left lobe of the liver containing air pockets and heterogeneous fluid, likely postoperative sequelae, but possibly communicating with the large hematoma in the gallbladder fossa. 3. Bilateral pleural effusions and lung base airspace opacities which could represent extensive atelectasis. Other considerations include aspiration or pneumonia. 4. Unchanged appearance of enlarged kidneys with perinephric stranding, consistent with renal disease as discussed on recent ultrasound examinations. 5. Stable appearance of calcified splenic lesion. Brief Hospital Course: Mr. [**Known lastname 3419**] was taken to the operating room on [**2153-4-23**] for attempted laparoscopic cholecystectomy; however he was converted to open due to extensive inflammation of his gallbladder. Please see operative report for further details of the operation. Postoperatively he was transferred to the floor in stable condition on Vancomycin and Zosyn. That evening he was transfused 1 unit of blood for low urine output, tachycardia, and hct of 26. His hematocrit responded appropriately. He did have some fevers overnight, but this was not completely unexpected given the nature of his operation. On POD 1 his diet was advanced to clears and he was restarted on his bumex for chronic CHF. In the late morning he developed atrial fibrillation with rapid ventricular response, which was unresponsive to boluses of lopressor and diltiazem, and he was also more hypotensive to SBP 90-100. He was transferred to the [**Hospital Unit Name 153**], where drips of amiodarone and verapamil were also unsuccessful. His troponins were mildly elevated but there was no evidence of active MI on his EKG or exam. Cardiology was [**Name (NI) 653**], he was he was chemically cardioverted with IV ibutilide x2 doses. He spontaneouly reverted back to sinus rhythm overnight, and stayed in sinus for the remainder of his hospitalizaion. Flagyl was added empirically to his antibiotic regimen for persistent fevers. On POD 2 he was restarted on a regular diet, and he was restarted on his Coumadin on POD3. His creatinine increased to 2.4 but returned to baseline with hydration. On POD 4, his hematocrit was found to be 17, so he was transfused 2 units of blood. He also had a CT without contrast, which revealed a 10 cm hematoma in his liver bed. He was never tachycardic or hypotensive. His hematocrit responded appropriately to the transfusion, and remained stable for the rest of his hospitalization. From POD [**4-25**] his condition improved markedly - his fevers subsided, he regained bowel function, tolerated regular diet, and was ambulating independently. He was restarted on his home dose of Coumadin on POD 6 and cleared by PT for discharge home on POD7. Medications on Admission: ASA 325', Bumex 4', colace PRN, Lantus 31units QPM, Novolog SS, coumadin, lipitor 20', Toprol XL 100', protonix 40' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Bumetanide 2 mg Tablet Sig: Two (2) 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*10 Tablet(s)* Refills:*0* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 9. Insulin Glargine 100 unit/mL Solution Sig: Thirty Nine (39) units Subcutaneous at bedtime. 10. Insulin Aspart 100 unit/mL Solution Sig: sliding scale units Subcutaneous four times a day: same sliding scale as before. 11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: chronic cholecystitis atrial fibrillation anemia acute on chronic renal failure Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. ACTIVITY: *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * Continue to ambulate several times per day. MEDICATIONS: * Please resume all regular home medications and take any new meds as ordered. Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please call Dr.[**Name (NI) 10946**] office ([**Telephone/Fax (1) 9**]) to schedule a followup appointment for 1-2 weeks from now. Please call the [**Hospital3 **] ([**Telephone/Fax (1) 10844**] to make an appointment for 1-3 days after your discharge to followup your INR and dose your Coumadin Call your Primary Care physician to schedule [**Name Initial (PRE) **] postoperative visit for 2-3 weeks from now. Completed by:[**2153-5-1**]

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icd9cm

[ [ [] ] ]

[ "99.04", "53.49", "51.22" ]

icd9pcs

[ [ [] ] ]

10831, 10837

7395, 9579

355, 447

10961, 10968

1960, 7372

12519, 12962

1526, 1608

9745, 10808

10858, 10940

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1623, 1623

276, 317

475, 896

1637, 1941

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1427, 1510

9,915

152,104

19719

Discharge summary

report

Admission Date: [**2137-10-18**] Discharge Date: [**2137-10-21**] Date of Birth: [**2087-2-5**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 9240**] Chief Complaint: melena Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: HPI: Pt is 50 yo f with h/o stage IIa clear cell cancer of the ovary, s/p surgery and six cycles of carboplatin and Taxol completed in [**2135-7-3**] with no known disease recurrence, who was found to have a hct of 16.9 today. Pt had seen her PCP several weeks ago, and reportedly had an abdominal CT showing enlarged "groin lymph nodes." Pt then had an abdominal MRI, which reportedly showed gallstones (unclear if lymph nodes were still considered to be pathologic by MRI). Pt says she has had fatigue for the past 5 days, as well as black, tarry stools x 5 days. She says she gets SOB after walking 1000ft. No CP, N/V, F/C, hematemesis, hemoptysis, or BRBPR. + night sweats x several days as well as lightheadedness x several days. She has used motrin, ASA, and alleve PRN x 3 days for a headache. Pt saw her oncologist today to discuss her recent radiographic findings, and also c/o fatigue at that time. CBC showed hct 16.9, and she was told to come to the ED. . In the [**Name (NI) **], pt had NGL which showed coffee-ground material, but reportedly then became negative after 800cc NS. She had guaiac + black stool on rectal exam. She recieved 1L NS, 1 U PRBC, and Protonix 40mg IV. The GI service was consulted. Pt is now being transferred to the [**Hospital Unit Name 153**] for further management. . . . [**Hospital Unit Name 13533**]: Pt arrived to the [**Hospital Unit Name 153**] in hemodynamically stable condition. Large bore IV's were placed, [**Hospital1 **] PPI started. She was seen by the GI service and underwent EGD on [**10-19**], which revealed 2 ulcers at the rim of her hiatal hernia. A single ulcer was actively oozing at its edge, and was treated with cautery. Pt received 3U PRBC in total, with increase in HCT from 16 to 28. On [**10-20**], pt was without further hematemesis. She had 2 BM which were formed, dark, but without red blood. She denies abdominal pain, n/v. She was tolerating clears without difficulty. H. pylori serologies were ordered. Pt was continued on sucralfate QID. She was transferred to the medical floor on [**10-20**]. Past Medical History: - stage IIa clear cell cancer of the ovary: found during surgery for endometriosis and fibroids, s/p TAH-BSO and six cycles of carboplatin and Taxol completed in [**2135-7-3**] with no known disease recurrence - pyloric stenosis status post vagotomy and pyeloplasty/pyloric sphincter in [**2123**] - ? h/o Afib - HTN - asthma - h/o R Bell's Palsy Social History: Married. No children. No smoking, EtOH, or IVDU. . Family History: Father had 2 MI's (first at age 63). Mother had MI in her 60's. Brother had MI at age 57. Physical Exam: Vitals: T 97.1 BP 136/60 HR 91 RR 16 O2 99% 2L Gen: NAD, lying in bed, pale HEENT: PERRL. Neck: Supple Cardio: RRR, nl S1S2, 2/6 SEM @ LUSB Resp: CTAB. No wheeze. Abd: obese, soft, nt, +BS. Healed midline vertical scar. Ext: no c/c/e Neuro: A&Ox3 Pertinent Results: [**2137-10-18**] 11:15PM WBC-10.7 RBC-2.85*# HGB-7.8*# HCT-23.2*# MCV-81* MCH-27.3 MCHC-33.6 RDW-17.3* [**2137-10-18**] 11:15PM PLT COUNT-348 [**2137-10-18**] 03:50PM GLUCOSE-129* UREA N-17 CREAT-0.8 SODIUM-140 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 [**2137-10-18**] 03:50PM IRON-22* [**2137-10-18**] 03:50PM calTIBC-312 FERRITIN-2.6* TRF-240 [**2137-10-18**] 03:50PM WBC-9.6 RBC-1.88* HGB-4.8* HCT-15.3* MCV-82 MCH-25.6* MCHC-31.4 RDW-19.0* [**2137-10-18**] 03:50PM NEUTS-77.1* LYMPHS-18.7 MONOS-2.5 EOS-1.6 BASOS-0.2 [**2137-10-18**] 03:50PM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-2+ [**2137-10-18**] 03:50PM PLT COUNT-403 [**2137-10-18**] 03:50PM PT-12.4 PTT-19.2* INR(PT)-1.1 [**2137-10-18**] 10:55AM ALT(SGPT)-17 AST(SGOT)-22 ALK PHOS-97 [**2137-10-18**] 10:55AM CA125-14 [**2137-10-18**] 10:55AM WBC-10.7 RBC-2.11*# HGB-5.4*# HCT-16.9*# MCV-80*# MCH-25.5*# MCHC-31.8 RDW-19.0* [**2137-10-18**] 10:55AM PLT COUNT-473* [**2137-10-18**] 10:55AM GRAN CT-7970 . CXR: Lungs clear. Heart size normal. No pleural effusion. Small hiatus hernia present. Nasogastric tube ends in the upper stomach. No pneumothorax or appreciable pleural effusion. . Brief Hospital Course: # UGIB/anemia - s/p successful cautery of two ulcers at edge of hiatal hernia via EGD on [**10-19**], felt likely due to excess NSAID usage, adised to avoid NSAIDs. - continue [**Hospital1 **] PPI (change to PO today), treated in house with sucralfate. - hct remained stable 24h post EGD -H. pylori negative . # ovarian ca - no known dx recurrence, f/u OSH imaging studies for ? of increased intrabdominal lymphadenopathy. Discussed with oncologist, f/u with Dr. [**Last Name (STitle) **]. . . # HTN - holding verapamil in setting of GIB, BP remained stable, restarted on d/c. . . # asthma - continue home meds. . . # FEN - - tolerating reg diet . Medications on Admission: Verapamil 80mg [**Hospital1 **] Singulair qd Ventolin PRN Flovent [**Hospital1 **] Advil, motrin, ASA prn Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. 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* 4. Ventolin 90 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 5. Verapamil 80 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI Bleed Discharge Condition: stable Discharge Instructions: Please continue your medications as listed below. Please make sure you avoid taking any over the counter pain medications other than tylenol without checking with your doctor. Please also avoid alcohol. Call your doctor if you experience continuing black stool beyond the next day, or lightheadedness, shortness of breath, or fatigue. Followup Instructions: 1. Please follow up with your PCP in the next 1-2 weeks. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21074**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2137-12-13**] 9:00 3. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2137-12-13**] 9:00

[ "531.40", "493.90", "285.1", "401.9", "E935.9", "553.3" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

5838, 5844

4462, 5112

280, 298

5903, 5912

3253, 4439

6295, 6627

2877, 2969

5268, 5815

5865, 5882

5138, 5245

5936, 6272

2984, 3234

234, 242

326, 2422

2444, 2792

2808, 2861

12,021

184,622

2863

Discharge summary

report

Admission Date: [**2151-5-15**] Discharge Date: [**2151-5-21**] Date of Birth: [**2110-9-2**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Abdominal pain with fever, chills. HISTORY OF PRESENT ILLNESS: The patient is a 40 year old male with a past medical history significant for HIV (diagnosed in [**2131**], with CD4 count 550 in [**11-16**], viral load less than 50), depression, and polysubstance abuse, who presented to the Emergency Department with complaints of abdominal pain associated with fevers and chills as well as transient chest pain following recreational drug use. The patient presented to the Emergency Department following several day history of recreational drug use including methamphetamine, GHB, and Viagra with complaint of transient episode of substernal chest pain. The patient's chest pain resolved by arrival to the Emergency Department. However, on review of systems, the patient reports a several day history of crampy abdominal pain associated with intermittent fever and chills. The patient denied diarrhea, nausea, vomiting, as well as intolerance of oral intake. The patient reported recent use of substances including Viagra, GHB and methamphetamine for purposes of sexual enhancement. The patient does report prolonged history of depressed mood with recent worsening, however, denied current intoxication as a suicide attempt and/or gesture. The patient is currently being treated for depression with medication as well as counselling therapy. He denies prior suicide attempts. On arrival to the Emergency Department, the patient was found afebrile and hemodynamically stable. However, shortly after presentation, the patient clinically deteriorated with spiking temperatures to 104.0 F. associated with myoclonic movement and decreased mental status. The patient received 6 mg of intravenous Ativan for myoclonus and subsequently was noted with symptomatic hypotension with systolic blood pressures in the 80s, heart rate in the 140s. The patient was subsequently intubated for airway protection. The patient's acute change in mental status with clinical deterioration was worked up in the Emergency Department with radiologic studies including a negative head CAT scan, normal chest x-ray, and abdominal CAT scan notable for diffuse colonic wall thickening (right greater than left). The patient's serum toxin screen was notable for amphetamines. The patient's initial blood work was notable for a white blood cell count of 15.8, total bilirubin of 3.6 with mildly elevated transaminases, a CPK of greater than 3,000, and an anion gap of 17. The patient underwent a lumbar puncture with evidence of benign CSF fluid. The patient received a total of 6 liters of intravenous fluids (no pressors) while in the Emergency Department and was started on broad spectrum antibiotics including Vancomycin, Ceftriaxone, Acyclovir, and Flagyl. The patient was subsequently transferred to the Medical Intensive Care Unit for further evaluation. PAST MEDICAL HISTORY: 1. HIV diagnosed in [**2131**] with a well preserved CD4 count, last 550 in [**11-16**], with a viral load less than 50. HIV complicated by opportunists including Giardia, thrush, hepatitis B virus, anogenital HSV, and VZV. The patient is reportedly compliant with his HAART therapy. 2. Depression with no prior suicide attempts. 3. PTFE. 4. Asthma. 5. Sinusitis. 6. History of congenital retinopathy. 7. Status post L5-S1 disc surgery. 8. Gastroesophageal reflux disease. 9. History of anal dysplasia. ALLERGIES: No known drug allergies. MEDICATIONS: On admission: 1. Neurontin 300 mg p.o. q day. 2. Abacavir 300 mg p.o. b.i.d. 3. Lamivudine 150 mg p.o. b.i.d. 4. Stavudine 40 mg p.o. b.i.d. 5. Wellbutrin SR 150 mg p.o. q.a.m. 6. Flovent 110 mcg 2 puffs inhaled b.i.d. 7. Albuterol 2 puffs q4 to 6 hours p.r.n. 8. Protonix 40 mg p.o. q day. SOCIAL HISTORY: The patient lives with his partner and reports a history of sexual addiction. He also reports a history of polysubstance abuse including Methamphetamines and GHB with a prior history of alcohol abuse (none currently). The patient is a prior tobacco user (quit in [**2142**]). FAMILY HISTORY: Notable for bipolar disease in the patient's mother and depression in the patient's father. PHYSICAL EXAMINATION: On admission the Medical Intensive Care Unit temperature 101.1, blood pressure 95/60 (previously 88/56), heart rate 72, respiratory rate 20, oxygen saturation 98%, intubated. In general, the patient is intubated and sedated. Spontaneously moving all 4 extremities with no response to voice, however, withdrawal to pain. HEENT exam: Normocephalic, atraumatic, extraocular movements intact bilaterally, pupils equally round and reactive to light and accommodation, moist mucous membranes. Neck exam: Supple with no lymphadenopathy or jugulovenous distension. Cardiovascular exam: Regular rate and rhythm with normal S1, S2, no murmurs, rubs or gallops. Pulmonary exam: Transmitted upper airway sounds otherwise, clear to auscultation bilaterally. Abdominal exam: Hyperactive bowel sounds, nondistended with mild tenderness to palpation diffusely, no guarding. Rectal exam: Heme negative with no masses appreciated. Extremities: Warm and well perfused and no lower extremity edema. Neurologic exam: Limited secondary to sedation, however, normal muscle tone, normal patellar reflexes, downgoing toes, generalized withdrawal to pain. LABORATORY DATA: On admission CBC with a white blood cell count of 15.8, hematocrit 40.7 and platelets of 301 with a white blood cell differential of 75% polys, 14% bands, 3% lymphs, 3% monos. Chem-7 with a sodium of 133, potassium 3.4, chloride 98, bicarb 18, BUN 15, creatinine 1.0 and glucose 92. LFT's with an ALT of 50, AST 105, CK 3,326, CK MB 3 and troponin I of less than 0.3. Amylase 46 and total bilirubin 3.6. Calcium 10. CSF fluid analysis with 3 white blood cells (7 polys, 87 lymphs, 7 monos) and one red blood cell, with 28 protein and 78 glucose. Serum tox screen notable for positive amphetamine, otherwise, negative. Urinalysis notable for 150 ketones, leuk esterase and nitrate negative, 0 to 2 white cells with occasional bacterial and less than 1 squamous epithelial cell. Initial ABG post intubation, the pH is 7.35, pCO2 31, pO2 243 (setting unknown). Radiologic study of note during hospitalization: Head CT on [**5-15**] with no acute intracranial process. Chest x-ray on [**5-15**] with no acute cardiopulmonary process. Abdominal CT on [**5-15**] with evidence of marked thickening of the cecum, ascending, and transverse colon extending to the splenic flexure with no air fluid levels, no free air, otherwise, unremarkable. Right upper quadrant ultrasound on [**5-18**] notable for a diffuse hypoechoic liver consistent with fatty infiltration with a patent portal vein and hepatopetal flow, gallbladder notable for presence of sludge with small pericholecystic fluid, without wall thickening or distention. Additional labs during the hospitalization: TSH of 2.1, cortisol level 22.5, vitamin B12 335 with a folate level pending at the time of admission and lactate of 1.4. Microbiologic studies during the hospitalization: Initial cultures from [**5-15**] including urine, CSF, and blood cultures without growth. Stool culture from [**5-16**] notable for Shigella flexneri, otherwise, negative for C. difficile, O and P, Giardia, uricemia, Campylobacter, as well as E. coli. Followup urine culture on [**5-18**] with no growth at the time of dictation. Chlamydia, PCR and RPR from [**5-18**] also negative. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with presumed sepsis in the setting of poly substance intoxication. The patient was pan cultured including blood, urine, CSF, as well as stool and started on broad spectrum antibiotics including ampicillin, Levofloxacin, and Flagyl as well as aggressive IV hydration. Following admission, the patient developed large, frequent stool output which was cultured on frequent occasions. The patient was evaluated by the Surgical as well as Gastroenterology Service for pan colitis with associated increased liver function tests. The pan colitis was initially felt to be likely secondary to ischemic colitis in the setting of amphetamine intoxication and the patient was treated conservatively with aggressive IV hydration. The patient was evaluated with a right upper quadrant ultrasound with evidence of gallbladder sludge and small amount of pericholecystic fluid, however, no wall thickening or distention was noted. The patient remained febrile until hospital day #3 and was continued on broad spectrum antibiotics for empiric coverage of potential abdominal process. The patient remained hemodynamically stable without requirement for blood pressure support on IV fluids alone and was successfully extubated on hospital day #2, without further need for respiratory support. The patient's metabolic abnormalities as well as rhabdomyolysis progressively improved with supportive therapy. The patient was noted on admission to have a mild hemolysis with decreased hematocrit in the setting of increased indirect bilirubin and decreased haptoglobin. The patient's hemolysis also progressively resolved without need for a transfusion. Throughout the [**Hospital 228**] Medical Intensive Care Unit stay, the patient continued with frequent loose stool output associated with mild crampy abdominal pains. On hospital day #4, the patient's stool culture grew Shigella flexneri, the presumed source of the patient's gastroenteritis associated with pan colitis. The patient was continued on Levofloxacin to complete a 5 day course. The patient defervesced by hospital day #3 and at the time of dictation, the patient remained afebrile, with a normal white blood cell count, with persistent, although improved, stool output with mild abdominal pain. On hospital day #3, status post extubation with progressively improving mental status, the patient was evaluated by the Psychiatry Service for history of depression, poly substance abuse, passive suicidal ideation with question of suicidal gesture. Given the patient's severe depression with ongoing passive suicidal ideation and extensive history of poly substance abuse as well as high risk behavior, the Psychiatry Service recommended psychiatric inpatient admission for treatment of dual diagnosis. The patient is in agreement for voluntary admission to an Inpatient Psychiatric Service following medical discharge. Once tolerating oral intake by hospital day #3, the patient is restarted on his psychiatric medications including Prozac, Wellbutrin, as well as Neurontin. The patient currently contracts for safety and without need for a one-to-one sitter. The patient was restarted on his HAART regimen on hospital day #3 and continues on his prior outpatient regimen of Abacavir, Lamivudine, and Stavudine. CONDITION ON DISCHARGE: Stable, afebrile, tolerating full solid diet without exacerbations in abdominal pain and/or diarrhea, with significantly depressed mood as well as anxiety. DISCHARGE DIAGNOSES: 1. Shigella enteritis complicated by pan colitis. 2. Dysthymia. 3. Poly substance abuse with history of prior alcohol dependence (in remission) and amphetamine abuse. 4. PTFE. 5. Human immunodeficiency virus. 6. Asthma. 7. History of sinusitis. 8. History of congenital retinopathy. 9. Gastroesophageal reflux disease. 10. Anal dysplasia. 11. Status post L5-S1 disc surgery. MEDICATIONS ON DISCHARGE: 1. Lamivudine 150 mg p.o. b.i.d. 2. Abacavir 300 mg p.o. b.i.d. 3. Stavudine 40 mg p.o. b.i.d. 4. Neurontin 300 mg p.o. b.i.d. 5. Protonix 40 mg p.o. q day. 6. Prozac 40 mg p.o. q day. 7. Flovent 110 mcg 2 puffs inhaled b.i.d. 8. Albuterol 1 to 2 puffs q4 to 6 hours p.r.n. 9. Atrovent 2 puffs q4 to 6 hours p.r.n. 10. Maalox p.r.n. 11. Ambien 5 to 10 mg p.o. q.h.s. p.r.n 12. Trazodone 50 mg p.o. q.h.s. p.r.n. 13. Wellbutrin 150 mg p.o. q.a.m. INSTRUCTIONS ON DISCHARGE: The patient is to be discharged to a psychiatric facility for inpatient admission for treatment of dual diagnosis. The patient is instructed to followup with his primary care physician on discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10621**], M.D. [**MD Number(1) 10622**] Dictated By:[**Doctor Last Name 13914**] MEDQUIST36 D: [**2151-5-20**] 02:48 T: [**2151-5-20**] 15:46 JOB#: [**Job Number 13915**]

[ "004.1", "493.90", "042", "300.4", "305.70", "557.9", "E854.2", "362.17", "969.7" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4204, 4297

11166, 11543

11569, 12029

7631, 10963

4320, 5308

12044, 12518

167, 203

232, 3019

3613, 3891

5325, 7613

3041, 3599

3908, 4187

10988, 11145

19,322

119,378

17145

Discharge summary

report

Admission Date: [**2194-12-2**] Discharge Date: [**2194-12-3**] Date of Birth: [**2131-12-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: admitted for elective pericardiocentesis after recent ECHO showed large pericardial effusion but no tamponade Major Surgical or Invasive Procedure: pericardiocentesis and drain placement History of Present Illness: HPI: Mr. [**Known lastname **] is a 62 year-old gentleman with a history of metastatic renal cell CA (diagnosed [**2181**], s/p L nephrectomy, recurrence in contralateral kidney, spine, and thoracic cavity detected in [**2192**], placed on radiation therapy and interleukin which was unsuccessful, then on Pfizer study medication x 2 years but recently dc'd due to cardiomyopathy) who presents for elective pericardiocentesis after recent ECHO showed 2cm pericardial effusion. Study medication was recently dc'd as ECHO on [**2194-10-20**] showed mildly dilated LA and mod dilated LV (6.1 cm), severe LV hypokinesis with an EF of 15-20% -- patient had dilated cardiomyopathy of unknown etiology, without evidence of effusion. Over the last few weeks, patient had gained ~ 20lbs, developed B/L LE edema, and had developed dyspnea on exertion. Patient was seen by Dr. [**Last Name (STitle) 696**] and started on lasix, with improvement in symptoms after 3 days. A CT scan on [**11-28**] on Mr. [**Known lastname **] revealed a pericardial effusion, and an ECHO that day revealed moderate circumferential pericardial effusion (up to 2 cm) with poor EF. Repeat ECHo on [**12-1**] showed no significant change -- pericardial effusion with large fibrin deposits and masses on the surface of the heart c/w extracardiac metastatic disease,a dn there were no clear echocardiographic signs of tamponade. Patient was admitted on [**12-2**] for elective pericardiocentesis. In cath lab, PP was 18, and RA . 1080 cc of straw-colored fluid were drained. On arrival to floor, patient was without CP/SOB/palpitations/fever/nausea/vomiting. Past Medical History: 1. Metastatic renal cell CA (s/p L nephrectomy [**2181**], metastatic disease detected [**2192**] including R kidney disease) 2. Bladder dysfunction Social History: Mr. [**Known lastname **] lives in [**Location 30150**] with his wife and 1 of his children. He works as an HVAC engineer. He denies any tobacco or alcohol use. He has in total 5 kids ranging in age from 19 to 35. Family History: Mr. [**Known lastname 48126**] mother had coronary artery disease and passed away from congestive heart failure. His father died of complication of alcoholic cirrhosis. He has a brother and sister who are both healthy. Physical Exam: VSS, Afebrile GEN: NAD, pleasant man HEENT: MMM. JVP ~8 cm. PERRL. EOMI. Trachea midline. CV: S1S2 RRR. soft HS. PMI mid-clavicular. LUNGS: CTA B/L. No R/W/C ABD: soft, NT/ND. +BS. No CVA tenderness EXT: DPs full, symmetric. Pertinent Results: [**2194-12-2**] 02:16PM OTHER BODY FLUID TOT PROT-5.0 GLUCOSE-106 LD(LDH)-155 AMYLASE-25 ALBUMIN-3.3 [**2194-12-2**] 02:16PM OTHER BODY FLUID WBC-216* RBC-294* [**2194-12-2**] 01:53PM GLUCOSE-86 UREA N-21* CREAT-1.3* SODIUM-140 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14 [**2194-12-2**] 01:53PM ALT(SGPT)-18 AST(SGOT)-28 LD(LDH)-230 ALK PHOS-136* TOT BILI-0.6 [**2194-12-2**] 01:53PM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2194-12-2**] 01:53PM WBC-5.7 RBC-4.03* HGB-13.0* HCT-38.4* MCV-95 MCH-32.2* MCHC-33.8 RDW-14.0 [**2194-12-2**] 01:53PM PLT COUNT-242 [**2194-12-2**] 01:53PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008 [**2194-12-2**] 01:53PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD [**2194-12-2**] 01:53PM URINE RBC-[**3-15**]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-<1 . CARDIAC CATH [**12-2**] 1. Selective coronary angiography of this right dominant system demonstrated no CAD. THe LMCA, LAD, LCX, and RCA were all without angiographically significant disease. 2. Resting hemodynamcis demonstrated mildly elevated left sided filling pressures, mean PCWP=13 mmHg, with mildly depressed systemic systolic and diastolic pressures. Right atrial pressures were significantly elevated with mean RA=19 mmHg, but without loss of the y-descent. There was a normal RV pressure waveform with mildly elevated right sided filling pressures with RVEDP=12 mmHg. Cardiac output was normal with a CI=2.7 L/min./m2. 3. Pericardiocentesis was performed with initial pericardial pressure of 10 mmHg. After removal of 1080cc of straw colored pericardial fluid, the pericardial pressure fell to 0 mmHg and the mean RA fell to 11 mmHg. Removal of all pericardial fluid was confirmed by TTE. Fluid was sent to the lab for cytologic and microbiologic assessment. Pericardial drain was sutured in place and drained to gravity. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Mild systolic and diastolic ventricular dysfunction. 3. Pericardiocentesis of 1L serosanguinous fluid. 4. Evidence of early pericardial tamponade. . POST-PROCEDURE ECHO Conclusions: 1. The left atrium is dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. 3. The aortic valve leaflets are mildly thickened. 4. There is no pericardial effusion. 5. Compared with the findings of the prior study (images reviewed) of [**2194-12-1**], the pericardial effusion is gone. . REPEAT ECHO on day of discharge Right ventricular chamber size and free wall motion are normal. There is no definite pericardial effusion seen (a small (focal), loculated pericardial effusion behind the RA cannot be excluded). Compared to the prior study dated (tape reviewed) there is probably no change. Brief Hospital Course: Patient is a 62 year-old male with metastatic renal cell CA and cardiomyopathy of unknown etiology who p/w pericardial effusion. Patient was admitted to the CCU and the following issues were addressed during his hospital stay: 1. CARDIOVASCULAR (pericardial effusion, coronary angiography, cardiomyopathy, blood pressure) A. Patient was taken to the catheterization laboratory after earlier CT Scan and ECHO showed evidence of moderate/large pericardial effusion. In the cath lab, pericardiocentesis was performed with initial pericardial pressure of 10 mmHg. After removal of 1080cc of straw colored pericardial fluid, the pericardial pressure fell to 0 mmHg and the mean RA fell to 11 mmHg. Removal of all pericardial fluid was confirmed by TTE. Fluid was sent to the lab for cytologic and microbiologic assessment. Pericardial drain was sutured in place and drained to gravity. Drain was kept in place for 1 day and removed when drainage had ceased (but line was flushable). Fluid chemistries consistent with exudate. Repeat ECHo on day of discharge confirmed no pericardial fluid collection. Patient to follow-up with oncologist regarding fluid cytology and microbiology. B. Coronary angiography showed no evidence of flow limiting lesions or coronary artery disease. Patient was continued on Aspirin 81mg. C. Per ECHO [**10-20**], patient with dilated cardiomyopathy and reduced EF 15-20%. EF could not be reliably assessed on recent ECHOs. Patient was continued on outpatient digoxin. Etiology of cardiomyopathy was still under investigation. Left heart cath without evidence of CAD. Outpatient SPEP/UPEP negative. TSH 11, FT4 WNL. Iron studies without evidence of hemochromatosis. Outpatient work-up had already been initiated, and continued work-up was deferred to patient's cardiologist, Dr. [**Last Name (STitle) 696**] D. Blood Pressure: Patient's blood pressures were asymptomatically in 80s post-procedure while in the CCU. Patient maintained good urine output, was alert and oriented x 3 without mental status changes, and extremities remained well-perfused. Relative hypotension was thought to be secondary to poor ejection fraction/cardiac output, and responded appropriately to gentle fluid boluses. . 2. UTI/Low-grade fever Patient with history of bladder atonia necessitating straight cath at home. UA positive for UTI on this admission, patient started on Cipro 500 [**Hospital1 **] x 7 days. . 3. RENAL CELL CARCINOMA Patient is followed as outpatient by Dr. [**Last Name (STitle) **]. Etiology of pericardial effusion is thought to be secondary to metastatic renal cell CA. Patient to follow-up with his oncologist as outpatient. . 4. F/E/N Patient received sodium bicarbonate before and after cath given 1 kidney and expected dye load. Creatinine remained stable at 1.2-1.3. . 5. Prophylaxis As inpatient, patient received Heparin 5000SC TID for DVT prophylaxis given malignancy and bedrest. Pneumoboots were also placed. Medications on Admission: Lasix 20mg PO qd Digoxin 0.125 mg PO qd ASA 325 mg PO qd Centrum Vitamin B6 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 4. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary 1. Pericardial effusion s/p pericardiocentesis Secondary 1. Metastatic renal cell CA Discharge Condition: ambulating without oxygen requirement, no chest pain, shortness of breath Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please seek medical attention if you experience shortness of breath, fever, chest pain, lightheadedness, or other concerning symptoms. Followup Instructions: 1) Please follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2194-12-11**] 11:00 2) Please follow-up with Dr [**Last Name (STitle) 48127**] and Dr [**Last Name (STitle) **]. Call to arrange. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2194-12-4**]

[ "197.1", "V10.52", "425.4", "276.52", "198.89", "198.5", "599.0", "198.0" ]

icd9cm

[ [ [] ] ]

[ "37.0", "88.56", "88.52", "37.23" ]

icd9pcs

[ [ [] ] ]

9336, 9342

5885, 8833

427, 468

9479, 9554

3023, 4958

9838, 10278

2542, 2763

8959, 9313

9363, 9458

8859, 8936

4975, 5862

9578, 9815

2778, 3004

277, 389

496, 2122

2144, 2294

2310, 2526

13,757

111,503

45344

Discharge summary

report

Admission Date: [**2134-2-16**] Discharge Date: [**2134-4-1**] Date of Birth: [**2078-8-9**] Sex: M Service: MEDICINE Allergies: Darvon / Percocet / Codeine / E-Mycin / Percodan / Darvocet-N 100 / Penicillins / Amoxicillin / Ampicillin Attending:[**First Name3 (LF) 398**] Chief Complaint: suprapubic pain, dysuria Major Surgical or Invasive Procedure: Right lung biopsy. Left lung biopsy. PICC line placement. Suprapubic catheter change. T9 CT guided biopsy History of Present Illness: Mr. [**Known lastname 96829**] is a 55 yo M w/long history of autonomic dysfunction complicated by urinary retention and suprapubic catheter placement who has multiple hospitalizations for recurrent UTI, most recently 2/[**2133**]. Of note, the pt's last UTI was positive for ESBL Klebsiella resistant to most abx except for meropenem/imipenem. Pt lives in a [**Hospital1 1501**] and reports 5 days pta noted onset of shaking chills, suprapubic pain/cramping, burning in the penis/urethra, and clouding of his urine. Pt also noted crusting material surrounding the catheter. He was not noted to be febrile at his [**Hospital1 1501**]. He denies abdominal pain, back pain, n/v/d. He does note intermittent chest pain x 1 wk. It is sharp, left sided and lasts seconds to minutes. It is not exertional, positional or pleuritic. Pt states it is different from his MI pain. He denies SOB. He does c/o productive cough over past few weeks, related to an episode 1 wk prior where he "stopped breathing, felt like I was choking." Pt unable to give color of sputum. Pt was taken from [**Hospital1 1501**] to the ED where a UA was positive. Pt was given one dose of meropenem and admitted to medicine. In the ED, a WBC was 8.5, lactate 1.2, temp was 99.4 Past Medical History: - autonomic dysfunction c/b urinary retention requiring indwelling Foley catheter, with recurrent UTIs - CAD: s/p MI [**2107**], tx with angioplasty - diffuse interstitial pneumonitis - anemia - autoimmune hepatitis - autoimmune thyroiditis - autoimmune peripheral neuropathy - intradural t10 mass - s/p cholecystectomy - chronic pain - depression Social History: Pt lived with wife and 30-year-old daughter prior to prolonged hospital/[**Hospital1 1501**] stay; disabled, but formerly a truck driver; uses wheelchair at home w/ bedside commode [**1-8**] autonomic dysfunction; Previosly smoked 1ppd x 20years, then quit for ~10 yr, restarted and now quit since [**10-12**]; no alcohol or IVDU. Family History: father had MI at 72; Sister had [**Location (un) 96830**] after vaccine Physical Exam: GEN: A&Ox3 HEENT: NCAT, PERRL, EOMI, OP clear, no LAD CV: RRR PULM: CTAB ABD: Soft, diffusely ttp w/o rebound or guarding. SP catheter site with mild erythema, crusting. +tenderness w/manipulation. EXT: No c/c/e NEURO: non-focal Pertinent Results: [**Hospital 93**] MEDICAL CONDITION: 55 year old man with productive cough, history of ? aspiration event. REASON FOR THIS EXAMINATION: please eval for infiltrate HISTORY: 55-year-old male with productive cough, questionable history of aspiration event. Evaluate for infiltrate. Comparison is made to prior radiographs dated [**2133-10-28**], [**2133-4-12**], and prior CT dated [**2132-9-26**]. AP AND LATERAL CHEST RADIOGRAPHS: Since most recent film there appears to be interval appearance to multiple ill-defined pulmonary nodules projecting over the right and left lower hemithoraces with the largest ill-defined opacity within the left mid hemithoraces measuring approximately 3.6 x 3.9 cm. Changes from previously noted interstitial lung disease appear slightly improved on current radiograph. Multiple calcified granulomas and calcified pleural plaques are better appreciated on prior CT examination. No evidence of pulmonary edema or pneumothorax. Cardiomediastinal silhouette and hilar contours are stable. Tip of left-sided PICC catheter is unchanged in appearance within the brachiocephalic confluence. IMPRESSION: Multiple new ill-defined pulmonary nodules with most dominant nodule projecting over the mid thorax. Appearance of these nodules is suspicious for neoplastic or metastatic involvement with focal infectious or fungal etiologies felt to be less likely. Recommend further evaluation with CT of the chest. CT CHEST W/O CONTRAST [**2134-2-17**] 10:53 AM CT CHEST W/O CONTRAST Reason: please eval for masses [**Hospital 93**] MEDICAL CONDITION: 55 year old man with nodules seen on CXR, concerning for mets REASON FOR THIS EXAMINATION: please eval for masses CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Evaluate nodules seen on CXR. CareWeb notes reveal the patient has a history of autoimmune hepatitis, thyroiditis, peripheral neuropathy, and autonomic dysfunction. TECHNIQUE: Multidetector helical scanning of the chest was performed without IV contrast. Contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal images were presented for interpretation. COMPARISON: Chest x-ray [**2134-2-16**] and CTA chest [**2132-9-26**]. NON-CONTRAST CT OF THE CHEST: A new 1.6-cm nodule with somewhat irregular borders is seen in the right upper lobe. Also, a 4.1-cm rounded solid appearing mass (soft tissue density), also with irregular contours is seen in the left lower lobe. There are no air bronchograms in this lesion. No other concerning nodules or masses are seen. There has been progression of the patient's interstitial lung disease with interlobular septal thickening and traction bronchiectasis, predominantly at the lung bases. Previously seen diffuse ground- glass opacities have resolved. Multiple tiny calcified granulomas are again noted reflecting prior granulomatous disease. The bronchi are patent to the subsegmental level. Coronary calcifications are noted. Otherwise, the heart, pericardium, and great vessels are unremarkable. No pathologically enlarged axillary, hilar, or mediastinal lymph nodes. Left PICC terminates in the left brachiocephalic vein. This exam is not optimized for subdiaphragmatic evaluation. The hypoattenuating lesion in the left lobe of the liver as well as bilateral renal cysts are unchanged. Bone windows reveal a 7-mm sclerotic lesion in the medial clavicle, unchanged from [**2131**], and likely a bone island. No other suspicious lytic or sclerotic lesions. IMPRESSION: 1. 4.4-cm solid left lower lobe mass and 1.5-cm right upper lobe nodule are new compared to CT from [**2132-9-6**]. The differential diagnosis for these lesions is very broad and includes infections (fungal infection or Nocardia), inflammatory conditions (cryptogenic organizing pneumonia), vasculitis (particularly as this patient has a history of autoimmune disorders), and neoplasm (synchronous primary carcinoma, metastasis, or pulmonary lymphoma). If the patient does not have a clinical findings of infection, a PET/CT may be helpful. 2. Mild progression of fibrotic component of chronic interstitial lung disease. PATIENT/TEST INFORMATION: Indication: Endocarditis. Height: (in) 66 Weight (lb): 142 BSA (m2): 1.73 m2 BP (mm Hg): 80/42 HR (bpm): 53 Status: Inpatient Date/Time: [**2134-2-18**] at 10:00 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W013-1:42 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.9 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aorta - Arch: 2.9 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.1 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 1.17 Mitral Valve - E Wave Deceleration Time: 224 msec TR Gradient (+ RA = PASP): 23 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [**2132-11-19**]. LEFT ATRIUM: Elongated LA. 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. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No masses or vegetations on aortic valve. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No mass or vegetation on mitral valve. Mild (1+) MR. 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 elongated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis. Compared with the prior study (images reviewed) of [**2132-11-19**], the findings are generally similar. The ASD is not visualized on the current study. CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2134-2-22**] 12:38 PM CTA CHEST W&W/O C&RECONS, NON- Reason: please eval for PE, and please eval for evolving LLL mass. Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 55 year old man with nodules seen on CXR, concerning for mets, mass evolving over weekend, ? now close enough to bronch? Also, new O2 requirement over weekend, pulmonology concerned re: PE. REASON FOR THIS EXAMINATION: please eval for PE, and please eval for evolving LLL mass. CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: 55-year-old male with lung masses. New O2 requirement over weekend. Evaluate for pulmonary embolus. COMPARISON: [**2134-2-17**]. TECHNIQUE: Non-contrast and contrast-enhanced multidetector CT acquired axial images of the chest. Multiplanar reformatted images were obtained. CT OF THE CHEST: The previously identified nodule within the right upper lobe and mass within the left lower lobe is unchanged compared to recent CT from [**2134-2-17**]. There are again interstitial abnormalities as evidenced by interlobular septal thickening and traction bronchiectasis, predominantly at the lung bases, the extent of which is not changed from [**2-17**], [**2133**]. Multiple tiny calcified granulomas are again noted reflecting prior granulomatous disease. The airways are patent to the subsegmental level. Coronary calcifications are noted within the LAD. Otherwise the heart and great vessels are unremarkable. There is no pericardial or pleural effusion. There is mild pleural thickening with calcified pleural plaques. No pulmonary embolus or thoracic aortic dissection is appreciated. The previously seen left PIC line has been removed. Small mediastinal lymph nodes are seen which do not meet CT criteria for pathologic enlargement. Osseous structures demonstrate no suspicious lytic or sclerotic lesions. A bone island is seen within the right clavicle, slightly increased in size from [**2127-10-6**], however, unchanged from [**2132-9-26**]. The visualized upper abdomen demonstrates hypodensities within the liver. The smaller hypodenisity in the left lobe of the liver (series 3,image 86) is not worrisome, however, the subtle hypoenhancing lesion in the right lobe of the liver, better seen on prior CT from [**2134-2-17**] is concerning and should be further evaluated with ultrasound. IMPRESSION: 1. No evidence of pulmonary embolus. 2. Compared to the prior CT from five days ago, there is no significant change in chronic interstitial lung disease or pulmonary mass/nodule. Again, the diagnostic consideration for the mass/nodule are very broad and includes infections, inflammatory and neoplasm. These lesions are ammenable to biopsy if clinically warrented. 3. Subtle hypoenhancing lesion in the right lobe of the liver, better seen on preious CT from [**2134-2-17**] and recommend ultrasound for better characterization. FNA, lung, left lower lobe mass, cell block: H&E stain shows alveolar spaces lined by atypical mucinous epithelium with intra-alveolar and background mucin, suspicious for a well-differentiated adenocarcinoma, bronchioloalveolar type. See also cytology report C07-10734L. Note: Slides reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**], with concurrence. RUL biopsy: Suspicious for well-differentiated adenocarcinoma with features suggestive of bronchioalveolar type. T9 bx: Poorly-differentiated metastatic carcinoma Brief Hospital Course: Unfortunately the patient did not survive this hospitalization. After an EGD that revealed food in the esophagus the patient likely aspirated which precipitated a PEA arrest. A code blue was called and per the wishes of the family the patient was aggressively resuscitated for 1.5 hours. Despite the teams best efforts the patient suffered irrepairable anoxic brain injury as revealed by an extremely limited physical exam and the findings on EEG. Per the family's wishes the patient was aggressively treated for approximately one week without improvement in his neurological status. Ultimately it became clear that the patient was entirely dependent on the ventilator. The family then decided to withdraw the ventilator which resulted in the rapid passing of the patient. Other issues addressed during this hospitalization were recurrent UTI, autonomic neuropathy, initial diagnosis of non-small cell lung cancer, anti-phospholipid syndrome, and bactermia. Medications on Admission: --levothyroxine 50 mcg po daily --midodrine 20 mg po at 6 am, 20 mg at noon, 10 mg at 2 pm, 10 mg at 5pm --trazodone 150 mg po HS --requip 0.5 mg po HS --demerol 50 mg po PRN pain Discharge Disposition: Extended Care Discharge Diagnosis: Lung Cancer Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Completed by:[**2134-4-4**]

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icd9cm

[ [ [] ] ]

[ "33.26", "96.04", "38.93", "45.16", "00.17", "96.6", "77.49", "31.42", "96.72" ]

icd9pcs

[ [ [] ] ]

14987, 15002

13789, 14756

389, 497

15058, 15068

2852, 2852

15121, 15155

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10527, 10717

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6969, 10490

2602, 2833

325, 351

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2165, 2498

12,108

174,404

4171

Discharge summary

report

Admission Date: [**2119-8-28**] Discharge Date: [**2119-8-29**] Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 297**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy with Cauterization of bleeding History of Present Illness: 86 y/o F, Iranian speaking, with PMH of diverticulosis, hemorrhoids, MI, CAD, HTN, with recent post-polypectomy bleed, cauterized 2 days PTA, presents with recurrent bright red blood per rectum. 6 episodes of BRBPR since 6pm the day of admission. No associated abdominal pain, N/V, CP/lightheadedness. . In ER, Hct 34.9->26.2. HD stable. Discussed w/ GI fellow. Plan for tagged red blood cell scan to evaluate for bleeding source. Given 2 units pRBCs. 2 large bore PIV. Admit to MICU. Past Medical History: CAD: MI in [**2116**] with reperfusion and stents in LAD Osteoporosis Hyperlipidemia HTN Diveticulosis Hemorrhoids Alzheimers disease Social History: born in [**Country **], married; No h/o tobacco, etoh, IVDU Family History: Mother died in her 60's from MI. Brothers died of MI at age 55 and 60. Physical Exam: vitals- T 97.6, BP 93/67, HR 89, RR 16, 99% 4l 02 via NC gen- awake, alert, NAD heent- EOMI. OP clear. no scleral icterus neck- supple. no jvd pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- soft, NT/ND ext- no c/c/e neuro- moving all extremities Pertinent Results: [**2119-8-27**] 08:52PM BLOOD WBC-10.2# RBC-4.01* Hgb-12.2 Hct-34.9* MCV-87 MCH-30.4 MCHC-35.0 RDW-14.7 Plt Ct-192 [**2119-8-28**] 04:46AM BLOOD WBC-8.1 RBC-2.92*# Hgb-8.8*# Hct-25.0* MCV-86 MCH-30.1 MCHC-35.2* RDW-14.9 Plt Ct-129* [**2119-8-29**] 03:58AM BLOOD WBC-7.7 RBC-4.00*# Hgb-11.8*# Hct-32.8* MCV-82 MCH-29.6 MCHC-36.0* RDW-15.4 Plt Ct-113* Brief Hospital Course: Pt was admitted to the MICU with bleeding from her rectum and falling hematocrit. She was seen and evaluated by GI and due to her hx it was presumed that she had bleeding from her old polypectomy site. Pt received colonoscopy prep and colonoscopy at which time a foci of bleeding was found and cauterized. She received 4 units of blood total and responded appropriately. She was D/C on HD #2 with stable HCT. She will f/u with her PCP for platelets, Hct, LFT [**Month/Day/Year 7941**]. Medications on Admission: 1. Donepezil 10 mg PO HS 2. Atorvastatin 80 mg PO DAILY 3. Trazodone 50 mg PO HS 4. Prilosec OTC 20 mg PO once a day. 5. Docusate Sodium 100 mg PO BID 6. Diovan 80 mg PO once a day 7. FOSAMAX 70 mg PO once a week. 8. Toprol XL 50 mg q24 PO once a day Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Post-polypectomy GI bleed Discharge Condition: Good Discharge Instructions: You have had a significant episode of bleeding that required transfusion of blood. You should follow-up with your doctor to monitor your platelet levels. You should be off of Aspirin for one month after leaving the hospital. You should also follow-up with your doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**] of your liver function on Lipitor. Please discuss this laboratory testing with Dr. [**Last Name (STitle) **]. You were admitted to the hospital for a GI bleed. You should call your doctor or return to the ER should you experience any of the following: Severe increase in drainage from rectum Increasing blood from rectum Fever > 101 Severe pain in abdomen Numbness/Tingling/Paralysis Severe Dizziness Loss of Consciousness Nausea/Vomiting Severe Chest Pain/SOB Any other symptoms that worry you. Followup Instructions: Please follow-up with your primary care doctor Dr. [**Last Name (STitle) **] within one week of discharge for blood work. You should call and schedule an appointment. Please follow-up with your regularly scheduled appointments below: Provider: [**First Name11 (Name Pattern1) 18169**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2119-10-6**] 3:00 Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2119-10-31**] 6:00 Completed by:[**2119-8-29**]

[ "414.01", "412", "E878.8", "287.5", "562.10", "998.11", "V45.82", "272.4", "401.9", "331.0", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

2988, 2994

1761, 2252

220, 265

3064, 3071

1387, 1738

3946, 4536

1032, 1105

2554, 2965

3015, 3043

2278, 2531

3095, 3923

1120, 1368

175, 182

293, 780

802, 938

954, 1016

65,669

183,845

26112+57479

Discharge summary

report+addendum

Admission Date: [**2113-5-16**] Discharge Date: [**2113-5-26**] Date of Birth: [**2080-9-18**] Sex: F Service: SURGERY Allergies: Shellfish / Aspartame / Cipro / Nsaids Attending:[**First Name3 (LF) 1**] Chief Complaint: Small-bowel obstruction secondary to internal hernia. Ischemic bowel. Major Surgical or Invasive Procedure: 1. Exploratory laparotomy, reduction of internal hernia, and abdomen left open for second-look operation on [**5-17**]. 2. Second-look operation. History of Present Illness: Young patient 11 months status post gastric bypass with the retrocolic Roux-Y anastomosis presented with a bowel obstruction present. Past Medical History: hypercholesterolemia, hypothyroidism, hypertension, mitral valve prolapse, migraine headaches bilateral carpal tunnel syndrome, chronic low back pain, history of pneumonia and urinary tract infection and gallbladder disease. Social History: She used to smoke 5 to 10 cigarettes a day for 7 years stopped two years ago, denies recreational drugs or alcohol usage, no carbonated beverages. She is employed as a business analyst for a technology company. She lives with her partner age 28 and her 9 month-old daughter. Family History: Her family history is noted for father living age 59 with diabetes and obesity; mother living age 55 with heart disease, hyperlipidemia, obesity, asthma and arthritis; sister living age 32 with hyperlipidemia, thyroid disease and obesity; grandmother deceased age [**Age over 90 **] with heart disease and grandfather deceased age 75 with stroke. Brief Hospital Course: Pt was admitted post-op. Pt's diet was advanced slowly owing to her prior gastric bypass surgery. Diet was advanced to Bariatric Stage 5. Pain was controlled. Pt also had difficulty urinating, which was present before surgery and hospitalization, and developed UTI, of which she had many previously. Pt was discharged on post-op day 11 and 10. Medications on Admission: albuterol, betamethasone valerate, synthroid, nystatin, biotin, calcium citrate, vit D, vit B12, iron, claritin, multivitamin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation for 1 months: take with pain meds. Disp:*60 Capsule(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain for 2 weeks: Please do not exceed more than 4000mg of acetaminophen in 24 hrs. Disp:*400 ML(s)* Refills:*0* 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: SBO internal hernia through transverse mesocolon . Secondary: morbid obesity, ^lipids, hypothyroidism, migraine HAs, MVP, dizziness, urinary tract infection, difficulty urinating Discharge Condition: Stable. Tolerating bariatric diet stage 5. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Followup Instructions: 1. Please call Dr.[**Name (NI) 10946**] office, [**Telephone/Fax (1) 9**], to make a follow up appointment in [**1-3**] weeks. Scheduled Appointments : Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2113-8-2**] 2:15 Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2113-8-2**] 2:30 Name: [**Known lastname 11426**] [**Last Name (LF) 11427**],[**First Name3 (LF) **] Unit No: [**Numeric Identifier 11428**] Admission Date: [**2113-5-16**] Discharge Date: [**2113-5-26**] Date of Birth: [**2080-9-18**] Sex: F Service: SURGERY Allergies: Shellfish / Aspartame / Cipro / Nsaids Attending:[**First Name3 (LF) 4**] Addendum: Bowel ischemia was an acute event. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16**] MD [**MD Number(1) 17**] Completed by:[**2113-6-5**]

[ "401.9", "346.90", "272.0", "244.9", "278.01", "599.0", "338.18", "780.4", "557.0", "552.8", "788.64", "424.0", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "54.12", "53.9" ]

icd9pcs

[ [ [] ] ]

5433, 5591

1609, 1958

367, 516

2990, 3079

4501, 5410

1238, 1586

2134, 2729

2779, 2969

1984, 2111

3103, 4245

4260, 4478

256, 329

544, 680

702, 928

944, 1222

28,870

185,161

53146

Discharge summary

report

Admission Date: [**2130-9-23**] Discharge Date: [**2130-9-28**] Date of Birth: [**2082-12-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin / Acyclovir Attending:[**First Name3 (LF) 9874**] Chief Complaint: blurry vision bilaterally Major Surgical or Invasive Procedure: PICC line placement. Lumbar puncture. History of Present Illness: 47 yo M with a history of HIV (last CD4 ([**1-1**]) 81, VL 48) who restarted HAART 3 weeks ago who presented to the ED from [**Hospital 18620**] clinic with a complaint of worsening vision loss. His symptoms started in mid-[**Month (only) 205**], when he suddenly developed some mild pain at the back of his left eye. His left eye then started to produce tear-like clear fluid. The vision in his left eye started to deteriorate over the course of the next week. His left eye had blurry vision, he had floaters in front of his eyes, and he noted central vision loss. He denied headache. These symptoms prompted him to present to his PCP and ophthalmologist, and he was prescribed PredForte drops Q1 h and scopolamine drops [**Hospital1 **], which initially provided relief of the symptoms. However, in [**Month (only) 216**], he developed similar symptoms in his right eye (pain, central vision loss, blurry vision) and he saw his ophthamologist again. He continued to use the eye drops in both eyes, but he still intermittently had blurry vision. During the week prior to admission, he started to experience exacerbation of his visual changes, and he may not have been compliant with using the eye drops. He reports the vision loss is worse in his left eye, and he can only see shadows. . He was seen by ophthalmology on the day prior to admission, and was diagnosed with bilateral panuveitis. Ophtho recommended that he be admitted for further workup. . Of note, per Logician notes, he was recently informed by the DOH that he had sexual contact with a person who was diagnosed with syphilis. Past Medical History: 1.HIV, diagnosed in [**2118**]. But possibly acquired the infection in [**2108**]. He didn't take any anti-retroviral drugs for 4 years, but restarted 3 weeks ago. (last CD4: 81 CELL/UL ([**2130-1-19**]); last viral load 48.01*HI ([**2130-1-19**]) 2.shingles [**2118**], no more incidence ever since 3.left meniscus tear s/p knee surgery 4.arthritis, especially of knees b/l 5.hyperlipidemia [**3-/2123**] 6.acute gingivitis [**5-/2123**] 7.viral warts [**2119**] 8.nonspecific skin rash [**4-/2123**] 9.cryptosporidiosis [**8-/2123**] 10.pityriasis versicolor [**10/2123**] 11.hepatitis A [**3-/2123**] 12.oral aphthae 13.depression 14. deviated septum . Allergies: penicillin causes itchy hives and rash (received PCN once as child and once in 20s-30s), vancomycin (red man syndrome), acyclovir (itchiness), seasonal allergies Social History: 10 pack-year smoking history, quit 15 years ago. Social EtOH use. Recreational illicit drug use in the past, but has not been using drugs during the past several years. Works part-time at Mistral restaurant as a server; also started to work as a photographer, had a photography show recently. Family History: DM (mother), colon CA (father, at 88 [**Name2 (NI) **]), kidney problems, stroke, HTN, GI problems. Physical Exam: VS: temp 99.8, bp 120/60, HR 89, RR 20, SaO2 100% RA General: Awake, alert, NAD HEENT: NCAT. MMM. OP clear, no oral thrush. Sclera anicteric. No supraclavicular, submandibular, or anterior cervical LAD. Patchy alopecia of hair and beard. CV: Regular rate, Nl S1, S2. No murmurs/rubs/gallops. Pulm: CTA bilaterally. No wheezes/rhonchi/rales Abd: Positive bowel sounds, Soft NTND abdomen. No HSM. No masses Ext: No lower extremity edema Skin: No rashes Neuro: Pupils dilated to 6 mm bilaterally, not reactive to light. Patient unable to cross eyes to check for accomodation. Patient could count fingers at 1 foot. Patient can not make out details in visitor's face at bedside. EOMI. Fundoscopic exam on R revealed normal vasculature, no obvious abnormalities of optic disc. Unable to visualize fundus/vessels on the L. Normal facial sensation and strength. Tongue protrudes in midline. Moving all extremities spontaneously. Pertinent Results: [**2130-9-28**] 04:55AM BLOOD WBC-4.1 RBC-3.92* Hgb-11.3* Hct-33.7* MCV-86 MCH-28.8 MCHC-33.5 RDW-18.2* Plt Ct-331 [**2130-9-24**] 11:55AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1 [**2130-9-24**] 06:45AM BLOOD WBC-6.4 Lymph-10* Abs [**Last Name (un) **]-640 CD3%-73 Abs CD3-467* CD4%-13 Abs CD4-80* CD8%-56 Abs CD8-358 CD4/CD8-0.2* [**2130-9-28**] 04:55AM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-141 K-4.6 Cl-104 HCO3-28 AnGap-14 [**2130-9-26**] 06:12AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.5 [**2130-9-27**] 04:55AM BLOOD ALT-13 AST-13 LD(LDH)-111 AlkPhos-93 Amylase-87 TotBili-0.1 [**2130-9-27**] 04:55AM BLOOD Lipase-35 [**2130-9-27**] 04:55AM BLOOD Albumin-3.3* Iron-133 [**2130-9-27**] 04:55AM BLOOD calTIBC-322 VitB12-324 Folate-5.9 Ferritn-218 TRF-248 [**2130-9-27**] 04:55AM BLOOD Ret Aut-1.4 [**2130-9-24**] 06:45AM BLOOD Osmolal-272* [**2130-9-25**] 08:15AM URINE Hours-RANDOM UreaN-407 Creat-48 Na-43 [**2130-9-25**] 08:15AM URINE Osmolal-308 [**2130-9-24**] 06:45AM BLOOD RheuFac-<3 HIV-1 Viral Load/Ultrasensitive (Final [**2130-9-28**]): 1,390 copies/ml. BLOOD TESTS: RPR REACTIVE FTA-ABS REACTIVE VZV AB IGM, EIA NEGATIVE ACE NORMAL HLA-B27 Pending Lyme by Western Blot: Lyme Disease Ab, Conf. IgG Western Blot 1 band <5 IgG Bands Detected 41 kDa IgM Western Blot 0 band <2 IgM Bands Detected None Detected kDa Interpretation -------------- Nonconfirmatory LYME SEROLOGY (Final [**2130-9-28**]): EIA RESULT NOT CONFIRMED BY WESTERN BLOT. EQUIVOCAL BY EIA. NEGATIVE BY WESTERN BLOT. VARICELLA-ZOSTER IgG SEROLOGY (Final [**2130-9-26**]): POSITIVE BY EIA. CMV IgG ANTIBODY (Final [**2130-9-26**]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 312 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [**2130-9-26**]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. TOXOPLASMA IgG ANTIBODY (Final [**2130-9-26**]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. TOXOPLASMA IgM ANTIBODY (Final [**2130-9-26**]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. [**2130-9-24**] 6:45 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2130-9-24**] BLOOD CULTURE: NGTD x2 CSF STUDIES: [**2130-9-24**] 3:41 pm CSF;SPINAL FLUID Source: LP. ADDED CRYPTOCOCCAL AG AND MYCOLOGY CX [**2130-9-25**] PER ADD ON REQUISITION. GRAM STAIN (Final [**2130-9-24**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2130-9-27**]): NO GROWTH. VIRAL CULTURE (Preliminary): No Virus isolated so far. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. CRYPTOCOCCAL ANTIGEN (Final [**2130-9-25**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. ANALYSIS WBC RBC Polys Lymphs Monos [**2130-9-24**] 03:41PM 190 5 72 24 4 2 CLEAR AND COLORLESS [**2130-9-24**] 03:41PM 110 400 47 42 11 Source: LP 2 CLEAR AND COLORLESS CHEMISTRY TotProt Glucose [**2130-9-24**] 03:41PM 113 29 VDRL Pending Treponema Antibody Pending Herpes Simplex Virus [**12-27**] Detection and Diff, PCR HSV 1 DNA Not Detected HSV 2 DNA Not Detected [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS (EBV) DNA, PCR Result: DETECTED STUDIES: CT Head ([**9-23**]): IMPRESSION: No evidence of intracranial mass or hemorrhage. CXR ([**9-23**]): IMPRESSION: No acute cardiopulmonary process. Brief Hospital Course: 47 yo male with HIV and recently diagnosed bilateral panuveitis who presents from ophthalmology clinic with worsening vision loss. . #Vision Loss: The patient was admitted with bilateral vision loss, central scotoma, and a recent exposure to syphilis. Infectious Disease was consulted, and followed him throughout his hospitalization. He was afebrile during the admission without an elevated WBC. He was initially empirically started on Vancomycin 1 gm IV q12hr for possible Staph uveitis and Acyclovir 10 mg/kg IV q8hr for possible CMV/HSV infection. The patient developed diffuse urticaria and rash after receiving Vancomycin, thought to be red man syndrome. His symptoms improved with premedication with Diphenhydramine prn and Ranitidine [**Hospital1 **]. MRI of the orbits was unable to be completed secondary to the patient's claustrophobia. Head CT showed no evidence of intracranial mass or hemorrhage. LP showed opening pressure of 8, elevated WBC, increased protein, decreased glucose. CSF showed no bacteria, no virus isolated so far, no fungus, and no cryptococcal antigen. The CSF was negative for HSV 1 and 2 but positive for EBV. CSF VDRL and Treponema antibody were pending at the time of discharge. Serum RPR was reactive, pending confirmation from the state. Serum FTA-ABS was reactive. The patient was thought to have neuro-ocular syphilis and was started on Penicillin G 4,000,000 Units IV q4 hours after PCN desensitization in the MICU. Vancomycin was discontinued on hospital day 3 as Staph uveitis was a less likely diagnosis. Acyclovir was discontinued on hospital day 5 when CSF viral culture showed no virus isolated so far. A PICC line was placed on [**9-27**], and the patient was sent home with an infusion pump for Penicillin G 4,000,000 U IV q4 hours for 14 day course (last day [**2130-10-9**]). He was sent home with an epinephrine pen in case he develops an anaphylactic reaction. The patient will have follow up with ID, ophthamology, and his PCP. [**Name Initial (NameIs) **] The patient may need an MRI brain as an outpatient to look for lymphoma as his CSF was positive for EBV. - Other Positive Blood Tests: VZV IgG, CMV IgG - Other Negative Blood Tests: VZV Ab IgM, CMV IgM, Toxoplasma IgG/IgM, Lyme Disease, Blood/Fungal Culture, Blood/AFB Culture, ACE, RF <3, PPD negative - Pending Blood Tests: Blood Cx x2 NGTD, HLA-B27 - Pending CSF Tests: AFB Cx, VDRL, Treponema Antibody . #Penicillin allergy: The patient reported a history of non-anaphylactic allergy to PCN, and had developed hives and a rash after receiving it once as a child and once in his 20s-30s. The patient's vision loss was due to neurosyphilis, and PCN-G IV is the recommended treatment. The patient was transferred to the MICU for PCN desensitization protocol, with 7 doses of increasing penicillin over 3 hours. The patient did not have any adverse reactions. If patient's PCN doses are separated by greater than 12 hours, he will need repeat desensitization. . #Bilateral panuveitis: The patient was seen in [**Hospital 18620**] clinic on the day prior to admission and was found to have OS synechiae/irregular pupil and no evidence of retinitis OU. Per their report, he had bilateral panuveitis and vision loss threatening OU. They recommended for him to continue Pred Forte 1 gtt Q1hr OU and Scopolamine 0.25% 1 gtt [**Hospital1 **] OU, which had been prescribed to him a few months earlier. These drops were continued during his hospitalization. Ophthamology followed him during his hospital stay, and he will follow up with them as an outpatient. . # HIV: The patient was diagnosed with HIV in [**2118**] [last CD4 ([**1-1**]) 81, VL 48]. He stopped taking antiretroviral medications 4 years ago, but was restarted on HAART 3 weeks prior to admission. His outpatient antiretroviral regimen was continued during the hospitalization (Darunavir, Emtricitabine-Tenofovir, Ritonavir, and Zidovudine). He also was continued on Bactrim DS daily for PCP [**Name Initial (PRE) 1102**]. The patient had a CD4 count of 80 and CD4% of 13, and his HIV Viral load was 1,390 copies/ml. A CXR showed no acute cardiopulmonary process. . #Hyponatremia: The patient presented with a Na of 134, which decreased to 131 on Day 2 of admission. Serum Osm 272, Urine Osm 308, Urine urea 407, UrineCr 48, UrineNa 43. The patient was thought to have SIADH, and was started on a 1 L free water restriction. Na improved to 141, and the patient was taken off of the free water restriction. . #Anemia: Hct upon admission was 37.9, but dropped to 31.1 on hospital day 2. The patient had guaiac negative stools, iron studies normal, normal reticulocyte count, and normal B12 and folate levels. His coags were all within normal limits. His Hct improved to 33.7 at the time of discharge, and his anemia was possibly due to hemodilution from SIADH. . #Arthritis: The patient has chronic arthritis especially in his knees bilaterally. He can follow up with his PCP upon discharge. . # Depression: The patient has been experiencing depressive symptoms intermittently. He was seen by Social Work while in the hospital, and was encouraged to follow up with his PCP upon discharge. Medications on Admission: 1.ritonovir 100mg PO BID 2.truvada 200-300 mg PO daily 3.retrovir 300mg Q12h 4.prezista 600mg PO BID 5.bactrim DS 800-160mg PO daily 6.androgel pack 50mg/5gm PO daily 7.predfort 1% 1 drop OU Q1h 8.scopolamine 0.25% 1 drop OU [**Hospital1 **] . Allergies: Penicillin Discharge Medications: 1. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Epinephrine HCl 0.1 mg/mL Syringe Sig: One (1) Injection as needed as needed for anaphylaxis. Disp:*1 syringe* Refills:*2* 3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 5. Darunavir 300 mg Tablet Sig: Two (2) Tablet PO bid (). Disp:*120 Tablet(s)* Refills:*2* 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Testosterone 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet Transdermal daily (). 8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q1H (every hour): 1 drop to each eye every hour. Disp:*1 bottle* Refills:*2* 9. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): 1 drop to each eye twice a day. Disp:*1 bottle* Refills:*2* 10. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: Five (5) mL PO Q4-6H () as needed for allergic reaction, itchy, hives. Disp:*1 bottle* Refills:*2* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 12. Penicillin G Potassium 1,000,000 unit Recon Soln Sig: [**Numeric Identifier 109457**] ([**Numeric Identifier 109457**]) Units Injection every four (4) hours for 12 days: End date [**2130-10-9**]. Disp:*[**Numeric Identifier 109458**] Units* Refills:*0* 13. PICC supplies PICC line care per CCS protocol 14. Outpatient Lab Work Please draw CBC, BUN, Cr, LFTs (AST, ALT, Alk Phos, amylase, lipase, T bili, LDH) on [**10-4**]. These results should be faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic at [**Hospital3 **] ([**Telephone/Fax (1) 1419**]). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: 1. Bilateral panuveitis 2. Neurosyphilis 3. HIV 4. Penicillin allergy Secondary: 1. Depression 2. Arthritis Discharge Condition: Stable, vision improving. Discharge Instructions: 1. If you develop a fever >101.5, increased vision loss, severe headache, rash, shortness of breath, chest pain, or any other symptoms that concern you, contact your primary care physician or come to the Emergency Department. 2. Take all of your medications as prescribed and on time. 3. Attend all of your follow up appointments. Followup Instructions: You have an appointment on [**2130-10-5**] at 12:00 with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 571**] at [**Hospital1 778**]. You have an appointment on [**2130-10-6**] at 8:45 with Dr. [**First Name (STitle) **] LOVE ([**Telephone/Fax (1) 457**]) in infectious diseases at [**Hospital Unit Name **], BASEMENT ID WEST. You have an appointment on [**2130-10-27**] at 10:30 with Dr. [**First Name (STitle) **] LOVE ([**Telephone/Fax (1) 457**]) in infectious disease at [**Hospital Unit Name **], BASEMENT ID WEST. You have an appointment with Dr. [**Last Name (STitle) 441**] ([**Telephone/Fax (1) 253**]) in ophthamology on [**2130-10-19**] at 9:00 at [**Hospital Ward Name 23**] Center, Floor 5. You will need a follow up MRI brain done for EBV in your CSF done in the outpatient setting, follow up about this with your primary care physician.

[ "042", "285.9", "360.12", "094.9", "276.1", "V07.1" ]

icd9cm

[ [ [] ] ]

[ "99.12", "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

15868, 15926

8382, 13579

323, 362

16088, 16116

4239, 6616

16500, 17380

3169, 3270

13895, 15845

15947, 16067

13605, 13872

16140, 16477

3285, 4220

7531, 8359

7203, 7492

258, 285

390, 1991

2013, 2843

2859, 3153

8,213

124,320

2590+55392

Discharge summary

report+addendum

Admission Date: [**2134-5-20**] Discharge Date: [**2134-6-15**] Date of Birth: [**2074-6-26**] Sex: F Service: MEDICINE Allergies: Slim-Fast Attending:[**First Name3 (LF) 905**] Chief Complaint: Low back pain (transfer from outside hospital) Major Surgical or Invasive Procedure: 1) Incision and drainage of right clavicle region abscess. 2) PICC placement. 3) CT guided drainage of retroperitoneal abscess. History of Present Illness: Pt is a 59 y/o f with a h/o depression who was admitted to an OSH with new lower back pain. Within the first twenty-four hours of admission, she became febrile and delirious. A CT scan of the head and abdomen were ordered; the head was a poor study but unrevealing, and the abdomen showed t12-l1 degenerative changes, consistent with either djd or osteomyelitis. In this setting she grew out 4/4 bottles with GPC in clusters. She was hemodynamically stable, but there was concern both that she could become septic and that the root of the problem may have been a epidural abscess, so she was transferred to [**Hospital1 18**] for ICU care and MRI under sedation. Of note 2 weeks prior to admission the daughter recalls that the patient fell and hit her right neck on the edge of her bathtub. She also notes that she has had multiple open wounds that she often itches and allows her dog to lick. Past Medical History: Depression Borderline HTN. Social History: Pt lives at home with her son who has Down's Syndrome. Denies tobacco, EtOH. Family History: Non-contributory. Physical Exam: PE: 97.6 (100)--- 72 (70-80s) --- 175/78 (SBP150s-170s) -- 16 -- 97% 5lNC; I/Os: +4L LOS Gen: pt sleepy but easily arousable, A&Ox2 but does not whether day or night. HEENT: Pupils 2mm equal and reactive b/l. Anicteric. NGT in place. OP clear with dry MMM. Neck: supple. Chest: Right chest surgical wound with packing, surrounding area is nonerythem, mild tndr. Right SCL CVL site C/D/I. Lungs: CTA ant. CV: tachy, nml S1S2 Abd: obese, soft, NT, ND, hyperactive BS, no masses Ext: edema of Right foot but nontender. 3+ DP pulses b/l. Skin: multiple excorations, none clearly infected. Neuro: Moves all 4 ext and [**3-23**] throughout. [**Last Name (un) **] grossly intact throughout. Pertinent Results: Bld Cx [**5-24**] NGTD. Wound Cx MSSA. CXR ([**5-24**]) mild CHF. CT right foot: nonspecific edema, degenerative changes, ? erosion along lateral 1st metatarsal. CT Head ([**5-23**]) negative. CT spine ([**5-21**]): no epidural abscess, nonspecific paraaortic LAD. TTE ([**5-20**]): negative for vegetation. [**2134-5-20**] 02:00AM WBC-22.5*# RBC-4.07* HGB-10.9* HCT-32.8* MCV-81* MCH-26.9* MCHC-33.3 RDW-16.3* [**2134-5-20**] 02:00AM NEUTS-90.9* BANDS-0 LYMPHS-7.2* MONOS-1.3* EOS-0.1 BASOS-0.4 [**2134-5-20**] 02:00AM PLT COUNT-325 [**2134-5-20**] 02:00AM PT-13.9* PTT-24.7 INR(PT)-1.3 [**2134-5-20**] 02:00AM GLUCOSE-100 UREA N-19 CREAT-0.6 SODIUM-138 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-25 ANION GAP-14 [**2134-5-20**] 02:00AM ALT(SGPT)-37 AST(SGOT)-26 LD(LDH)-223 ALK PHOS-150* AMYLASE-35 TOT BILI-0.9 [**2134-5-20**] 02:00AM LIPASE-32 [**2134-5-20**] 02:36AM LACTATE-1.2 [**2134-5-20**] 02:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG Brief Hospital Course: 59 y.o. woman with MSSA bacteremia. 1) MSSA bacteremia: Blood cultures remained clear, and pt continued on nafcillin. A PICC line was placed for continued administration of nafcillin likely [**3-24**] week course. A search for source of bacteremia revealed an abscess near the rigth clavicle. This was I&D'd by surgery with good result. ID was consulted, however, it was felt that this abscess was a result of the bacteremia and not the source. A TTE/TEE were negative for endocarditis. The Pt had right foot swelling but a CT was not definitive for osteomyelitis. The pt could not have an MRI in house because of size, but a CT spine did not show any definitive evidence of vertebral osteomyelitis or epidural abscess. A CT abdomen did show psoas muscle assymetry concerning for abscess. This was drained under CT guidance and the fluid was sent for culture and cytology. Pt was taken for spine MRI to eval for osteomyelitis/diskitis--if this is negative, pt will be discharged but if positive will need ortho/spine consult. Nafcillin was changed to cefazolin as there was mild concern the nafcillin could be contributing to anemia--duration of treatment will remain unchanged. 2) Delerium: On arrival to MICU here at [**Hospital1 18**], the pt was intubated for agitation/delerium. No primary lung pathology was discovered and the pt was extubated several days later. CXR showed mild CHF, accounting for mild hypoxia. The delerium was likely due to acute illness and hospitalization as it resolved and pt's MS returned to baseline. Her respiratory status also improved and she was weaned off oxygen without difficulty. 3) HTN: Though pt had a question of HTN in past, in the MICU, the patient had moderate to severe HTN with SBP in 180's and 190s. She was started on lopressor and this was uptitrated. Then also started on HCTZ. As she then developed hypokalemia, the HCTZ was changed to an ACE-I. Captopril was uptitrated and then changed to lisinopril. Lopressor was changed to toprol xl. She didn't have significant hypertension on the floor. 4) Hypokalemia: Possibly due to NGT secretions and HCTZ but given combination with HTN, concern for hyperaldo state. Renin and aldosterone levels were sent but pending at this time. She was started on standing potassium with relatively stable K. 5) Anemia: Hct trended down likely due to bleeding from abscess I&D and iron labs c/w ACD. She was guiaic neg throughout the admission. B12, folate normal and hemolysis labs negative. Pt did not require any tranfusion. In addition, pt also had one episode of vaginal bleeding and this should be evaluated by Gyn as outpatient. 6) Psych: PT continued on SSRI for depression. While she was here she demonstrated situational anxiety during procedures requiring prn ativan, but nothing on an ongoing basis. 7) Rash: While here, pt also developed a maculopapular rash on the torso. Initially there was concern that this could a drug rash, however it resolved without any change in meds. Pt states she has had similar "heat rashes" in the past, and this was likely a recurrence. She was started on prn [**Doctor First Name 130**] and sarna lotion. 8) FULL CODE Medications on Admission: Celexa. Discharge Medications: 1. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. Disp:*1000 cc* Refills:*0* 3. Cefazolin 10 g Recon Soln Sig: Two (2) g Injection Q8H (every 8 hours) for 4 weeks. 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for itching. 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: MSSA bacteremia Delerium Anemia of chronic disease and blood loss anemia Hypertension Hypokalemia. Discharge Condition: Good. Discharge Instructions: Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **], pain, worsening rash. Followup Instructions: Please call your PCP for follow up within 1-2 weeks. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2134-6-15**] 10:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Name: [**Known lastname 1953**],[**Known firstname 1954**] Unit No: [**Numeric Identifier 1955**] Admission Date: [**2134-5-20**] Discharge Date: [**2134-6-15**] Date of Birth: [**2074-6-26**] Sex: F Service: MEDICINE Allergies: Slim-Fast Attending:[**First Name3 (LF) 391**] Addendum: This is an addendum for [**6-2**] thru [**6-14**]. Please see hospital course. Major Surgical or Invasive Procedure: 1) Incision and drainage of right clavicle region abscess. 2) PICC placement. 3) CT guided drainage of retroperitoneal abscess. 4) T12-L3 laminectomy and epidural abscess debridement. Brief Hospital Course: 1) Epidural abscess: MRI of the lumbar spine showed epidural abscess. Orthopedic surgery was consulted, and the patient was taken for laminectomy and debridement. Pt tolerated the procedure well without post-op complication except expected pain. She did not have any further fevers and continued on IV antibiotics--plan for total 6 week course. She was changed back from cefazolin to oxacillin for improved activity against MSSA and thinking that the nafcillin had not been responsible for her anemia. 2) Anemia: In addition, pt had a drop in Hct that was gradual but without clear etiology. It was likely a combination of blood loss anemia from surgery and anemia of chronic disease. She was transfused 2U PRBC with an appropriate increase in her hematocrit. 3) Hypokalemia: She continued on standing potassium supplementation, and her potassium remained within normal range on this. She will require outpatient work up of this persistent hypokalemia once acute issues are resolved. Aldosterone level returned as low but patient had already been started on ACE-I so it was not useful. Other issues remained stable without change from prior d/c summary. Discharge Medications: 1. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. Disp:*1000 cc* Refills:*0* 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for itching. 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams Injection Q4H (every 4 hours) for 3 weeks. Disp:*252 grams* Refills:*0* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day): until patient ambulating regularly. 15. Morphine IR 15mg q4-6hrs prn Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] Discharge Diagnosis: MSSA bacteremia Psoas muscle abscess Epidural abscess Delerium Anemia of chronic disease and blood loss anemia Hypertension Hypokalemia. Discharge Condition: Good. Discharge Instructions: Please take medications as prescribed. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 1956**], pain not controlled by medications, worsening rash, new focal weakness or loss of sensation. Followup Instructions: Please call your PCP for follow up within 1-2 weeks after your leave the rehab. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 384**] (CARDIOTHORACIC SURGERY) for follow up of your chest abscess on [**6-22**] at 11am in [**Hospital Ward Name **] Clinical Center. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of orthopedic surgery in 3 weeks--[**2139-7-7**]:30 AM. Call [**Telephone/Fax (1) 1957**] for office directions. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1958**], MD Where: LM [**Hospital Unit Name 495**] DISEASE Phone:[**Telephone/Fax (1) 496**] Date/Time:[**2134-7-13**] 10:30 [**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**] Completed by:[**2134-6-14**]

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icd9cm

[ [ [] ] ]

[ "88.72", "03.09", "96.72", "83.45", "38.93", "96.6", "77.89", "83.39", "83.95", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

11716, 11797

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17,764

158,663

46733

Discharge summary

report

Admission Date: [**2110-8-21**] Discharge Date: [**2110-8-29**] Date of Birth: [**2026-12-6**] Sex: F Service: MEDICINE Allergies: Hydrochlorothiazide / Bactrim / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**Last Name (NamePattern1) 15287**] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: None History of Present Illness: 83F hx IDDM, HTN, CAD s/p MI in [**2077**], seizure disorder, SLE, CKD (baseline Cr 1.2), and recent admission for bradycardia thought secondary to propanolol who is admitted for evaluation of bradycardia and hypotension. Per report, the patient presented for an emergent outpatient appointment in cardiology clinic today after experiencing epigastric pain/N/V the evening prior. In cardiology clinic, the patient had a glucose of 30, for which she was treated with oral sugar. She became tremulous and was taken to [**Company 191**] for evaluation. At [**Company 191**], she appeared acutley ill with audible wheezing. An O2 sat was unable to be obtained, BP 102/50, and pulse 40. EMS was called, and patient given 0.5mg atropine in the field with improvement in her HR and BP per records. Of note, the patient was recently admitted to the [**Hospital1 1516**] service from [**Date range (1) **] with bradycardia and shortness of breath. Her bradycardia was thought to be secondary to recent initiation of propanolol. She was monitored in the hospital, and her bradycardia resolved. Her SOB she was thought to be secondary to mild volume overload, for which she was diuresed with 20 mg IV furosemide. In the ED, initial vitals were 97.0 67 143/48 14 100% 3L Nasal Cannula. Labs were significant for Na 120, K 5.3, and Cr 1.6 (1.2 at recent discharge). HCT 29.7 (baseline ~32) and plts 145. CXR showed findings concerning for RLL infiltrate versus aspiration, widespread bilateral interstitial abnormality. Received CTX/levoflox. She received 1L NS for hyponatremia. On arrival to the MICU, pt is agitated, but a/o x3. ROS difficult to obtain [**12-26**] mental status. only complain is sensation of having to urinate with foley Past Medical History: - Seizure disorder - Insulin dependent diabetes (Dr. [**Last Name (STitle) 713**], [**Last Name (un) **]) - CAD (s/p MI [**2077**]) - Hypertension - Hypercholesterolemia - SLE (Dr. [**Last Name (STitle) **], [**Hospital1 18**]) - Rheumatoid arthritis - Osteoporosis - Cervical dysplasia - Bell palsy - Syphilis s/p penicillin Rx - Fibular Fx and Tibial Fx s/p ORIF, [**2102**] Social History: Lives at home with her daughter. She lives on the ground floor and does not have to use stairs, but she does ambulate with a cane and walker and occasionally walks around outside independently. She is a former book-keeper at a furniture store in [**Country **], moved here in [**2069**]. Denies alcohol & tobacco use. Family History: Mother - DM, CVA. Daughter - DM Physical Exam: ADMISSION EXAM: General: agitated, a/o 3 but difficult to calm, tremulous HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffusely wheezy anteriorly Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: agitaed, a/ox3, moving all extremities Discharge Exam: VS 98.3, 172/60, 79, 20, 98% RA GEN Alert, calm, A&O x2 today (self and place) HEENT NCAT MMM EOMI sclera anicteric, OP clear PULM Poor inspiratory effort, crackles at bilateral lung bases CV RRR normal S1/S2, 3/6 systolic murmur with radation to carotids ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: ADMISSION LABS: [**2110-8-21**] 02:30PM BLOOD WBC-6.2 RBC-3.30* Hgb-9.9* Hct-29.7* MCV-90 MCH-30.0 MCHC-33.4 RDW-13.6 Plt Ct-145* [**2110-8-21**] 02:30PM BLOOD Neuts-68.4 Lymphs-19.9 Monos-9.8 Eos-1.7 Baso-0.1 [**2110-8-21**] 02:30PM BLOOD PT-10.7 PTT-30.9 INR(PT)-1.0 [**2110-8-21**] 02:30PM BLOOD Glucose-219* UreaN-44* Creat-1.6* Na-120* K-5.3* Cl-88* HCO3-22 AnGap-15 [**2110-8-21**] 02:30PM BLOOD cTropnT-<0.01 [**2110-8-22**] 12:24AM BLOOD CK-MB-6 cTropnT-0.02* [**2110-8-22**] 03:48AM BLOOD CK-MB-7 cTropnT-0.02* [**2110-8-22**] 12:24AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.8 [**2110-8-22**] 12:24AM BLOOD Osmolal-271* [**2110-8-21**] 02:30PM BLOOD Cortsol-18.4 Discharge Labs: [**2110-8-29**] 06:40AM BLOOD WBC-7.3 RBC-3.03* Hgb-8.8* Hct-28.0* MCV-92 MCH-29.0 MCHC-31.4 RDW-15.0 Plt Ct-204 [**2110-8-29**] 06:40AM BLOOD PT-11.3 PTT-31.8 INR(PT)-1.0 [**2110-8-29**] 06:40AM BLOOD Glucose-145* UreaN-18 Creat-0.8 Na-143 K-4.4 Cl-109* HCO3-30 AnGap-8 [**2110-8-29**] 06:40AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1 Imaging: CHEST XRAY [**8-21**] IMPRESSION: 1. Findings concerning for right lower lung infection versus aspiration pneumonitis. 2. Possible mild interstitial pulmonary edema. 3. Widespread bilateral pulmonary interstitial abnormality, chronic in appearance. CXR [**8-22**]: Comparison is made with prior study [**8-21**]. Right lower lobe consolidations have worsened. Left lower lobe opacities have markedly increased this could be due to atelectasis and/or pneumonia. Small bilateral pleural effusions are larger on the right side. Moderate pulmonary edema has increased. Patient has known chronic interstitial disease. Head CT [**8-22**]: No evidence of hemorrhage, mass effect, or acute infarction. The study and the report were reviewed by the staff radiologist. CXR [**8-23**]: 1. Overall cardiac and mediastinal contours are likely unchanged, although somewhat obscured by the diffuse airspace process, which has worsened. Given the change, this would favor worsening pulmonary edema, although a diffuse pneumonia should also be considered. Small bilateral effusions are less well visualized on the current examination. No pneumothorax. CXR [**8-24**]: 1. Stably enlarged heart. Unfolded calcified tortuous aorta consistent with atherosclerosis. Diffuse bilateral airspace process does not appear to be significantly changed and could reflect moderate-to-severe pulmonary edema or bilateral infectious process. Clinical correlation is advised. Probable small layering left effusion. No pneumothorax. ADMISSION EKG [**8-21**]: Baseline artifact. Most likely atrial flutter with slow ventricular response. Non-specific ST-T wave changes. Compared to the previous tracing of [**2110-8-16**] atrial flutter rhythm is new. Discharge EKG [**8-26**]: Sinus rhythm with slowing of the rate as compared to the previous tracingof [**2110-8-25**]. Left atrial abnormality. A-V conduction delay. Left ventricular hypertrophy. Non-specific lateral ST-T wave changes. Absence of ventricular ectopy as compared to the previous tracing of [**2110-8-25**]. Otherwise, no diagnostic interim change. Microbiology: [**8-21**] Blood Culture: Negative [**8-23**] Blood Culture: Negative [**8-23**] Urine Legionella: Negative [**8-24**] Urine Culture: Negative [**8-25**] Urine Culture: Negative [**8-27**] C. Diff: Negative Brief Hospital Course: Brief Course: 83F hx IDDM, HTN, CAD s/p MI in [**2077**], seizure disorder, SLE, CKD (baseline Cr 1.2), and recent admission for bradycardia thought secondary to propanolol who is admitted for evaluation of bradycardia and hypotension. Bradycardia was responsive to atropine and the hypotension improved as the bradycardia improved. Patient was also found to be hyponatremic which was corrected with diuresis and hypertonic saline. A pneumonia was identified on chest xray and treated for HCAP with cefepime, vancomycin, and azithromycin. Active Issues: #Hyponatremia: Thought to be secondary to hypovolemia/poor forward flow with possible component of SIADH. Na+ was 120 on admission and nadired to 117 that night. Renal was consulted and recommended diuresis along with hypertonic saline which was administered with frequent Na+ checks. Sodium improved and was within normal range upon discharge. #Hospital Acquired Pneumonia: Pt significantly wheezy and visibly tachypenic on admission. CXR with findings concerning for right lower lung infection versus aspiration pneumonitis. She was started on HCAP coverage with vanc/cefepime for an 8 day course with addition of azithromycin for atypical coverage. Urine legionella was negative. Her respiratory status improved. #Delirium: Most likely multifactorial due to hyponatremia, sundowning, infection. CT head ruled out acute intracranial process. We treated her pneumonia and hyponatremia as above. We did our best to reorient her and eliminate tethering tubes and drains. Patient's delirium improved although she was still not back at her baseline at discharge. Of note, her mental status made her an increased aspiration risk so she was evaluated by speech and swallow who recommended pureed solids and nectar thick liquids. #Bradycardia: Etiology is not entirely clear at this point. Prior episode had been attributed to propranol, but her symptoms have persisted since her last discharge. It is possible that the patient had continued taking the propanolol, although her daughter reports that this was discontinued. Patient did respond to atropine in the ED, and did not have any episodes of bradycardia in-house. Likely has a component of conduction disease but cardiology at this point deferred pacer placement. #Hypertension: Blood pressures persistently elevated in the 140-170s. She was initially hypotensive in the ED when bradycardic therefore her amlodipine and ACE-I had been held on admission. Patient was restarted on her home blood pressure medications when her hypotension and [**Last Name (un) **] resolved. #Hyperkalemia: Persistently > 5 over the 1st part of admission, likely in setting of acute on chronic renal failure. Less likely to be from adrenal insufficiency or beta blocker toxicity, though this was considered. K+ slowly improved over hospital stay with diuresis. #Hypoglycemia: Resolved with oral glucose. [**Month (only) 116**] have been due to poor PO intake in setting of worsening clinical status. Adrenal insufficiency considered but less likely given normal random cortisol. Once glucose levels improved, she was started back on her home insulin regimen. #[**Last Name (un) **]: Cr elevated to 1.6 on admission from baseline 1.1-1.2. Thought to have a component of low flow from volume overload, with low urine Na+ on admission. Cr improved with diuresis back to baseline. Enalapril was initially held, then restarted after the [**Last Name (un) **] improved. # Anemia/thrombocytopenia: Hct of 29 on admission, down from low-mid 30s recent baseline. Plt 145 on admission, down from 215 last discharge. Likely secondary to bone marrow suppression in the setting of her acute illness. TTP was kept in the differential given AMS and [**Last Name (un) **]. However, both the anemia and thrombocytopenia improved and stabilized. Inactive Issues; #CAD: Continued ASA, simvastatin #Seizure History: Continued Levetiracetam 750 mg PO BID #SLE: Continued home prednisone 5mg daily and hydroxychloroquine sulfate. Transitional Issues: 1. Code Status: FULL 2. Communication: Daughter [**Name (NI) 24606**] 3. Medication Changes: -START IV Cefepime (last day [**2110-8-31**]) -START IV Vancomycin (last day [**2110-8-31**]) 4. Pending studies: None 5. Follow up: PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**] Medications on Admission: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 500 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Enalapril Maleate 20 mg PO BID 6. Hydroxychloroquine Sulfate 200 mg alternating with 400 mg DAILY 7. NPH 15 Units Breakfast, NPH 5 Units Dinner 8. LeVETiracetam 750 mg PO BID 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain 10. PredniSONE 5 mg PO DAILY 11. Simvastatin 10 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY 13. DimenhyDRINATE 50 mg PO Q8H:PRN nausea 14. Furosemide 20 mg PO 3X/WEEK (MO,WE,FR) 15. Doxazosin 2 mg PO HS 16. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Doxazosin 2 mg PO HS 5. Enalapril Maleate 20 mg PO BID 6. DimenhyDRINATE 50 mg PO Q8H:PRN nausea 7. Lidocaine 5% Patch 1 PTCH TD UNDEFINED pain 8. NPH 15 Units Breakfast NPH 5 Units Dinner 9. LeVETiracetam 750 mg PO BID 10. Omeprazole 20 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. PredniSONE 5 mg PO DAILY 13. Simvastatin 10 mg PO DAILY 14. Furosemide 20 mg PO MWF 15. Hydroxychloroquine Sulfate 200 mg PO EVERY OTHER DAY 16. Hydroxychloroquine Sulfate 400 mg PO EVERY OTHER DAY alternating with 200mg dose 17. Calcium Carbonate 500 mg PO BID 18. Acetaminophen 1000 mg PO Q8H 19. Bisacodyl 10 mg PO DAILY:PRN constipation hold for loose stools 20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheeze 21. OLANZapine (Disintegrating Tablet) 5 mg PO QHS 22. Senna 2 TAB PO BID hold for loose stools 23. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 24. Vancomycin 1000 mg IV Q 24H 25. CefePIME 2 g IV Q24H 26. Maalox/Diphenhydramine/Lidocaine 15 mL PO BID:PRN mouth pain 27. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Primary: Bradycardia Altered mental status Hospital acquired pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 99188**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with low heart rate and low blood pressure that were stabilized in the ICU. You were also found to have a pneumonia that is being treated with antibiotics through your veins. You became confused during your hospitalization which improved, although you are still not quite back to your baseline. Please make the following changes to your medications: START IV Cefepime (last day is [**2110-8-31**]) START IV Vancomycin (last day is [**2110-8-31**]) Please have the facility remove your PICC line once antibiotic course is completed. Make sure you STOP your propanolol because this causes your heart rate to be low Followup Instructions: Please follow up with the following appointments: Department: [**Hospital3 249**] When: WEDNESDAY [**2110-9-10**] at 11:00 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2110-9-22**] at 8:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2110-8-30**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

13490, 13610

7261, 7801

359, 366

13725, 13725

3890, 3890

14666, 15355

2887, 2920

12233, 13467

13631, 13704

11624, 12210

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2552, 2871

70,642

119,768

950

Discharge summary

report

Admission Date: [**2151-5-29**] Discharge Date: [**2151-6-1**] Date of Birth: [**2101-10-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p head-on collision bicyclist vs bicyclist Major Surgical or Invasive Procedure: laceration repair right brow History of Present Illness: 49M transfer from [**Hospital1 **] [**Location (un) 620**] s/p bicycle accident (head-on collision with another bicyclist). He was helmeted and there was a possible LOC, brought to [**Location (un) 620**] where patient was initially A + O x 3, workup there included CT head showing ICH, right orbital fracture, overlying laceration concern raising for open fracture. At OSH, the pt became somnolent and less responsive after receiving pain meds (dilaudid 1mg IV), and was intubated electively for airway protection. He received Td and Ancef 1g IV at OSH. Reportedly only able to visualize counting fingers w. R eye at OSH prior to intubation During transport had difficulty sedating with propofol, titrated up to maximal dosing, switched to versed and fentanyl on arrival for better sedation. FAST was negative in the ED. Past Medical History: PMH: Retinitis Pigmentosa, R radial head fxr tx'ed nonoperatively PSH: R shoulder reconstruction [**4-/2150**] Social History: Social History: by report patient is nonsmoker Family History: NC Physical Exam: Per NSURG Eval in ED: PHYSICAL EXAM:(this exam was performed off sedation of 10 mins) GCS=7T E: 1 V:1T Motor: 5 O: BP: 122/76 HR:65 R:16 O2Sats: 100% on assit control ventilation Gen:appears sedated, right eye hematoma, right eye laceration x 2 HEENT: Pupils: 2.5mm NR bilaterally EOMs; patient does not participate Neck:hard cervical collar on Extrem: Warm and well-perfused. Neuro: Mental status: intubated GCS 7T Orientation/Recall/Language: patient is non verbal , intubated, not opening eyes Cranial Nerves: I: Not tested II: Pupils NR 2.5 bilaterally III, IV, VI: Extraocular movements-eyes are fixed V, VII: Facial strength appears grossly symmetric VIII: Hearing unable to test IX, X: Palatal elevation unable to test [**Doctor First Name 81**]: Sternocleidomastoid and trapezius- unable to test XII: Tongue - unable to test Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full localizes bilateral upper extremities, flexes and withdraws lower extremities, will lift leg and bend knees off bed to noxious stimulus. Pronator drift- unable to test Sensation: Intact-unable to test Toes downgoing bilaterally Coordination:unable to test Per Plastic Surgery Eval: Collared, intubated, and sedated HEENT: Minimal exam obtainable given intubation and sedation. Pupils minimally reactive bilaterally. Midface stable. No palpable step-off particularly at bilateral orbital rims. There is no proptosis. There are two lacerations lateral to the left eye and along the temple. The lateral eyelid laceration is ~1cm partially avulsed skin flap, the upper laceration is a complex macerated and abraded 2-2.5cm laceration. Pertinent Results: CXR [**5-29**]: No acute intrathoracic process. CT Torso [**5-29**]: 1. Slightly anteriorly displaced fracture of the body of the right scapula. 2. Small amount of free fluid in the pelvis without evidence of visceral organ, bowel or mesenteric injury. 3. No pneumothorax. CT C-spine [**5-29**]: 1. No fracture or malalignment. CT head [**5-29**]: 1. Interval slight progression of the right anterior temporal lobe intraparenchymal hemorrhage adjacent to a sphenoid fracture consistent with intracerebral contusion. On attending overread, this was read as "The anterior temporal abnormality appears to be an epidural hematoma." 2. Unchanged and two small foci of right frontal lobe intraparenchymal hemorrhage. Redemonstrated are fractures of all four walls of the right orbit and all four walls of the right maxillary sinus. Repeat CT head [**5-29**]: 1. Slight increase in size of small epidural hematoma overlying the right temporal lobe, now measuring 7 mm, previously 5 mm. 2. Small right frontal lobe contusion, stable. No new intracranial hemorrhage seen. 3. Multiple facial fractures with associated hemorrhage, stable. CT sinus/max/face/mandible [**5-29**]: Fractures of the right orbital superior, lateral, and inferior walls are unchanged with stable 5-mm depression of the inferior orbital wall. The right inferior rectus muscle is not involved. There is a hemorrhage within the right frontal sinus with fracture of the posterior wall. Fracture and slight widening of the frontozygomatic suture is stable. Small focus of air and hematoma seen adjacent to a minimally depressed right superior orbital wall fracture, unchanged. Subcutaneous emphysema and soft tissue swelling over the right face remains stable. The globes are intact. A small epidural hematoma overlying the right temporal lobe and contusion of the right frontal lobe is also stable, and better described on same-day head CT. Communited fractures of the right aspect of the sphenoid sinus /optic strut region are also seen. R arm xrays: Three views of the right elbow demonstrate no evidence of acute fracture, dislocation, or joint effusion. Apparent lucent and slightly expansile lesion in the proximal shaft of the radius measuring 2 cm in diameter has well-defined geographic margins favoring a non-aggressive lesion. However, if symptoms are localized to this region, a bone scan may be considered for further evaluation. [**2151-5-31**] 05:50AM BLOOD WBC-7.1 RBC-3.37* Hgb-11.0* Hct-31.9* MCV-95 MCH-32.7* MCHC-34.5 RDW-13.2 Plt Ct-175 [**2151-5-30**] 01:37AM BLOOD WBC-7.9 RBC-3.58* Hgb-11.9* Hct-33.9* MCV-95 MCH-33.3* MCHC-35.2* RDW-13.2 Plt Ct-205 [**2151-5-29**] 02:00PM BLOOD WBC-10.6 RBC-4.29* Hgb-14.2 Hct-41.6 MCV-97 MCH-33.2* MCHC-34.2 RDW-13.4 Plt Ct-287 [**2151-5-31**] 05:50AM BLOOD Plt Ct-175 [**2151-5-29**] 02:00PM BLOOD PT-12.0 PTT-21.4* INR(PT)-1.0 [**2151-5-29**] 02:00PM BLOOD Fibrino-226 [**2151-5-31**] 05:50AM BLOOD Glucose-117* UreaN-7 Creat-0.8 Na-135 K-3.6 Cl-103 HCO3-26 AnGap-10 [**2151-5-30**] 01:37AM BLOOD Glucose-131* UreaN-9 Creat-1.0 Na-140 K-3.9 Cl-106 HCO3-27 AnGap-11 [**2151-5-31**] 05:50AM BLOOD Calcium-8.1* Phos-1.8* Mg-2.1 [**2151-5-30**] 01:37AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.8 [**2151-5-30**] 01:37AM BLOOD Phenyto-10.4 [**2151-5-29**] 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2151-5-29**] 11:10PM BLOOD Lactate-1.5 Brief Hospital Course: Mr. [**Known lastname 6330**] was admitted to the Trauma SICU after being seen by ophtho in ED where they verified no entrapment (forced duction intact), an intraocular pressure 22 on R, 10 at L, and a question of intraretinal hemorrhages. They determined that it was difficult to rule out traumatic or compressive optic neuropathy given poor view of optic canal, with a poor view of optic nerve. He remained intubated and hemodynamically stable after admission to the ICU. For his head injury, he was placed on dilantin. His vent was weaned as tolerated over that day. He became hypotensive with precedex so this was discontinued. Over his first hospital day, he continued to be quite sensitive to sedation/pain control. On [**5-30**], his vent settings were weaned and he was subsequently extubated. His R frontal laceration was repaired by plastic surgery and he was noted to have a R facial nerve paralysis, mostly in the frontotemporal branch as well as the zygomatic branch. This was thought to be likely from a contusion of the nerve, but possibly a transection of the more distal portions of the frontal branch. He was transferred to the floor on [**5-30**]. Upon transfer to the floor, he was reevaluated by Opthamology who did not note any major acute injury and recommended follow up with his ophthalmologist for visual field testing given his retinitis pigmentosa. He will continue on his dilantin for 1 week with follow up in Neurology in 1 month. His vital signs are stable and he is afebrile. He is tolerating a liquid diet/soft but continues to report pain upon jaw movement. Over the last 24 hours, he has reported new onset of double vision. Opthalmology was consulted and he has a follow up appointment this week. He was evaluated by OMFS for jaw mal-occlusion and will follow-up with his dentist. He has an appointment with Plastics in 3 days for removal of sutures. Medications on Admission: none Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) cc PO BID (2 times a day): hold for loose stool. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation: hold for loose stool. 3. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to right orbial laceration and debrided areas, cover with tegaderm. 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 6. tobramycin-dexamethasone 0.3-0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*5 cc* Refills:*1* 7. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic twice a day as needed for dry eyes. 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. dilantin 100 mg TID started [**5-29**] through [**6-5**] Discharge Disposition: Home Discharge Diagnosis: trauma: Injuries: R medial and lateral orbital wall fx R sphenoid fx involving optic canal contusion R frontal and temporal lobes R Ext corneal hematoma R scapula fx free fluid in pelvis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after you struck another cyclist while riding your bike. You sustained facial injuries. You were seen by Plastic surgery, and the oral-maxillary surgeons. You are now preparing for discharge home with the following instructions: SINUS PRECAUTIONS Because of the close relationship between the upper back teeth and the sinus, a communication between the sinus and the mouth sometimes results from surgery. This condition has occurred in your case, which often heals slowly and with difficulty. Certain precautions will assist healing and we ask that you faithfully follow these instructions: 1. Take the prescribed medications as directed. 2. Do not forcefully spit for several days. 3. Do not smoke for several days. 4. Do not use straws for several days. 5. Do not forcefully blow your nose for at least 2 weeks, even though your sinus may feel ??????stuffy?????? or there may be some nasal drainage. 6. Try not to sneeze; it will cause undesired sinus pressure. If you must sneeze, keep your mouth open. 7. Eat only soft foods for several days, always trying to chew on the opposite side of your mouth. 8. Do not rinse vigorously for several days. GENTLE salt water swishes may be used. Slight bleeding from the nose is not uncommon for several days after the surgery. Please keep our office advised of any changes in your condition, especially if drainage or pain increases. It is important that you keep all future appointments until this condition has resolved Followup Instructions: Follow up with Plastic Surgery to have your sutures removed. Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD Phone:[**Telephone/Fax (1) 6331**] Date/Time: Friday, [**2151-6-4**] 9:00AM Dr. [**First Name (STitle) **] is located on the [**Hospital Ward Name **], [**Hospital Unit Name **], [**Location (un) 6332**], [**Hospital Unit Name 6333**]. He should follow up with Dr. [**Last Name (STitle) 739**] in one month with a noncontrast CT head. The patient can call [**Telephone/Fax (1) 1669**] for this appointment. Please let the office know that you will need a ct scan prior to your visit. You will also need to follow up with Opthamology, Dr. [**Last Name (STitle) 6334**] on Fri., [**5-13**] at 3:45. You will be seen in the Sharprio building..[**Location (un) 442**]. You will also need to follow-up with your dentist to evaluate your jaw. Please follow-up with Dr. [**First Name (STitle) **] in 1 month. You can schedule your appointment by calling # [**Telephone/Fax (1) 6335**] Completed by:[**2151-6-1**]

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icd9cm

[ [ [] ] ]

[ "96.71", "86.59", "08.81" ]

icd9pcs

[ [ [] ] ]

9577, 9583

6611, 8512

348, 379

9817, 9817

3189, 6587

11505, 12572

1478, 1482

8567, 9554

9604, 9796

8538, 8544

9968, 11482

1533, 1895

264, 310

407, 1231

2025, 3170

9832, 9944

1253, 1366

1398, 1462

41,013

136,277

38268

Discharge summary

report

Admission Date: [**2189-10-6**] Discharge Date: [**2189-10-14**] Date of Birth: [**2107-2-25**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3376**] Chief Complaint: Decreased ostomy output. Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions, partial colectomy and creation of colostomy, cecectomy and jejunal colonic anastomosis and transrectal drainage of pelvic abscess. History of Present Illness: 82 yo F w/ hx of recurrent Stage IIa colon cancer s/p local excision ([**4-/2188**]) complicated by leak and abscess now s/p radiotherapy and proctectomy w/ end colostomy ([**2189-8-26**]). She presents with one day of no ostomy output, including stool or gas. She has had several episodes of loose brown, watery stool out of her rectum. No bloody BMs are reported. She denies any abdominal pain, no n/v, no fevers/chills. Her appetite has been poor since her operation, but has been more reduced of late. She otherwise has been feeling well, no CP/SOB. Past Medical History: Past Oncologic History: Rectal cancer stage IIA (T3N0M0) by imaging - [**1-/2188**] developed weight loss and some bloody stools - Routine colonoscopy with rectal lesion - [**4-/2188**] She was admitted for excision of this rectal lesion to [**Hospital3 **] and apparently tolerated the procedure well and was maintained on perioperative antibiotics; however, had a low-grade temperature on postoperative day #2, had a CT scan of her abdomen, which demonstrated a surgical site leak with air tracking into the retroperitoneum. She was subsequently transferred to [**Hospital3 **] for management of the rectal leak and the retroperitoneal free air. - Pathology revealed a moderately differentiated adenocarcinoma, which extends through the muscularis propria at least into the pericolic fibroadipose tissue and is present at the inked resection margin. Given this finding, the patient has at least T3 disease. - [**4-/2188**] Chest CT in [**Hospital3 **], which was negative, we are presuming that she does not have any evidence of metastatic disease as we do not have the report. - [**2188-5-27**] She had a drain placed into a partly walled off pelvic abscess. She was treated with antibiotics and remained stable during her admission from [**2188-5-23**] to [**2188-5-29**]. - [**2188-6-11**] initial visit to rectal clinic at which point she deferred decision for surgery - [**2189-1-8**] CT and MRI with residual tumor in the right mid-to-upper rectum, 1-cm spiculated necrotic node in the midline presacral area, suspicious for metastatic disease, and no evidence of more distant mets. - [**2189-2-25**] Pt deferring further treatment, CEA 9.7 - [**5-/2189**] Underwent CT torso and colonoscopy at [**Hospital3 **] which showed no grossly progressive rectal cancer - [**2189-7-1**] seen for reevaluation of surgery for her rectal cancer. CEA 20. - [**2189-7-10**] PET CT and rectal MRI showed slight increase in her primary tumor and a new avid lymph node enlarged to 1.2 cm but no distant metastatic disease . Other Past Medical History: - CAD: She had an MI in [**2183**]. She is status post stenting. - Spinal stenosis s/p underwent back surgery in [**2181**] - Hysterectomy in [**2166**]. - Hearing loss - Asthma - Glaucoma Social History: - Tobacco: Smoked half a pack a day for 50 years, quit [**2184**], 25 pack years - Alcohol: Denies - Illicits: Denies Family History: - Mother: MI - Father: MI - Sister: Breast cancer - Sister: Breast cancer - Sister: Throat cancer - Sister; Alzheimer's dementia - Brother: CVA Physical Exam: General: Patient doing well, out of bed to chair, respirtaory effort much improved, tolerating a regular diet, no nausea, no vomiting, no pain VS: 98.3, 98.0, 116, 164/95, 22, 95%RA Neuro: A&OX3, HOH at baseline Cardiac: RRR Lungs: Slightly deminished at bases bilaterally, but improved after lasix administration and nebulizzer treatments Abd: round, appropriately tender, vertical midline incision intact and closed with staples and retention sutures, ileostomy with flatus and liquid stool in appliance. Rectum: mallencot rectal drain in place and draining moderate amounts (300cc in 24 hours), peri-anal breakdown wounds noted GU: Foley catheter in place to prevent contamination of rectal area Lower Extremities: no edema noted Pertinent Results: [**2189-10-11**] 04:00AM BLOOD WBC-11.2* RBC-3.25* Hgb-9.7* Hct-30.1* MCV-93 MCH-29.7 MCHC-32.1 RDW-15.1 Plt Ct-318 [**2189-10-10**] 06:47AM BLOOD WBC-11.5* RBC-3.26* Hgb-9.5* Hct-30.7* MCV-94 MCH-29.2 MCHC-31.0 RDW-15.7* Plt Ct-282 [**2189-10-9**] 02:11AM BLOOD WBC-13.2* RBC-3.06* Hgb-8.9* Hct-29.2* MCV-95 MCH-29.0 MCHC-30.4* RDW-15.5 Plt Ct-278 [**2189-10-8**] 12:31PM BLOOD WBC-14.0* RBC-3.15* Hgb-9.2* Hct-30.1* MCV-95 MCH-29.3 MCHC-30.7* RDW-15.5 Plt Ct-244 [**2189-10-8**] 03:42AM BLOOD WBC-13.7* RBC-3.02*# Hgb-9.0*# Hct-27.1* MCV-90 MCH-29.8 MCHC-33.2 RDW-16.0* Plt Ct-208 [**2189-10-7**] 12:15PM BLOOD Hct-31.0* [**2189-10-7**] 02:27AM BLOOD WBC-11.8* RBC-4.31 Hgb-12.6 Hct-39.7 MCV-92 MCH-29.3 MCHC-31.8 RDW-15.7* Plt Ct-253 [**2189-10-6**] 07:13PM BLOOD WBC-8.7 RBC-4.27# Hgb-12.6# Hct-39.6# MCV-93 MCH-29.4 MCHC-31.7 RDW-15.5 Plt Ct-269 [**2189-10-6**] 06:10AM BLOOD WBC-12.3* RBC-3.24* Hgb-9.3* Hct-30.6* MCV-94 MCH-28.6 MCHC-30.3* RDW-15.8* Plt Ct-326 [**2189-10-6**] 06:10AM BLOOD Neuts-71.2* Lymphs-21.4 Monos-7.0 Eos-0.2 Baso-0.1 [**2189-10-11**] 04:00AM BLOOD Plt Ct-318 [**2189-10-10**] 06:47AM BLOOD Plt Ct-282 [**2189-10-8**] 12:31PM BLOOD Plt Ct-244 [**2189-10-8**] 03:42AM BLOOD Plt Ct-208 [**2189-10-6**] 07:13PM BLOOD PT-14.5* PTT-30.5 INR(PT)-1.3* [**2189-10-6**] 06:10AM BLOOD Plt Ct-326 [**2189-10-6**] 06:10AM BLOOD PT-13.8* PTT-26.4 INR(PT)-1.2* [**2189-10-14**] 05:00AM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-144 K-3.5 Cl-104 HCO3-29 AnGap-15 [**2189-10-13**] 06:12AM BLOOD Glucose-124* UreaN-9 Creat-0.9 Na-141 K-3.5 Cl-104 HCO3-30 AnGap-11 [**2189-10-12**] 05:45AM BLOOD Glucose-133* UreaN-7 Creat-0.8 Na-142 K-3.4 Cl-104 HCO3-32 AnGap-9 [**2189-10-11**] 04:00AM BLOOD Glucose-116* UreaN-6 Creat-0.5 Na-140 K-4.1 Cl-104 HCO3-30 AnGap-10 [**2189-10-10**] 10:05PM BLOOD Glucose-115* UreaN-5* Creat-0.5 Na-139 K-3.9 Cl-103 HCO3-30 AnGap-10 [**2189-10-10**] 06:47AM BLOOD Glucose-117* UreaN-6 Creat-0.4 Na-137 K-4.1 Cl-102 HCO3-30 AnGap-9 [**2189-10-9**] 02:11AM BLOOD Glucose-130* UreaN-9 Creat-0.3* Na-136 K-4.0 Cl-105 HCO3-27 AnGap-8 [**2189-10-8**] 03:42AM BLOOD Glucose-111* UreaN-9 Creat-0.4 Na-140 K-3.2* Cl-109* HCO3-24 AnGap-10 [**2189-10-7**] 02:27AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-139 K-3.7 Cl-103 HCO3-27 AnGap-13 [**2189-10-6**] 07:13PM BLOOD Glucose-135* UreaN-9 Creat-0.4 Na-140 K-3.6 Cl-105 HCO3-27 AnGap-12 [**2189-10-6**] 06:10AM BLOOD Glucose-115* UreaN-11 Creat-0.4 Na-139 K-3.3 Cl-102 HCO3-30 AnGap-10 [**2189-10-10**] 10:05PM BLOOD CK(CPK)-25* [**2189-10-8**] 03:42AM BLOOD ALT-10 AST-21 AlkPhos-49 TotBili-0.7 [**2189-10-6**] 07:13PM BLOOD CK(CPK)-41 [**2189-10-14**] 05:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.0 [**2189-10-13**] 06:12AM BLOOD Calcium-8.1* Phos-3.9# Mg-2.1 [**2189-10-12**] 05:45AM BLOOD Calcium-7.1* Phos-2.3* Mg-1.9 [**2189-10-11**] 04:00AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.3 [**2189-10-10**] 10:05PM BLOOD Calcium-7.4* Phos-2.3* Mg-1.9 [**2189-10-10**] 06:47AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9 [**2189-10-9**] 02:11AM BLOOD Calcium-7.4* Phos-1.8* Mg-1.9 [**2189-10-8**] 03:42AM BLOOD Albumin-2.2* Calcium-6.8* Phos-2.7# Mg-2.2 [**2189-10-7**] 12:15PM BLOOD Mg-2.5 [**2189-10-13**] 06:12AM BLOOD Vanco-21.0* [**2189-10-12**] 05:42PM BLOOD Vanco-25.2* [**2189-10-12**] 05:45AM BLOOD Vanco-28.5* [**2189-10-10**] 09:40PM BLOOD Vanco-19.0 [**2189-10-8**] 06:08PM BLOOD Vanco-14.2 [**2189-10-7**] 07:12PM BLOOD Vanco-11.2 [**2189-10-6**] 04:28PM BLOOD Type-ART pO2-275* pCO2-47* pH-7.42 calTCO2-32* Base XS-5 Intubat-INTUBATED [**2189-10-6**] 03:07PM BLOOD Type-ART pO2-252* pCO2-43 pH-7.46* calTCO2-32* Base XS-6 Intubat-INTUBATED [**2189-10-6**] 04:28PM BLOOD Glucose-120* Lactate-0.9 Na-135 K-3.0* Cl-100 [**2189-10-6**] 03:07PM BLOOD Glucose-139* Lactate-0.8 Na-134 K-2.8* Cl-100 [**2189-10-6**] 11:10AM BLOOD Lactate-1.2 [**2189-10-6**] 04:28PM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-98 [**2189-10-6**] 03:07PM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-98 [**2189-10-6**] 04:28PM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-98 [**2189-10-6**] 03:07PM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-98 [**2189-10-6**] 03:07PM BLOOD freeCa-1.04* Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 85281**],[**Known firstname 27975**] [**2107-2-25**] 82 Female [**-1/4389**] [**Numeric Identifier 85282**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rate SPECIMEN SUBMITTED: PORTION OF COLON WITH COLOSTOMY. Procedure date Tissue received Report Date Diagnosed by [**2189-10-6**] [**2189-10-7**] [**2189-10-10**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tk?????? Previous biopsies: [**-1/3725**] Rectum. [**-9/2368**] Slides referred for consultation. DIAGNOSIS: Portions of colon and colostomy, resection: 1. Colonic segments with diffuse acute serositis and marked serosal fat necrosis (most prominent in segment with colostomy site); no significant mucosal ischemic change seen. 2. Unremarkable appendix. 3. Regional lymph nodes, within normal limits. CT ABD & PELVIS WITH CONTRAST Study Date of [**2189-10-6**] 8:43 AM IMPRESSION: 1. Incompletely enhancing wall indicating developing organization of a presacral collection of feculent material, extravasated oral contrast, fluid, and free air which is adjacent to the distal resection site. In this area are found innumerable small bowel loops with thickened wall and adjacent fat stranding. In addition, there is free fluid found within the peritoneal cavity and mesentery. 2. Small bowel findings likely relate to radiation therapy. It is postulated that a segment of bowel wall has necrosed and has allowed bowel contents to communicate with peritoneal cavity. 3. Right hydronephrosis likely secondary to inflammatory processes in the area of observed constriction. 4. Ostomy site is unremarkable. 5. Bilateral pleural effusions with small stable lung nodules seen in the left lower lobe. 6. Small degree of wound dehiscence seen along the midline consistent with the surgical incision. Brief Hospital Course: The patient presented to the emergency department with symptoms described in the emergency and colorectal surgery consult notes. After CT findings of presacral collection and leakage of bowel contents into the abdominal cavity were reported to the surgical team, the patient was taken to the operating room on [**2189-10-6**] where she had her previously listed surgical intervention. The patient was then transferred to the SICU on the [**Hospital Ward Name **] of [**Hospital1 18**] to recover where she was intubated with a nasogastric tube for gastric decompression. On [**2189-10-7**] she remained in the SICU post-operatively and was bolused with intravenous fluids for low urine output. She was resuscitated as appropriate. She was extubated and was alert and orientedX3. She was given a seven day course of intravenous antibiotics of Vancomycin and Zosyn. Ostomy output was serosanguinous. On [**2189-10-8**] 2 episodes of 6 beats of V-tach, which spontaneously resolved after Lopressor administration. The patient continued to do well, her nasogastric tube was removed and was stable for transfer to the inpatient floor on [**2189-10-9**]. The rectal tube which was placed through the rectum and into the presacral collection was monitored closely and continued to put out thick brown output which eventually progressed to clear sero-sang drainage until the time of discharge. The patient's surgical wound remained intact. On the inpatient unit the patient continued to advance her diet as tolerated. On [**2189-10-12**] started Imodium 1mg [**Hospital1 **] for increased stoma output and the patient's vancomycin was held for trough of 28.5. The Patient was screened for rehabilitation placement. On [**2189-10-12**] the patient tolerated a clear liquid diet. The Foley catheter was removed and the patient voided however was incontinent of urine, this was a concern as the rectal tube remained in place and she was noted to have some perianal skin breakdown, the Foley catheter was replaced. [**2189-10-12**] the patient was tolerating a regular diet and her sentral venous access line was removed from the right neck without issue. On [**2189-10-13**] the patient was triggered for RR 34 after ambulation. The patient remained asymptomatic with an O2 sat of 96% on room air and a heart rate of 92. A chest Xray was obtained which showed pleural effusion on the right which was treated with 10mg of IV Lasix x1 and followed with 40mg of Lasix by mouthX1 with good affect. She was also given nebulizing treatments which also improved lung function. The patient was noted to be slightly hypertensive prior to discharge and her Lopressor was increased to 50mg tid. Ileostomy output remained slightly higher on 1mg of Imodium and therefore was increased to 2mg of Imodium [**Hospital1 **]. It is vital that these medications continue to be monitored at rehab and ileostomy output is monitored and Imodium is titrated appropriately. The patient was ordered to receive 2 additional days of Lasix after discharge with the intension that she will be evaluated and these medications will be adjusted accordingly. Please remove foley catheter 7 days after discharge. Medications on Admission: albuterol 90 2 puffs q4h prn timolol 0.5% 1gtt [**Hospital1 **] latanoprost 0.005% 1gtt [**Hospital1 **] metoprolol 200mg daily nitro 0.4 prn simvastatin 40mg qd theragran prochlorperazine 5mg ASA 81mg daily cipro 500mg q12 omeprazole 10mg Discharge Medications: 1. timolol maleate 0.5 % 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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for PRN. 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for yeast infection. 6. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours: Do not give more than 4000mg of tylenol in 24 hours. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for sbp<100 or hr<65, please monitor vitals and titrate medications appropriately. 12. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): please monitor ileostomy output, goal is between 500cc-1200cc, titrate medication as appropriate. Capsule(s) 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 doses: please give friday [**2189-10-15**] and saturday [**2189-10-16**] and monitor urine output and resp status. continue diuresis if needed. please monitor electrolytes as patient has required K+ repletion. . 14. omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Bowel Perforation and Pelvic Abcess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a partial colectomy and creation of colostomy, cecectomy and jejunal colonic anastomosis and transrectal drainage of pelvic abscess for surgical management of your pelvic abcess and break down of your rectal stump. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these results they will contact you before this time. You have tolerated a regular diet, passing gas and stool through your ileostomy and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. You had an abcess in your pelvis near the rectum, this was drained in the operating room and a mallencot drain was placed. This is connected to a drainage bag and is drianing fluid that is gradually clearing. This drain should stay in place and be monitored for infection. It does not require irrigation. This should remain connected to the drainage bag and it will be evaluated in clinic by Dr. [**Last Name (STitle) 1120**] for removal. You will keep your foley catheter for 7 more days to allow the area near your rectum to heal. Please monitor your bowel function closely. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonges loose stool, or constipation. You have a long vertical incision on your abdomen that is closed with staples and stay sutures which are plastic. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples and sutures become irritated from clothing. The staples and stutures will stay in place until your first post-operative visit at which time they can be removed in the clinic, most likely by the office nurse. Please monitor the incision for signs and symptoms of infection including: increasing redness at the incision, opening of the incision, increased pain at the incision line, draining of white/green/yellow/foul smelling drainage, or if you develop a fever. Please call the office if you develop these symptoms or go to the emergency room if the symptoms are severe. You may shower, let the warm water run over the incision line and pat the area dry with a towel, do not rub. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as gatoraide. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a mosified regular diet with your new ileostomy. However it is a good idea to avoid spicy or fatty foods. You have had elevated ileostomy output and been started on immodium 2mg twice daily which has improved the output greatly. You should continue this medication and the rehab will help your to titrate these medications. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for buldging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery, You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. No heavy lifting for at least 6 weeks after surgery unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may gradually increase your activity as tolerated but clear heavy excersise with Dr. [**Last Name (STitle) 1120**]. You will be prescribed a small amount of the pain medication oxycodone. Please take this medication exactly as prescribed. You may take Tylenol as recommended for pain. Please do not take more than 4000mg of Tylenol daily. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) **] in follow-up 2 weeks after discharge. Call [**Telephone/Fax (1) 160**] to make this appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 49562**], MD Phone:[**Telephone/Fax (1) 19886**] Date/Time:[**2189-10-14**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2189-10-14**] 1:00 Completed by:[**2189-10-14**]

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